Intertrigo (Intertrigo Candidiasis)

Are You Confident of the Diagnosis?

Intertrigo is inflammation of the skin localized to the axillary, inguinal, and/or inframammary skin folds (intertriginous regions). The etiology and differential diagnosis for a rash at these sites is broad and can be seen in many cutaneous diseases. This term can be used to describe both inflammatory dermatoses and infectious conditions of the genitocrural and flexural skin folds. A stepwise approach to this entity is prudent to make the correct diagnosis and devise the appropriate treatment.

What you should be alert for in the history

Patients with intertrigo may present with complaints of itching, burning, and/or pain of intertriginous sites. They will likely mention redness or scaling of the axillary, inframmary and/or genitocrural areas. Most patients have tried over-the-counter remedies, and it is important to make note of the topical agents they have used, as allergic contact dermatitis is often an exacerbating or primary component of intertrigo. It is also important to focus on gathering information regarding a history of diabetes, obesity, urinary or fecal incontinence, and immunosuppression such as human immunodeficiency virus (HIV). A family history of similar complaints can lead one to consider a genetic cause, such as Hailey-Hailey disease.

Characteristic findings on physical examination

Expected results of diagnostic studies

Several quick and straight forward diagnostic studies can be completed in the clinic to help guide diagnosis and treatment. A potassium hydroxide preparation (KOH) can be utilized to evaluate for dermatophytes and yeast (Figure 2). A Wood’s Lamp can be used to screen for green fluorescence of a Pseudomonas infection or coral red fluorescence of erythrasma.

KOH-positive annular scaling patches in the inframammary crease consistent with intertriginous candidiasis.

Bacterial and mycologic cultures with speciation and sensitivities can aid in identification of infectious causes. This is an important point, as many patients with intertrigo have secondary infection of the involved sites.

Lastly, skin biopsy, while being mindful of risk of infection in these infection prone sites, may be necessary to make the correct diagnosis. Skin biopsy is especially helpful for diagnosing flexural involvement of Hailey-Hailey disease, extramammary Paget’s disease, Langerhans’ cell histiocytosis, and pemphigus.

Diagnosis confirmation

Intertrigo is easily mimicked. The differential diagnosis includes, but is not limited to the following:

Candidiasis

Seborrheic dermatitis

Allergic and irritant contact dermatitis

Erythrasma

Dermatophytosis

Inverse psoriais

Inverse lichen planus

Granular parakeratosis

Pemphigus vegetans and other pemphigus variants

Hailey-Hailey disease

Extramammary Paget’s disease

Langerhans’ cell histiocytosis

Acrodermatitis enteropathica

Systemic drug-related intertriginous and flexural erythema

Each entity has unique characteristics that will aid the clinician in narrowing the differential diagnosis. Scalp involvement is commonly seen in association with seborrheic dermatitis. The clinician should look for nail pitting and other signs of psoriasis if inverse psoriasis is being considered. Inverse psoriasis presents with well defined patches, but there is often less scaling than what is seen with classic plaque psoriasis. Lichen planus also has a flexural or inverse form that should be considered when the patient has violaceous patches in the intertriginous sites.

Candidiasis classically has satellite papules and pustules. A history of recent application of topical preparations on inflamed intertriginous skin puts the patient at risk for development of allergic contact dermatitis which, in the appropriate clinical setting, can be further evaluated with patch testing. The presence of erosions and/or blisters would be more consistent with pemphigus variants or Hailey-Hailey disease. Patients with acrodermatitis enteropathica will often have perioral and oral involvement in addition to their intertriginous findings.

A detailed review of the patient’s medications, including any new medications can help rule out “baboon syndrome” or systemic drug-related intertriginous and flexural erythema (SDRIFE). Lastly, despite many of these entities having similar clinical presentations, differentiation often requires histologic review. (one period after review)

Who is at Risk for Developing this Disease?

Intertrigo is most commonly seen in patients who are overweight, obese, or incontinent. Hyperinsulinemia and insulin resistance are often present in this patient population. Immunosuppression and HIV also make patients susceptible. Lastly, infants and children can be particularly at risk for developing inflammation at intertriginous sites secondary to diaper dermatitis, which in itself has a broad differential.

What is the Cause of the Disease?

Etiology

Intertrigo is caused by skin-on-skin friction in areas of occlusion that have increased moisture.

Pathophysiology

Obesity and poor hygiene create a fertile environment for growth of candida, dermatophytes, and bacteria. It is also more difficult for these skin sites to heal and recover from infection, irritation, or a primary inflammatory process.

Systemic Implications and Complications

Intertrigo is commonly associated with diabetes and screening with a blood glucose level may be indicated. Screening for HIV can also be considered in a patient with risk factors.

Treatment Options

Medical

Topical

Absorptive powders (talc, cornstarch)
Topical barriers (zinc oxide)
Topical low- to midpotency corticosteroids (hydrocortisone cream 2.5%, desonide 0.05%)
Nonsteroidal anti-inflammatory/immunomodulators (pimecrolimus 1%, tacrolimus 0.1%)
Antifunal (ciclopirox 1%, ketoconazole 2%) – add parentheses after 2%
Antibacterial (hydrocortisone/idoquinol 1%, Clindamycin 1%, Erythromycin 2%)

Systemic (Treat based on sensitivities)

Antibacterial: Cephalexin, Dicloxacillin, Doxycycline
Antifungal: Fluconazole, Itraconazole, Ketoconazole. Terbinafine is not effective in treating candidiasis.

Physical

Dry intertriginous areas completely after bathing
Minimize moisture and friction
Wear light, absorbent clothing

Optimal Therapeutic Approach for this Disease

The cornerstone to successful treatment of intertrigo is proper skin care. Patients should be educated on ways to keep the involved areas clean and dry. They should avoid wearing clothing made of nylon and wear clothing made of light, absorbent materials. Topical barriers can be used as well.

Infectious etiologies, either primary or secondary, should be treated with appropriate antifungal and antibacterial agents. This is especially important to consider before using anti-inflammatory agents. Low-potency topical corticosteroids (class VII or VI) can be used initially to gain control. More potent steroids should not be used chronically, given the increased risk of skin atrophy and breakdown at these occluded sites.

Lotrisone (Clotrimazole-Betamethasone) is often prescribed for intertrigo, but betamethasone is too potent for intertriginous sites and should be avoided here. If the patient requires chronic topical steroid use for intertrigo, it may be advisable to switch to a nonsteroidal topical anti-inflammatory, such as pimecrolimus or tacrolimus for chronic use.

Patient Management

Intertrigo is often chronic, especially in obese patients who are unable to lose weight and achieve glycemic control. Patients using topical steroids should be followed closely to monitor for signs of skin atrophy, telangiectasia, or striae. Close follow-up is also necessary when treating a primary or secondary infection to ensure complete treatment has been achieved.

Unusual Clinical Scenarios to Consider in Patient Management

It has been reported that HIV and immunosuppression can be a risk factor for intertrigo. It is important to note that intertrigo has been documented as a sign of primary HIV infection. HIV should specifically be considered in a patient with acute intertrigo and a mononucleosis-like illness.

Another unusual clinical scenerio to consider is SDRIFE. A detailed review of a patient’s most recent medications is important, as SDRIFE is a cutaneous reaction that occurs within hours to days of systemic exposure to the causative agent. SDRIFE is a systemically induced allergic contact dermatitis most commonly associated with beta-lactam antibiotics, but has also been reported to occur after chemotherapy. Patch testing with the causative medication can be performed in this clinical scenario.

What is the Evidence?

Janniger, CK, Schwartz, RA, Szepietowksi, JC, Reich, A. ” Intertrigo and common secondary skin infections”. Am Fam Physician. vol. 72. 2005 Sep 1. pp. 833-8. (A comprehensive generalized review of the differential diagnosis, treatment, and prevention of intertrigo.)

Yosipovitch, G, DeVore, A, Dawn, A. “Obesity and the skin: skin physiology and skin manifestations of obesity”. J Am Acad Dermatol. vol. 56. 2007 Jun. pp. 901-16. (This review discusses skin changes observed in obese patients including skin infections, intertrigo, and psoriasis.)

Drake, LA, Dinehart, SM, Farmer, ER, Goltz, RW, Graham, GF, Hordinsky, MK. “Guidelines of care for superficial mycotic infections of the skin: mucocutaneous candidiasis”. J Am Acad Dermatol. vol. 34. 1996 Jan. pp. 110-15. (The academy guidelines for diagnositc criteria, diagnositc tests, and recommended treatment modalities for mucocutaneous candidiasis.)

Drake, LA, Dinehart, SM, Farmer, ER, Goltz, RW, Graham, GF, Hardinsky, MK. “Guidelines for superficial mycotic infections of the skin: tinea corporis, tinea cruris, tinea faciei, tinea manuum, and tinea pedis”. J Am Acad Dermatol. vol. 34. 1996 Feb. pp. 282-6. (The academy guidelines for diagnostic criteria, diagnostic tests and recommended treatment modalities for superficial mycotic infections of the skin.)

Gehrig, KA, Dinulos, JGH. “Acrodermatitis due to nutritional deficiency”. Curr Opin Pediatr. vol. 22. 2010 Feb. pp. 107-12. (This review outlines the skin findings associated with a variety of nutritional deficiencies.)

Guitart, J, Woodley, DT. ” Intertrigo: a practical approach”. Compr Ther. vol. 20. 1994. pp. 402-9. (This is a useful guideline to the therapeutic approach to intertrigo.)

Elmariah, SB, Cheung, W, Wang, N, Kamino, H, Pomeranz, MK. “Systemic drug-related intertriginous and flexural exanthema (SDRIFE)”. Dermatol Online J. vol. 15. 2009 15. pp. 3(A case report of a 72-year-old male with SDRIFE after receiving an experimental drug infusion for the treatment of metastatic melanoma.)

Calikoglu, E, Soravia-Dunand, VA, Perriard, J, Saurat, J.-H., Borrador, L. ” Acute Genitocrural Intertrigo: A sign of primary human immunodeficiency virus type 1 Infection”. Dermatology. vol. 203. 2001. pp. 171-3. (A case report of a 49-year-old male who presented with an acute mononucleosis-like illness and acute intertrigo. The patient was found to have acute HIV-1 infection.)

Scheinfeld, N. “Diaper dermatitis: a review and brief survey of eruptions of the diaper area”. Am J Clin Dermatol. vol. 6. 2005. pp. 273-81. (This is a useful review that divides diaper dermatitis into primary and secondary etiologies along with recommendations for treatment and prevention.)

Chapman, MS, Brown, JM, Linowski, GJ. “0.1% Tacrolimus ointment for the treatment of Intertrigo”. Arch Dermatol. vol. 141. 2005 Jun. pp. 787(A brief comment on a case series of ten patients with intertrigo and treatment with 0.1% tacrolimus ointment for 6 weeks.)

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