History

Fact Explanation
Skin lesion Intertrigo is an inflammatory rash of skinfolds caused by skin-on-skin friction. This usually occurs in opposing surfaces of a skin fold. Initially an erythema appears. The distribution of the lesion is more or less symmetrical along the mid line of the skin fold. It commonly occurs in the groin, axillae, and infra-mammary folds. Antecubital fossae, umbilical, perineal, or interdigital areas, neck creases, and folds of the eyelids are also affected. This erythema is usually ill demarcated and mild in severity. [1,2,3,4]
Itching Patients may present with intense itching, burning, and pain in the affected areas. Severe itching or pain is attributed to severe form of inflammation caused by secondary bacterial/ fungal infection.[2,3,5]
Associations/ complications Some cases may complicated with secondary infections. Staphylococcus aureus, Group A Beta-hemolytic Streptococcus, Pseudomonas aeruginosa, Proteus mirabilis, or Proteus vulgaris are the involved bacteria. Candida, yeasts, molds, and dermatophytes are also involved. Sharply demarcated erythematous areas appear as a result of mechanical causes or cellulitis caused by deep spread bacterial infections in the subcutaneous areas. Intertrigo of interweb areas, intergluteal and crural folds, axillae, or inframammary regions can rarely be complicated by erythrasma caused by Corynebacterium minutissimum. [1,3,5,6]
Risk factors Body folds that have high skin temperature, moisture from insensible water loss has a high risk of affected by intertrigo. Individuals who are obese and diabetic also carry a higher predisposition. Other predisposing risk factors include urinary and fecal incontinence, hyperhidrosis, poor hygiene, and malnutrition. Toe interweb intertrigo may be associated. People who wear losed-toe or tight-fitting shoes such as those who are participating in occupational, athletic, or recreational activities have a risk. [1,2,3,6]
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 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  2. MISTIAEN P, VAN HALM-WALTERS M. Prevention and treatment of intertrigo in large skin folds of adults: a systematic review. BMC Nurs [online] 2010 Jul 13:12 [viewed 05 September 2014] Available from: doi:10.1186/1472-6955-9-12
  3. BLOCK SL. Tricky triggers of intertrigo. Pediatr Ann [online] 2014 May 1, 43(5):171-6 [viewed 05 September 2014] Available from: doi:10.3928/00904481-20140417-04
  4. CARLETON A. Persistent Intertrigo.? Diagnosis. Proc R Soc Med [online] 1942 Dec, 36(2):46 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19992582
  5. NAZZARO G, VAIRA F, COGGI A, GIANOTTI R. A 42-year-old woman with a submammary intertrigo. Int J Dermatol [online] 2013 Sep, 52(9):1035-6 [viewed 05 September 2014] Available from: doi:10.1111/ijd.12079
  6. PAVLOVIć MD. Dermatitis herpetiformis presenting as intertriginous dermatitis. Acta Dermatovenerol Alp Pannonica Adriat [online] 2006 Mar, 15(1):52-4 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850100

Examination

Fact Explanation
Skin redness At the initial stage patients may present with symmetrically distributed ill demarcated plaque like erythematous skin lesions in the skin fold areas in the groin, axillae, infra-mammary folds, antecubital fossae, umbilical, perineal, or interdigital areas, neck creases, and folds of the eyelids. [1,2,3,4]
Macerations Initial mild erythema may progress into severe inflammation with erosions, maceration, and crusting. [2,3,4]
Secondary bacterial infections Due to severe itching, intertrigo can be complicated by secondary bacterial infections. As a result, patient may have skin erosions that are oozing with exudates. [1,3,5]
Erythrasma Small, red-brown macules that may coalesce into sharply demarcated larger patches with sharp borders will co-exist in some cases. This is owing to a chronic superficial infection of intertriginous areas of the skin caused by Corynebacterium minutissimum. [3,4,5]
Satellite lesions Intertrigo complicated with candida infections manifest as satellite papules and pustules. [1,3,4]
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 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  2. CARLETON A. Persistent Intertrigo.? Diagnosis. Proc R Soc Med [online] 1942 Dec, 36(2):46 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19992582
  3. MISTIAEN P, VAN HALM-WALTERS M. Prevention and treatment of intertrigo in large skin folds of adults: a systematic review. BMC Nurs [online] 2010 Jul 13:12 [viewed 05 September 2014] Available from: doi:10.1186/1472-6955-9-12
  4. BLOCK SL. Tricky triggers of intertrigo. Pediatr Ann [online] 2014 May 1, 43(5):171-6 [viewed 05 September 2014] Available from: doi:10.3928/00904481-20140417-04
  5. PAVLOVIć MD. Dermatitis herpetiformis presenting as intertriginous dermatitis. Acta Dermatovenerol Alp Pannonica Adriat [online] 2006 Mar, 15(1):52-4 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850100

Differential Diagnoses

Fact Explanation
Contact dermatitis Contact dermatitis is caused by an inflammation after contact with certain external substances. Patients present with erythematous and pruritic rash at the site of contact. There are two sub categories of contact dermatitis, namely Irritant contact dermatitis and Allergic contact dermatitis. Poison ivy, nickel, and fragrances are classical example for substances that cause it. The rash is characterized with well demarcated erythema and scaling involving hands, face and neck, although any area can be affected. [1]
Atopic dermatitis A dermatitis of an immunologic basis with chronically relapsing skin disorder . The clinical presentation varies from mild to severe. Atopic dermatitis may interfere with normal growth and development in worst cases. Major characteristics include pruritus, typical morphology and distribution (extensor and facial involvement in infants and young children, linearity and flexural lichenification in adults) personal or family history of atopy and chronic or chronically relapsing dermatitis. [2]
Scabies Scabies is an itchy rash caused by a little mite that burrows in the skin surface. The human scabies mite's scientific name is Sarcoptes scabiei. Scabies is nearly always acquired by skin-to-skin contact with someone else with scabies. The contact may be quite brief such as holding hands. [3]
Seborrheic dermatitis Seborrheic dermatitis is a chronic or relapsing papulosquamous inflammatory disease of the skin. The exact pathophysiology is unknown, but is thought to be due to inflammation induced by metabolites of the proliferating Malassezia furfur, which is a commensal. It mainly affects the scalp and face. It is generally confined to areas where sebaceous glands are most prominent. So, the rash is often prominent around the ear, the eyebrows or the eyelids. With time, it may spread to affect armpit and groin folds. Infantile seborrhoeic eczema affects infants under the age of 3 months. An intermittent active phase (flare) is characterized by gradually appearing diffuse or patchy, greasy scaling on scalp (Cradle cap). The scaly lesion is yellowish in color. Crusting is formed due to secondary infection. It is usually not itchy and does not bother the baby. Seborrheic dermatitis usually resolves by 6–12 months of age. [4]
References
  1. BONAMONTE D, FOTI C, VESTITA M, ANGELINI G. Noneczematous contact dermatitis. ISRN Allergy [online] 2013 Sep 15:361746 [viewed 06 August 2014] Available from: doi:10.1155/2013/361746
  2. YOO J, MANICONE AM, MCGUIRE JK, WANG Y, PARKS WC. Systemic sensitization with the protein allergen ovalbumin augments local sensitization in atopic dermatitis. J Inflamm Res [online] 2014:29-38 [viewed 06 August 2014] Available from: doi:10.2147/JIR.S55672
  3. GUNNING K, PIPPITT K, KIRALY B, SAYLER M. Pediculosis and scabies: treatment update. Am Fam Physician [online] 2012 Sep 15, 86(6):535-41 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23062045
  4. SAMPAIO AL, MAMERI AC, VARGAS TJ, RAMOS-E-SILVA M, NUNES AP, CARNEIRO SC. Seborrheic dermatitis. An Bras Dermatol [online] 2011 Nov-Dec, 86(6):1061-71; quiz 1072-4 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22281892

Investigations - for Diagnosis

Fact Explanation
Wood lamp examination Wood's light is an ultraviolet light used to accentuate pigmentary changes in skin. It may help in identifying may identify a co-existing Pseudomonas infection by green fluorescence or erythrasma by coral-red fluorescence characterized to those conditions. [1,2,3,4]
A scraping for mycology Skin scraping are taken and prepared with potassium hydroxide preparation for microscopical examination. This is mostly to exclude fungal diseases that may complicate intertrigo. Hyphae should be apparent with dermatophytes, whereas pseudohyphae should appear if candidiasis is present. [2,3,4]
Blood culture Culture with sensitivities should be performed if secondary bacterial infections are suspected. [1,3,5]
Fasting blood sugar This is done in patients who do not respond to optimal treatment as undiagnosed or uncontrolled diabetes mellitus can results in such situations. [1,2,3]
References
  1. MISTIAEN P, VAN HALM-WALTERS M. Prevention and treatment of intertrigo in large skin folds of adults: a systematic review. BMC Nurs [online] 2010 Jul 13:12 [viewed 05 September 2014] Available from: doi:10.1186/1472-6955-9-12
  2. CARLETON A. Persistent Intertrigo.? Diagnosis. Proc R Soc Med [online] 1942 Dec, 36(2):46 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19992582
  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 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  4. BLOCK SL. Tricky triggers of intertrigo. Pediatr Ann [online] 2014 May 1, 43(5):171-6 [viewed 05 September 2014] Available from: doi:10.3928/00904481-20140417-04
  5. PAVLOVIć MD. Dermatitis herpetiformis presenting as intertriginous dermatitis. Acta Dermatovenerol Alp Pannonica Adriat [online] 2006 Mar, 15(1):52-4 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850100

Management - General Measures

Fact Explanation
Prevention Making the environment unfavorable to develop intertrigo is the best way in prevention. Skin to skin friction should be minimized. The high risk areas such as axillae and groin should be kept dry and clean. The heat and moisture around the skin folds should be reduced. Though physical exercise usually is desirable the high risk areas should be dried thoroughly after a shower. Open-toed shoes may prevent toe web intertrigo. Obese patients should lose weight, if possible. Patients should wear light, nonconstricting, and absorbent clothing and should avoid nylon and other synthetic fibers. [1,2,3]
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 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  2. PAVLOVIć MD. Dermatitis herpetiformis presenting as intertriginous dermatitis. Acta Dermatovenerol Alp Pannonica Adriat [online] 2006 Mar, 15(1):52-4 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850100
  3. CARLETON A. Persistent Intertrigo.? Diagnosis. Proc R Soc Med [online] 1942 Dec, 36(2):46 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19992582

Management - Specific Treatments

Fact Explanation
Antiperspirant Antiperspirants are chemical agents that reduce perspiration or sweating. The active ingredients of roll-on and spray formulations are traditionally the metallic salts aluminium chloride and aluminium chlorohydrate. Aluminium-based complexes react with the electrolytes in the sweat to form a gel plug in the duct of the sweat gland. Sweating may be reduced with a gentle antiperspirants that helps in keeping the skin folds dry. [1,2,3]
Antibiotics This is needed when intertrigo is complicated with secondary bacterial infection. Bacteria may be treated with topical antibiotics such as fusidic acid cream, mupirocin ointment, or oral antibiotics such as flucloxacillin and erythromycin. [2,3,4]
Antifungals Yeasts and fungi may be treated with topical antifungals such as clotrimazole and terbinafine cream or oral agents such as itraconazole or terbinafine. [2,3,4,5]
Steroids Topical mild steroids such as hydrocortisone are used in cases of predominant inflammation. It decreases inflammation by suppression of macrophage and leukocyte migration. [4,5,6]
Topical calcineurin inhibitors Topical calcineurin inhibitors such as pimecrolimus and tacrolimus are effective in refractory cases. They are thought to inhibits T-lymphocyte activation and there by suppress inflammation. These drugs are available as creams or ointments. [1,3,6]
References
  1. MISTIAEN P, VAN HALM-WALTERS M. Prevention and treatment of intertrigo in large skin folds of adults: a systematic review. BMC Nurs [online] 2010 Jul 13:12 [viewed 05 September 2014] Available from: doi:10.1186/1472-6955-9-12
  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 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16156342
  3. CARLETON A. Persistent Intertrigo.? Diagnosis. Proc R Soc Med [online] 1942 Dec, 36(2):46 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19992582
  4. BLOCK SL. Tricky triggers of intertrigo. Pediatr Ann [online] 2014 May 1, 43(5):171-6 [viewed 05 September 2014] Available from: doi:10.3928/00904481-20140417-04
  5. NAZZARO G, VAIRA F, COGGI A, GIANOTTI R. A 42-year-old woman with a submammary intertrigo. Int J Dermatol [online] 2013 Sep, 52(9):1035-6 [viewed 05 September 2014] Available from: doi:10.1111/ijd.12079
  6. PAVLOVIć MD. Dermatitis herpetiformis presenting as intertriginous dermatitis. Acta Dermatovenerol Alp Pannonica Adriat [online] 2006 Mar, 15(1):52-4 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850100