II. Definition

  1. Inflammation and secondary infection at skinfolds

III. Pathophysiology

  1. Friction between skin at folds
  2. Moisture increased and air flow decreased
  3. Inflammation and maceration results in epidermal erosions and other skin breakdown
  4. Conditions allow for secondary superinfection

IV. Risk Factors

  1. Obesity
    1. Linear worsening in severity with increasing BMI > 30 kg/m2
  2. Diabetes Mellitus
  3. Immunocompromised state (especially HIV Infection)
  4. Incontinence of urine or stool (with occlusive barriers such as diapers)
  5. Immobility
  6. Hyperhidrosis
  7. Poor hygiene
  8. Hot and humid environments

V. Organisms

  1. Fungus
    1. Candidal Intertrigo or Candidiasis (most common)
      1. Presents with erythema, Scaling, satellite lesions and foul odor
    2. Dermatophytes
      1. See Tinea Pedis and Tinea Cruris
  2. Bacteria
    1. Staphylococcus aureus
    2. Beta-hemolytic Streptococcus
    3. Pseudomonas aeruginosa
    4. Proteus mirabilis
    5. Proteus vulgaris
    6. Corynebacterium minutissimum (Erythrasma)

VI. Distribution

  1. Most common sites
    1. Groin
    2. Axillae
    3. Inframammary folds
    4. Interdigital toe web space
      1. Athletes, laborers with closed-toe or tight shoes
  2. Less common sites
    1. Antecubital or popliteal fossa
    2. Umbilicus
    3. Perineum
    4. Neck area in infacts
    5. Angular Cheilitis

VII. Symptoms

  1. Itching, burning, and redness in affected skin fold
  2. Foul odor may be present

VIII. Signs

  1. Starts with mild erythema
  2. Later, area may become eroded, macerated, fissured

IX. Labs

  1. Potassium Hydroxide (KOH) for fungal organisms
  2. Wood's Lamp Examination
    1. Pseudomonas fluoresces green
    2. Erythrasma (Corynebacterium) fluoresces coral-red

X. Differential Diagnosis

  1. Inflammatory conditions
    1. Contact Dermatitis (Irritant or allergic)
    2. Atopic Dermatitis
  2. Skin Infections
    1. Erythrasma
    2. Pyoderma
    3. Scabies
  3. Chronic skin disorders
    1. Seborrheic Dermatitis
    2. Psoriasis
    3. Pemphigus Vegetans
    4. Pemphigus Vulgaris
    5. Lichen Sclerosus
  4. Skin manifestations of endocrine disorders
    1. Acanthosis Nigricans
    2. Hidradenitis Suppurativa
  5. Skin malignancy
    1. Bowen disease (squamous cell cancer in situ)
    2. Paget Disease

XI. Management

  1. General
    1. Eliminate skin friction
      1. Consider absorbent (e.g. gauze) or breathable barrier agents between overlapping skin
    2. Eliminate moisture in skin folds with drying agents
      1. Talcum powder
    3. Barrier ointment
      1. Petroleum Jelly (Petrolatum, Vaseline)
      2. Zinc oxide
    4. Wear light, breathable, or absorbent clothing
  2. Treat infection
    1. Space application 2-3 hours from topical drying or barrier agents
    2. Antifungals
      1. Consider initial empiric Antifungal therapy
        1. Perform additional testing (e.g. KOH Preparation) if fails to improve after initial therapy
      2. First-line: Topical Antifungals
        1. Imidazoles (e.g. Clotrimazole, Oxiconazole, Econazole) cover all fungus (including candida and dermatophytes)
        2. Nystatin covers only Cutaneous Candidiasis (but this is most common)
      3. Second-line: Broad-spectrum Topical Antifungals
        1. Naftifine (Naftin)
        2. Terbinafine (Lamisil)
        3. Ciclopirox (Loprox)
        4. Butenafine (Mentax)
      4. Third-line: Oral Antifungals
        1. Fluconazole (Diflucan) 100-200 mg daily for 7 days (adult dose)
        2. Itraconazole (Sporanox)
    3. Antibiotics for Streptococcus or Staphylococcus
      1. See Erythrasma
      2. See Tinea Pedis
      3. See Interdigital Intertrigo Secondary Infection
      4. Topical Mupirocin (Bactroban)
      5. Oral antibiotics
        1. See Cellulitis
        2. Streptococcus or MSSA
          1. Dicloxacillin
          2. Cephalexin
        3. MRSA (consider if abscess present, poorly demarcated or refractory to MSSA antibiotics)
          1. Add trimethoprim-sulfamethoxazole (e.g. Septra) to Dicloxacillin or Cephalexin OR
          2. Doxycycline OR
          3. Clindamycin (depending on MRSA sensitivity in community)
      6. Consider antibiotic in combination with topical low dose Corticosteroids (e.g. 1% Hydrocortisone)

XII. Prevention

  1. Keep intertriginous areas clean and dry
    1. Change moist or soiled clothing multiple times daily
  2. Weight loss
  3. Avoid heat and humidity
  4. Wear open-toe shoes
  5. Apply skin Emollients and barrier agents frequently

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Ontology: Intertrigo (C0021807)

Definition (SCTSPA) Dermatitis superficial en superficies cutáneas opuestas
Definition (SNOMEDCT_US) Superficial dermatitis on opposed skin surfaces
Definition (MSH) A superficial dermatitis occurring on skin surfaces in contact with each other, such as the axillae, neck creases, intergluteal fold, between the toes, etc. Obesity is a predisposing factor. The condition is caused by moisture and friction and is characterized by erythema, maceration, burning, and exudation.
Concepts Disease or Syndrome (T047)
MSH D007402
ICD10 L30.4
SnomedCT 156366001, 200947005, 58759008
English Intertrigo, intertrigo, intertrigo (diagnosis), Intertrigo [Disease/Finding], Eczema intertrigo, Erythema intertrigo, Intertrigo (disorder), eczema; intertriginous, erythema; intertrigo, intertriginous; eczema, intertrigo; erythema
Japanese 間擦疹, カンサツシン
Swedish Intertrigo
Czech opruzení, intertrigo, Intertrigo
Finnish Intertrigo
Russian INTERTRIGO, OPRELOST', ИНТЕРТРИГО, ОПРЕЛОСТЬ
German Intertriginoeses Ekzem, Intertrigo
Korean 간찰성 홍반
Polish Wyprzenie
Hungarian Intertrigo
Norwegian Intertrigo
Dutch eczeem; intertrigineus, erytheem; intertrigo, intertrigineus; eczeem, intertrigo; erytheem, Intertrigineus eczeem, intertrigo, Eczeem, intertrigineus, Intertrigo
Spanish intertrigo (trastorno), intertrigo eccematoso, intertrigo eczematoso, intertrigo eritematoso, intertrigo, Intertrigo
French Intertrigo
Italian Intertrigine
Portuguese Intertrigo