Updated: 10/9/2017

Intertrigo

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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
 

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