Intertrigo

Contents

What is intertrigo

What is intertrigo

Intertrigo describes an inflammatory skin rash in the body folds, such as behind the ears, in the folds of the neck, under the arms (armpits), under a protruding abdomen, under the breasts, in the groin, between the buttocks, in the finger webs or toe spaces. Intertrigo is caused by irritation of touching skin surfaces (skin-on-skin friction) in body fold regions (armpits, under the breasts, belly, buttocks, groin, and sometimes between fingers or toes). Intertrigo’s Latin translation, inter (between) and terere (to rub) helps explain the physiology of the condition ¹. Intertrigo tends to occur in warm, moist areas of the body where two skin surfaces rub or press against each other. Such areas are called intertriginous areas. Intertrigo can be worsened by any conditions causing increased heat, wetness, and friction. Intertrigo may be complicated by superficial skin infection with fungus or bacteria.

Intertrigo can be acute (recent onset), relapsing (recurrent), or chronic (present for more than 6 weeks).

Although intertrigo may affect one skin fold, it is common for it to involve multiple sites. Intertrigo is most commonly found in the groin, armpits and under the breasts (inframammary folds). It also may affect antecubital fossae; umbilical, groin, or interdigital areas between fingers or toes; neck creases; and folds of the eyelids.

Intertrigo affects the top layers of skin. It is caused by moisture, bacteria, or fungus in the folds of the skin. The affected areas of skin are usually pink to brown. The exact appearance and behavior depends on the underlying cause or causes. The skin affected by intertrigo is inflamed, i.e., reddened and uncomfortable. It may become moist and macerated, leading to fissuring (cracks) and peeling. If the skin is very moist, it may begin to break down. In severe cases, there may be a bad odor.

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

Intertrigo is most common in people who are overweight and obese. It may also occur in people who must stay in bed or who wear medical devices such as artificial limbs, splints, and braces. These devices may trap moisture against the skin.

Intertrigo is common in warm, moist climates.

Clinical findings

Morphology

Intertrigo is characterized 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

Investigations

If a secondary infection is suspected a swab should be taken for culture and sensitivity (C&S)
If there is scale, skin scrapings should be sent for mycology to look for tinea

Treatment options for intertrigo include:

Antibiotic or antifungal cream applied to the skin
Drying medicine, such as Domeboro soaks
Low-dose steroid cream or immune modulating cream may be used
Creams that protect the skin

Self-care guidelines

Gently cleanse the affected areas daily with mild soap substitutes.
Keep the areas dry and exposed to the air. If this is not easy to do, using absorbent cotton or fabric, as well as absorbent powders, may help (as long as fabrics are changed if they become damp). Mild antiperspirants may help, but these can cause further irritation in some individuals.
Barrier creams, such as zinc oxide paste, may be helpful for individuals wearing diapers or having incontinence problems.
If overweight, weight loss is recommended.
For persistent irritation, 0.5–1.0% hydrocortisone cream twice daily may help. Discontinue if you are no better after 2 weeks of use. Adding a topical antifungal to the hydrocortisone, such as clotrimazole cream, may help if yeast infection is suspected. Apply the barrier paste (if used) after application of these creams.

To properly treat intertrigo, it is imperative to recognize the underlying factor that is causing the condition (see intertrigo causes).

For mild cases, your doctor will tell you to keep the affected area of your skin dry and exposed to air. Your doctor may also want to prescribe a topical steroid cream. For more severe cases, your doctor may prescribe an antibiotic or antifungal cream. There are also antifungal powders that may help dry the skin. Talk to your doctor about which treatment is right for you.

Figure 1. Intertrigo rash

Figure 2. Intertrigo armpit

Figure 3. Intertrigo groin

Figure 4. Intertrigo buttocks

Figure 5. Intertrigo baby

Figure 6. Intertrigo fingers

Is intertrigo contagious?

No. Intertrigo is primarily caused by skin-on-skin friction where it is facilitated by moisture trapped in deep skinfolds. Intertrigo affects the top layers of skin. The microorganisms that are normally resident on the folds of the skin, the microbiome, include corynebacteria, other bacteria and yeasts. These multiply in warm moist environments and may cause intertrigo.

Intertrigo is common in warm, moist climates.

Who’s at risk of intertrigo?

Intertrigo can affect people of all ages. Intertrigo is most frequently seen in overweight people, diabetics, people spending a lot of time in bed, diaper users, or anyone with incontinence problems. It can also occur in individuals wearing or using anything that causes friction or holds moisture against the skin surface.

Intertrigo is most commonly seen in skin fold areas. In people who are obese, the skin my become inflamed in neck creases, on the skin behind the knee or in front of the elbows, in the thigh and groin folds, or, less commonly, under the breast or belly folds. Redness and breaks in the skin (erosions) of opposing skin surfaces may be noted. The area may ooze or be sore or itchy.

What causes intertrigo

Intertrigo is due to genetic and environmental factors.

Genetic tendency to skin disease
Hyperhidrosis (excessive sweating)

Intertrigo is primarily caused by skin-on-skin friction where it is facilitated by moisture trapped in deep skinfolds where air circulation is limited.

Flexural skin has relatively high surface temperature
Moisture from insensible water loss and sweating cannot evaporate due to occlusion.
Friction from movement of adjacent skin results in chafing.

Individuals at particular risk of intertrigo include:

Obese or overweight 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 fecal incontinence, hyperhidrosis, diabetes, poor hygiene, and malnutrition

The moist damaged skin associated with intertrigo is a fertile breeding ground for various germs, and secondary skin 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.

Experts classify intertrigo into infectious and inflammatory origin but there is often overlap:

Infections tend to be unilateral and asymmetrical.
Inflammatory disorders tend to be symmetrical affecting armpits, groins, under the breasts and the abdominal folds, except atopic dermatitis, which more often arises on the neck, and in elbow and knee creases.

Infections causing intertrigo

Candida albicans (thrush)

Rapid development
Itchy moist peeling red and white skin
Small superficial papules and pustules

Erythrasma (Corynebacterium minutissimum)

Persistent brown patches
Minimal scale
Asymptomatic

Tinea (Trichophyton rubrum + Trichophyton interdigitale)

Tinea cruris (groin) and athletes foot (between toes)
Slowly spreads over weeks to months
Irregular annular plaques
Peeling, scaling

Impetigo (Staphylococcus aureus and Streptococcus pyogenes)

Rapid development
Moist blisters and crusts on red base
Contagious, so other family members may also be affected

Common inflammatory skin conditions causing intertrigo

Flexural psoriasis

Well-defined smooth or shiny red patches
Very persistent
Common under the breasts and groin creases
Symmetrical involvement
May fissure (crack) in the crease
Red patches on other sites are scaly

Seborrheic dermatitis

Ill-defined salmon-pink thin patches
Common in axilla and groin creases
Fluctuates in severity
May be asymmetrical
Often unnoticed
Red patches on face and scalp tend to be flaky

Atopic dermatitis

First occurs in infancy
Common in elbow and knee creases
Characterized by flares
Very itchy
Acute eczema is red, blistered, swollen
Chronic eczema is dry, thickened, lined (lichenified)

Contact irritant dermatitis

Acute, relapsing or chronic

Irritants include:

Body fluids: sweat, urine
Friction due to movement and clothing
Dryness due to antiperspirant
Soap
Excessive washing

Contact allergic dermatitis

Acute or relapsing

Allergen may be:

Fragrance, preservative or medicament in deodorant, wet-wipe or other product
Component of underwear (rubber in elastic, nickel in bra wire).

Can intertrigo be prevented or avoided?

You can help prevent intertrigo by doing these things:

Keep skin cool and dry.
Do not wear tight shoes or clothing. Wear a bra that has good support.
Wear clothes made with absorbent fabrics, such as cotton. Avoid nylon or other synthetic (manmade) fibers.
If you are overweight, try to lose weight.
After exercising, shower and dry off completely. Use a hair dryer with a cool setting to dry areas that can trap wetness, such as under your arms or breasts.

Intertrigo symptoms

Symptoms of intertrigo include a red or reddish-brown rash that can appear anywhere skin rubs together or traps wetness. This rash may burn or itch. The most common areas include:

between toes
in the armpits
in the groin area
on the underside of the belly or breasts
in the crease of the neck.

Intertrigo can also affect the skin between the buttocks. The affected skin will often be very raw and may itch or ooze. In severe cases, intertrigo may cause a foul odor, and the skin may crack and bleed.

Intertrigo diagnosis

Your doctor can usually tell if you have the condition by looking at your skin.

Other tests may include:

A skin scraping and a test called a KOH (potassium hydroxide) examination to rule out a fungal infection
Looking at your skin with a special lamp called a Wood’s lamp, to rule out a bacterial infection called erythrasma
A swab for microscopy and culture of bacteria (microbiology)
A scraping for microscopy and culture of fungi (mycology)
In rare cases, a skin biopsy may be performed for histopathology if the skin condition is unusual or fails to respond to treatment.

How to treat intertrigo

Treatment depends on the underlying cause, if identified, and on which micro-organisms are present in the rash. Combinations are common.

Sweating may be reduced with a gentle antiperspirant.
Physical exertion should be followed by a bath and completely drying the skin folds using a hair dryer on cool setting, soft towel and/or corn starch powder.
Triple paste contains petrolatum, zinc oxide, and aluminium acetate solution to reduce friction, irritation and sweating.
Bacteria may be treated with topical antibiotics such as fusidic acid cream, mupirocin ointment, or oral antibiotics such as flucloxacillin and erythromycin.
Yeasts and fungi may be treated with topical antifungals such as clotrimazole and terbinafine cream or oral antifungal agents such as itraconazole or terbinafine.
Inflammatory skin diseases are often treated with low potency topical steroid creams such as hydrocortisone. More potent steroids are usually avoided in the flexures because they may cause skin thinning resulting in stretch marks (striae) and even ulcers. Calcineurin inhibitors such as tacrolimus ointment or pimecrolimus cream may also prove effective.

Step 1: Prevention and general measures

Optimal prevention includes minimizing 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 twice daily, 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 twice daily for 2-4 weeks can still be used first-line, however, if not responding consider:
- Swabs should be taken for culture and sensitivity (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 oral twice daily
- 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

Intertrigo home treatment

To properly treat intertrigo, it is imperative to recognize the underlying factor that is causing the condition (see intertrigo causes).

If there is an infectious component to the rash, then the proper antimicrobial should be administered.

In simple intertrigo, drying agents such as antiperspirants can be used to minimize the sweating.
It may help to lose weight and often change your body position.
Separate skin folds with dry towels.
Wear loose clothing and moisture wicking fabrics.
Blow a fan on moist areas.
A bath with proper drying using a soft towel should follow excessive physical activity that causes excessive perspiration.
Aluminum acetate solution, zinc oxide, and petrolatum, the ingredients that comprise triple paste, is an effective antiperspirant that also reduces frictional exposure and improves skin irritation ².
Staying cool by wearing loose clothing, and working in air-conditioned environments will help in the prevention of the rash.
Absorbent powders compress with an aqueous solution of aluminium triacetate 1:40, and wet tea bags are other preventative measures that have been proven to be effective.
Absorbent diapers are more effective at decreasing the moisture; however, if treatment is required, petrolatum ointment cream is effective and safe for diaper dermatitis.

If the lesion is infected with a bacteria, then use a topical treatment such as mupirocin. If oral medication is required, an effective option against gram-positive bacteria, notably Staphylococcus or Streptococcus, like flucloxacillin or erythromycin should be prescribed. Topical clotrimazole is an effective treatment for yeast or fungal infected intertrigo. Low-dose steroids may be initiated for anti-inflammatory properties, for example, hydrocortisone cream, yet it is not always needed. A lower strength steroid should be preferred if chosen to prevent atrophy in the already thinner epidermis of the flexural surfaces ³.

Living with intertrigo

Intertrigo may come and go many times over. If you know that you are predisposed to getting intertrigo, take precautions. Before physical activity, treat the area with deodorant or with petroleum jelly. Do what you can to keep skin folds dry.

Intertrigo prognosis

Intertrigo prognosis is positive for the majority of patients. The underlying risk factors should be addressed to diminish the intertrigo outbreaks. However, if the risks such as diabetes and obesity are not properly managed, the condition tends to relapse quite frequently.

Candidal intertrigo

Candidal intertrigo refers to superficial skin-fold infection caused by the yeast, candida.

Candidal intertrigo is triggered by a combination of the following factors:

The hot and damp environment of skin folds, which is conducive to the growth of candida species, particularly Candida albicans ⁴
Increased skin friction ⁵
Immunocompromise ⁶

Who gets candidal intertrigo?

Factors that increase an individual’s risk of developing candidal intertrigo include:

Occlusive clothing, gloves and footwear
Obesity
Excessive sweating (hyperhidrosis)
Incontinence causing irritant contact dermatitis
Diabetes mellitus
Immune deficiency conditions, such as human immunodeficiency virus infection (HIV) or immune suppression by medications (chemotherapy, systemic corticosteroids) ⁷.

What are the clinical features of candidal intertrigo?

Candidal intertrigo classically presents as erythematous and macerated plaques with peripheral scaling. There are often associated superficial satellite papules or pustules ⁸.

Affected areas may include:

Skin folds below the breasts or under the abdomen
Armpits and groin
Web spaces between the fingers or toes (erosio interdigitalis blastomycetica) ⁹.

Figure 7. Candidal intertrigo

How is candidal intertrigo diagnosed?

Diagnosis of candidal intertrigo requires recognition of consistent clinical features. In cases of uncertainty, confirmation can be sought by way of fungal microscopy and culture of skin swabs and scrapings ¹⁰. Skin biopsy is usually not necessary.

Candidal intertrigo treatment

Predisposing factors should be addressed primarily, such as weight loss, blood glucose control and avoidance of tight clothing ¹¹.
Patients should be advised to maintain cool and moisture-free skin. This may be aided by regular use of a drying agent such as talcum powder, especially if infection is recurrent ¹².
Topical antifungal agents such as clotrimazole cream are recommended as first-line pharmacological treatments ¹³.
Severe, generalised and/or refractory cases may require oral antifungal treatments such as fluconazole or itraconazole ¹⁴.

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