Intertrigo and Secondary Skin Infections



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Am Fam Physician. 2014 Apr 1;89(7):569-573.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/intertrigo.html.

Author disclosure: No relevant financial affiliations.

Intertrigo is a superficial inflammatory dermatitis occurring on two closely opposed skin surfaces as a result of moisture, friction, and lack of ventilation. Bodily secretions, including perspiration, urine, and feces, often exacerbate skin inflammation. Physical examination of skin folds reveals regions of erythema with peripheral scaling. Excessive friction and inflammation can cause skin breakdown and create an entry point for secondary fungal and bacterial infections, such as Candida, group A beta-hemolytic streptococcus, and Corynebacterium minutissimum. Candidal intertrigo is commonly diagnosed clinically, based on the characteristic appearance of satellite lesions. Diagnosis may be confirmed using a potassium hydroxide preparation. Resistant cases require oral fluconazole therapy. Bacterial superinfections may be identified with bacterial culture or Wood lamp examination. Fungal lesions are treated with topical nystatin, clotrimazole, ketoconazole, oxiconazole, or econazole. Secondary streptococcal infections are treated with topical mupirocin or oral penicillin. Corynebacterium infections are treated with oral erythromycin.

Intertrigo is caused by cutaneous inflammation of opposing skin surfaces. It is more common in hot and humid environments and during the summer. Skin folds, including inframammary (Figure 1), intergluteal, axillary, and interdigital (Figure 2) areas, may be involved.1 Intertrigo is more common in young and older persons secondary to a weakened immune system, incontinence, and immobility, although it can occur at any age.24

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Intertrigo associated with Candida should be managed with topical antifungals applied twice daily until the rash resolves.

C

14

Fluconazole (Diflucan), 100 to 200 mg daily for seven days, is used for intertrigo complicated by a resistant fungal infection. Patients who are obese may require an increased dosage.

C

14

Skin barrier protectants, such as zinc oxide ointment and petrolatum, as part of a structured skin care routine that also includes gentle cleansing and moisturizing may reduce recurrent intertrigo infections.

C

20, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Intertrigo associated with Candida should be managed with topical antifungals applied twice daily until the rash resolves.

C

14

Fluconazole (Diflucan), 100 to 200 mg daily for seven days, is used for intertrigo complicated by a resistant fungal infection. Patients who are obese may require an increased dosage.

C

14

Skin barrier protectants, such as zinc oxide ointment and petrolatum, as part of a structured skin care routine that also includes gentle cleansing and moisturizing may reduce recurrent intertrigo infections.

C

20, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Figure 1.

Inframammary intertrigo appearing as skin discoloration with no evidence of fungal or bacterial superinfection.

Copyright © Logical Images, Inc.

View Large


Figure 1.

Inframammary intertrigo appearing as skin discoloration with no evidence of fungal or bacterial superinfection.

Copyright © Logical Images, Inc.


Figure 1.

Inframammary intertrigo appearing as skin discoloration with no evidence of fungal or bacterial superinfection.

Copyright © Logical Images, Inc.

Figure 2.

Severe interdigital intertrigo with erythema suggestive of cellulitis.

View Large


Figure 2.

Severe interdigital intertrigo with erythema suggestive of cellulitis.


Figure 2.

Severe interdigital intertrigo with erythema suggestive of cellulitis.

Etiology and Predisposing Factors

Intertrigo most often occurs in patients with obesity (body mass index more than 30 kg per m2), diabetes mellitus, or human immunodeficiency virus infection, and in those who are bedridden. It also occurs in patients with large skin folds and those who wear diapers or other items that trap moisture against the skin. There is a linear increase

The Authors

MONICA G. KALRA, DO, is research director of the family medicine residency at Methodist Health System of Dallas (Tex.). She is also an assistant professor at the Texas College of Osteopathic Medicine in Fort Worth and a clinical adjunct professor at the University of Texas Southwestern Medical School in Dallas.

KIM E. HIGGINS, DO, is medical director and owner of Physician Senior Services in Dallas. She is also medical director of Envoy Hospice in Fort Worth, Tex.

BRUCE S. KINNEY, DO, is chief resident for the family medicine residency at Methodist Health System of Dallas.

Address correspondence to Monica G. Kalra, DO, Methodist Health System of Dallas, 3500 W. Wheatland, Dallas, TX 75237 (e-mail: monicakalra@mhd.com). Reprints are not available from the authors.

The authors thank Brenda Iyamu, MD; Eric South, DO; and Mark Hand, DO, for their contribution to this article.

REFERENCES

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