Snapshot A 26-year-old obese woman presents to her physician’s office for an pruritic rash under her breasts. She reports to have recently started attending exercise classes, wearing sports bras and tight-fitting tops. However, because of her busy schedule, she often does not change out of these clothes. Physical exam reveals erythematous plaques with erosions and macerations, and multiple satellite papules and pustules in the inframammary region. She is given a topical corticosteroid and topical antifungal agent for treatment. Introduction Clinical definition inflammatory condition of the intertriginous areas (two skin surfaces in close proximity) often caused by superficial infection of Candida spp. Epidemiology demographics children and adults infants candidal diaper dermatitis location intertriginous regions risk factors warm and moist environment of skin folds obesity constricting clothing hyperhidrosis incontinence diabetes Etiology Candida spp. unicellular and dimorphic fungus with budding yeast often have septate hyphae and pseudohyphae most common Candida albicans Pathogenesis T-cell mediated immunity is used against candidal infections Candida spp. are part of the skin’s normal flora in low numbers can cause infection when the bacterialo flora is altered when host defenses are impaired when trauma, occlusion, or abrasions can disrupt skin integrity Associated conditions persistent candidal infections may indicate immunodeficiency diabetes HIV Presentation Symptoms pruritus painful if there is significant maceration easily irritated Physical exam erythematous and macerated plaques “beefy red” erosions with peripheral scaling erythematous satellite papules and pustules classic for candidal cutaneous infections locations inguinal folds axilla intergluteal folds inframammary folds Studies KOH preparation skin scrapings at active edge of lesion mixed with KOH presence of septated hyphae and spores indicates fungal infection Fungal culture skin scrapings at edge of lesion indications if there is any doubt about diagnosis Making the diagnosis a clinical diagnosis satellite lesions are classic and support the diagnosis of candidal intertrigo Differential Tinea cruris Atopic dermatitis Erythrasma Treatment Conservative weight loss indication prevention of future recurrence Medical topical antifungal therapy indications first-line treatment localized disease drugs nystatin clotrimazole ketoconazole topical corticosteroids indications adjunctive therapy for symptomatic relief should be used with antifungal topical therapies drugs 2% hydrocortisone oral antifungal therapy indications severe and refractory disease widespread disease drugs fluconazole itraconazole Complications Secondary bacterial infection