History

Fact Explanation
Erythematous area /plaque on both sides of skin folds with maceration and scaling(commonest sites are under armpits, groins, under the breasts,) Candida albicans[1],[2] is the commonest pathogen.Candida tropicalis is less common[2]. When skin folds rub against each other, and where heat and moisture accumulate, maceration and inflammation occurs[3]. The condition can progress in to erosions, oozing, fissures, exudation, maceration, and crusting[4].
Features of secondary bacterial infection. Prominent inflammation, pain, indicates bacterial infection.Usually, keratinocytic necrosis is present. Staphylococcus aureus may present alone or with group A beta-hemolytic streptococcus (GABHS).[4]
Itchiness, burning sensation. Itch is caused by the metabolites produced by the fungi
Nail changes( there is Erythema and thickening of proximal nailfold(bolstering) and cuticle is lost.Nail dystrophy and discoloration is prominent) This is a chronic condition .It involves the proximal nail fold and nail matrix.[1],[2]It occurs in hands and feet that are under prolonged immersion in water.[2]
Risk factors( obesity, poor hygiene,urinary and fecal incontinence, hyperhidrosis,pregnancy, and malnutrition). Toe interweb intertrigo( tight-fitting shoes and in athletes) In obese people and in normal skin flexures, there are skin folds.In between them,moisture accumulates and allows fungal growth.Similarly, increased sweating causes moisture to be accumulated between skin folds(such as groins or armpit).[1],[2],[3]
Presence of underlying diseases When widespread skin involvement or recurrence is present, underlying diseases should be suspected.[3] Ex:1.Prolonged use of systemic corticosteroids or antibiotics[1],[3] . 2.Dermatological conditions such as psoriasis and seborrhoeic eczema, where skin is unable to work as a barrier[3]. 3.Immuno-deficiency (In conditions such as HIV infection, or as an effect of chemotherapy, immunosuppressive drugs )[3] 4.In disease conditions such as Diabetes[1],[3] or Anemia[3] where some of the defense mechanisms get suppressed.
References
  1. WELLER,Richard P,J.B. et al. Clinical Dermatology.4th ed.Oxford:Blackwell publishing Ltd.2008.pp.252-254
  2. BROWN,Robin Graham.BURNS,Tony.Lecture notes:Dermatology.10th ed.Sussex:WILEY-BLACKWELL,2011.pp.36-38
  3. Candida - skin.Clinical knowledge summaries.NICE[online]2013[viewed 10 May 2014].Available form: http://cks.nice.org.uk/candida-skin
  4. JANNIGER CK, SCHWARTZ RA, SZEPIETOWSKI JC, REICH A. Intertrigo and common secondary skin infections. Am Fam Physician [online] 2005 Sep 1, 72(5):833-8 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342

Examination

Fact Explanation
Moist area with erythema and maceration on adjacent skin folds.Scaling is present. Candida albicans[1],[2] is the commonest pathogen.Candida tropicalis is less common[2]. When skin folds rub against each other, and where heat and moisture accumulate, maceration and inflammation occurs[3]. The condition can progress in to erosions, oozing, fissures, exudation, maceration, and crusting[4].
Satellite papulopustules at the margins These are due to candida super-infection.The pustules are creamy and easily ruptured and scaling is followed.There is a typical scalloped edge in the affected area.[2]
Signs of secondary bacterial infection(Intense erythema, localised edema,tenderness,pus discharge) Usually, keratinocytic necrosis is present. Staphylococcus aureus may present alone or with group A beta-hemolytic streptococcus (GABHS).[4]
Nail deformities. (Erythema and thickening of proximal nailfold(bolstering) and cuticle is lost.Nail dystrophy and discoloration is prominent) This is a chronic condition .It involves the proximal nail fold and nail matrix.[1],[2]It occurs in hands and feet under prolonged immersion in water. there is present[2]
Signs of underlying conditions. Ex-1.urinary and fecal incontinence[3] -(due to cerebral or spinal lesion) -localizing signs , 2.pregnancy[1]-abdominal distention,linea nigra, fetal poles 3.malnutrition[3]-Low BMI,reduced sub cutaneous fat 4.Dermatological conditions such as psoriasis and seborrhoeic eczema[3] 5.Diabetes[1],[3]-peripheral neuropathy, signs of renal failure,diabetic foot
References
  1. WELLER,Richard P,J.B. et al. Clinical Dermatology.4th ed.Oxford:Blackwell publishing Ltd.2008.pp.252-254
  2. BROWN,Robin Graham.BURNS,Tony.Lecture notes:Dermatology.10th ed.Sussex:WILEY-BLACKWELL,2011.pp.36-38
  3. Candida - skin.Clinical knowledge summaries.NICE[online]2013[viewed 10 May 2014].Available form: http://cks.nice.org.uk/candida-skin#!topicsummary
  4. JANNIGER CK, SCHWARTZ RA, SZEPIETOWSKI JC, REICH A. Intertrigo and common secondary skin infections. Am Fam Physician [online] 2005 Sep 1, 72(5):833-8 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342

Differential Diagnoses

Fact Explanation
Dermatophyte infections The lesions are well demarcated plaques with erythematous elevated borders and central scaling.The lesions are more dry, intensely itchy,asymmetrical or unilateral[1] and don't have satellite lesions.[2]
Erythrasma Erythrasma is asymptomatic.The lesions are well-circumscribed red-brown macules with wrinkled and scaling.There are macerated white areas. Usually observed in the axillae and groin.[1],[3]
Flexural psoriasis The lesions are well demarcated red plaques.[1] There is less scaling, glistening, with fissuring in the depth of the fold.[1],[2]
Dermatitis types 1.Allergic contact dermatitis-There is Intense pruritus present[3].The lesions are poorly demarcated. They have coalescing vesicles and papules on pink plaques.[1]There are other areas of eczema.[3]Allergen can be identified.[1] 2.Irritant contact dermatitis- Intense pruritus is present.[3]Commonly seen on hands and forearms[1].Detergents,alkali,solvents, are common agents.[1] 3. in Atopic dermatitis, pruritus is present.There is coexisting atopic diseases-( asthma, rhinitis) or positive family history[3]. Dry excoriation, and lichenification is present[1] in the lesions.Common sites are the antecubital and popliteal fossae[3] 4.In seborrheic dermatitis, there are erythematous scaly patches on the scalp.[3]
Pemphigus vegetans There are both erosions and blisters on skin and mucosae.[3]
Hailey-Hailey disease (familial benign chronic pemphigus) There are blisters at the margines. Palmoplantar keratoderma, longitudinal nail stripes can be observed.[3]
Vitamin deficiency There will be other signs of vitamin deficiency. (e.g., phrynoderma)[3]
References
  1. WELLER,Richard P,J.B. et al. Clinical Dermatology.4th ed.Oxford:Blackwell publishing Ltd.2008.pp.58,79-103,221,248-254,
  2. Candida - skin.Clinical knowledge summaries.NICE[online]2013[viewed 10 May 2014].Available form: http://cks.nice.org.uk/candida-skin#!diagnosissub:1
  3. JANNIGER CK, SCHWARTZ RA, SZEPIETOWSKI JC, REICH A. Intertrigo and common secondary skin infections. Am Fam Physician [online] 2005 Sep 1, 72(5):833-8 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342

Investigations - for Diagnosis

Fact Explanation
Swab sent for culture and antibiatogram. Usually the diagnosis is clinical[1],[2].But swabs are taken in following situations.[1] 1.Uncertain diagnosis.[1] 2.Poor response to treatment.[1] 3.Secondary bacterial infection.[1] 4.Prior to starting systemic treatment.[1] 5.Immunocompromised patient.[1]
Wood’s light examination This is used to exclude differential diagnosis.(Ex-coral-red fluorescence with erythrasma.)[2]
Potassium hydroxide cytologic examination This is used in diagnosing secondary fungal infections. [2]
References
  1. Candida - skin.Clinical knowledge summaries.NICE[online]2013[viewed 10 May 2014].Available form: http://cks.nice.org.uk/candida-skin
  2. JANNIGER CK, SCHWARTZ RA, SZEPIETOWSKI JC, REICH A. Intertrigo and common secondary skin infections. Am Fam Physician [online] 2005 Sep 1, 72(5):833-8 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342

Investigations - Fitness for Management

Fact Explanation
Blood sugar levels and urine sugar status. This is to identify underlying diabetes mellitus.[1]
Full blood count, Differential counts, This is done under immunological work-up in a patient with immunodeficiency.[3]
Leucucyte function tests. This is done under immunological work-up in a patient with immunodeficiency.[3]
Testing for HIV This is done if recurrent or wide involvement is present and clinically suspicious. (EX-Enzyme-linked immunosorbent assays (ELISAs) , Flow cytometry is used to monitor CD4+ T-cell count , polymerase chain reaction (PCR) assays,)[2]
References
  1. WELLER,Richard P,J.B. et al. Clinical Dermatology.4th ed.Oxford:Blackwell publishing Ltd.2008.pp.254
  2. WU G, ZAMAN MH. Low-cost tools for diagnosing and monitoring HIV infection in low-resource settings. Bull World Health Organ [online] 2012 Dec 1, 90(12):914-20 [viewed 10 May 2014] Available from: doi:10.2471/BLT.12.102780
  3. REZAEI, Nima. AGHAMOHAMMADI Asghar ,NOTARANGELO Luigi D.ed.Primary Immunodeficiency Diseases: Definition, Diagnosis, and Management.1st ed.Berlin :springer.2008.pp.24-25

Management - General Measures

Fact Explanation
Patient education Educate the patient that, the condition is due to a fungal infection and it is curable.The patient should be informed about the importance of good hygienic practices.
Keeping Skin folds, inter-digital spaces and other high-risk areas clean and dry. Under the skin folds, moisture and heat accumulates.There is reduced air circulation.These factors promote fungal growth. [1]
Obese patients should lose weight They develop skin folds (ex-subabdominal).Under the skin folds, moisture and heat accumulates.There is reduced air circulation.These factors promote fungal growth[1]
Wear suitable clothing Light, not tight[2] and absorbent clothing should be worn.Synthetic fibers(e.g-nylon) should be avoided and bio-textiles (e.g- cotton) should be worn.[1]
Wearing open-toed shoes This can prevent toe web intertrigo[1]
Wash skin regularly with soap substitute (for example, use emulsifying ointment) [2]
References
  1. JANNIGER CK, SCHWARTZ RA, SZEPIETOWSKI JC, REICH A. Intertrigo and common secondary skin infections. Am Fam Physician [online] 2005 Sep 1, 72(5):833-8 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  2. Candida - skin.Clinical knowledge summaries.NICE[online]2013[viewed 10 May 2014].Available form: http://cks.nice.org.uk/candida-skin

Management - Specific Treatments

Fact Explanation
Topical imidazole cream (clotrimazole, econazole, miconazole, or ketoconazole) or terbinafine. This is considered in less widespread and immunocompetent patients.[1] Imidazoles interfere with fungal oxidative enzymes and cause accumulation of hydrogen peroxide that alters the cellular function of the fungi.[3]
mildly potent corticosteroid cream (EX-hydrocortisone 1%) If there is itch, this is prescribed in addition to a topical antifungal agent.[1]
oral fluconazole This treatment is consideredIf infection is widespread, ineffective topical treatment, or for immunodeficient patient.[1] This is a Imidazole and it interfere with fungal oxidative enzymes and cause accumulation of hydrogen peroxide that alters the cellular function of the fungi.[3]
Treat Secondary bacterial infections Ex- for Group A Beta Haemolytic Streptococci(GABHS)topical treatment (e.g mupirocin , erythromycin) and/or oral antibiotics can be considered[2]
Reffering to speciailists or Treat underlying conditions Ex- 1.anti-diabetic treatment in Diabetes mellitus 2.anti-retroviral therapy in HIV
References
  1. Candida - skin.Clinical knowledge summaries.NICE[online]2013[viewed 10 May 2014].Available form: http://cks.nice.org.uk/candida-skin
  2. JANNIGER CK, SCHWARTZ RA, SZEPIETOWSKI JC, REICH A. Intertrigo and common secondary skin infections. Am Fam Physician [online] 2005 Sep 1, 72(5):833-8 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  3. BENNETT, Peter N. BROWN, Morris J. CLINICAL PHARMACOLOGY.10th ed.London:CHURCHIL LIVINGSTONE ELSEVIRE. 2008.pp.236