Intertrigo

LAST UPDATED: Apr 25, 2023

Introduction

Intertrigo is an inflammatory condition of the skin folds caused by skin-on-skin friction. Secondary infection with bacterial or fungal infection is common. Intertrigo is most commonly found in the groin, axillae, and inframammary folds. It also may affect antecubital fossae; umbilical, perineal, or interdigital areas; neck creases; and folds of the eyelids.

This chapter is set out as follows:


Aetiology

  • Intertrigo is primarily caused by skin-on-skin friction where it is facilitated by moisture trapped in deep skinfolds where air circulation is limited
     
  • Individuals at particular risk include:
    • Obese patients
    • Infants, due to short necks, relative chubbiness, and flexed posture. Drooling also can facilitate intertrigo in infants
    • Toe web intertrigo may be associated with closed-toe or tight-fitting shoes and commonly affects persons participating in athletic, occupational, or recreational activities
    • Other predisposing factors include urinary and faecal incontinence, hyperhidrosis, diabetes, poor hygiene, and malnutrition 
  • Infection - the moist damaged skin associated with intertrigo is a fertile breeding ground for various pathogens, and secondary cutaneous infections are commonly observed in these areas:
    • Bacterial infection - Staphylococcus aureus, group A beta-haemolytic streptococcus, and various gram-negative organisms may occur alone or simultaneously. Proliferation may be associated with keratinocytic necrosis
    • Fungal infection - candida is the fungus most commonly associated with intertrigo. In the toe webs, gram-negative bacteria are often copathogens

History

  • Patients may present with itching, burning, and pain in the affected areas

Clinical findings

Distribution

  • The condition is most commonly found in the groin, axillae, and inframammary folds. It also may affect antecubital fossae; umbilical, perineal, or interdigital areas; neck creases; and folds of the eyelids 

Morphology

  • Characterised primarily by erythematous patches, which are often symmetrical
  • The erythema may progress to more intense inflammation with erosions, fissures, exudation, crusting and maceration
  • Candidal intertrigo may present as typical satellite macules, papules or pustules
  • Toe web intertrigo may be mild, and asymptomatic, but it also can present with intense erythema and desquamation, which sometimes is erosive, malodorous, and macerated. Patients also may have profuse or purulent discharge and be unable to ambulate. Patients with advanced gram-negative infections may have green discoloration at the infection site. Individuals with severe toe web intertrigo who are overweight or who have diabetes are at a higher risk for cellulitis 

Differential diagnosis

  • Seborrhoeic eczema and psoriasis may have presentations similar to intertrigo, but may have other cutaneous manifestations, scalp involvement, and psoriasis is often associated with nail changes. Flexural lesions in psoriasis are usually symmetrical, red, glistening, and well-demarcated 
  • Tinea eg tinea cruris - lesions are often annular or polycyclic, and tend to have a leading erythematous scaly edge

Images

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Investigations

  • If a secondary infection is suspected a swab should be taken for MC&S
  • If there is scale, skin scrapings should be sent for mycology to look for tinea

Management

Step 1: prevention and general measures

  • Optimal prevention includes minimising skin-on-skin friction, reducing heat and moisture around skinfolds, and keeping high-risk areas clean and dry. Patients should be warned about heat, humidity, and outside activities. Physical exercise usually is desirable, but patients should shower after exercise and keep intertriginous areas thoroughly dry. Wearing open-toed shoes may help prevent toe web intertrigo
  • Obese patients should lose weight, if possible
  • Patients should wear light, non-constricting, and absorbent clothing and avoid nylon and other synthetic fibres. Bio-textiles (eg cotton or polyester gauze with built-in antiseptic molecules) may help patients with intertrigo
  • Avoid the use of absorptive powders, such as talc and cornstarch, which may irritate the skin 

Step 2: medical treatment

  • Daktacort cream BD, for many, is a sensible first-line option as it contains miconazole (which treats candida, as well as having some Gram‐positive bacteriostatic action) and 1% hydrocortisone cream (helps reduce inflammation)
  • For more significant inflammation consider the short-term use of Trimovate ® cream
  • If the skin is not settling then further treatment, such as topical or oral antibiotics, or oral antifungal therapy, may be required, the specific treatment should be guided by results of skin swabs
  • Toe web infection can be very difficult to treat:
    • The skin must be allowed to breathe by the wearing of appropriate footwear and leaving the feet bare at home when possible
    • Daktacort cream BD for 2-4 weeks can still be used first-line, however, if not responding consider:
      • Swabs should be taken for C&S as the proper identification of organisms is critical so that effective therapy can be initiated
      • For potential co-existing gram-negative bacteria, soak the feet in 1:80000 potassium permanganate solution (one Permitab ® dissolved in four litres warm water), twice a day for 10-15 minutes. Warn patients to apply Vaseline to nails to avoid staining them brown. Keep the Pemitabs away from children
      • In those responding poorly to treatment consider a ten day trail of ciprofloxacin 500 mg BD
      • Occasionally tissue removal may be needed to allow absorption of topical treatments 

Step 3: other treatments

  • Surgery, to remove excess skin, may be required for patients with moderate-severe recalcitrant intertrigo

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