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Intertrigo

Intertrigo is a superficial inflammatory dermatitis occurring where two skin surfaces are in apposition. It is discussed here because of its clinical association with several bacterial diseases in this chapter. As a result of friction (skin rubbing skin), heat, and moisture, the affected fold becomes erythematous, macerated, and secondarily infected. There may be erosions, fissures, and exudation, with symptoms of burning and itching. Intertrigo is most frequently seen during hot and humid weather, chiefly in obese persons. Children and elderly persons are also predisposed. This type of dermatitis may involve the retroauricular areas; the folds of the upper eyelids; the creases of the neck, axillae, and antecubital areas; finger webs; inframammary area; umbilicus; inguinal, perineal, and intergluteal areas; popliteal spaces; and toe webs.

As a result of the maceration, a secondary infection by bacteria or fungi is induced. The inframammary area in obese women is most frequently the site of intertriginous candidiasis. The groin is also frequently affected by fungal (yeast or dermatophyte) infection. Bacterial infection may be caused by streptococci, staphylococci,Pseudomonas, orCorynebacterium. IfPseudomonas is involved, it may stain the underwear bluish green. Streptococcal intertrigo favors the neck, axillary, and inguinal folds of young children. There is a well-demarcated, fiery-red, moist, shiny surface and a foul smell, with an absence of satellite lesions.

The differential diagnosis includes seborrheic dermatitis, intertriginous psoriasis, erythrasma, and if the groin lesions are fissured, Langerhans cell histiocytosis.

Treatment of intertrigo is directed at elimination of maceration. Appropriate antibiotics or fungicides are applied locally. Separating the apposing skin surfaces with gauze or InterDry Ag textile is helpful. The latter has an antimicrobial silver complex impregnated within the fabric that when placed in the folded area not only wicks away moisture, but also retains the activity against fungi and bacteria for up to 5 days. Botulinum toxin type A has been used to dry out areas predisposed to recurrent disease. Castellani paint is also useful, as is an antibacterial ointment. Low-potency topical corticosteroids and topical tacrolimus are helpful to reduce inflammation, but these should always be used in conjunction with a topical antifungal or antimicrobial agent.

Kaya TI, et al: Blue underpants sign. J Am Acad Dermatol 2005; 53: 869.

Muller N: Intertrigo in the obese patient. Ostomy Wound Manage 2011; 57: 16.

Neri I, et al: Streptococcal intertrigo. J Pediatr 2015; 166: 1318.

Santiago-et-Sánchez-Mateos JL, et al: Botulinum toxin type A for the preventative treatment of intertrigo in a patient with Darier's disease and inguinal hyperhidrosis. Dermatol Surg 2008; 34: 1733.

Intertrigo

Intertrigo is the most prevalent skin disease in obese people. It is linked to skin rubbing against skin, wearing underwear and pants that are too tight. The friction, maceration, warmth, sweating, and moisture often lead to a candidal infection, or less often, a bacterial infection. Diagnosis is based on the clinical appearance, guided by potassium hydroxide wet mounts and cultures. The differential diagnoses of intertrigo include tinea cruris for inguinal intertrigo, candidal intertrigo, inverse psoriasis of the intertriginous areas, erythrasma, and less often, allergic contact dermatitis resulting from use of wipes after toileting, or axillary application of antiperspirants and deodorants. Treatment is via antifungal creams and powders such as nystatin, which also provide lubrication, and if indicated, antimicrobials. Intertrigo may be treated with drying agents if there is no yeast or bacteria detected. Other options include talcum powder, Burow’s solution compresses, and superabsorbent powders.

Intertrigo.

A red, macerated, half moon–shaped plaque, resembling tinea of the groin and extending to an equal extent onto the groin and down the thigh, forms after moisture accumulates in the crural fold (Fig. 13.20A–B). The sharp borders touch where the apposed surfaces of the skin folds of the groin and thigh meet. Obesity contributes to this inflammatory process, which may be infected with a mixed flora of bacteria, fungi, and yeast. Painful, longitudinal fissures occur in the crease of the crural fold (Fig. 13.20C–D). Groin intertrigo recurs after treatment unless weight and moisture are controlled. Psoriasis and seborrheic dermatitis of the groin may mimic intertrigo (see the section Candidiasis of Large Skin Folds,p. 516).

Intertrigo

Intertrigo is a disorder of the skinfolds resulting from the friction created by opposing skin surfaces combined with a moist environment. Infants are particularly susceptible to intertrigo because they have deep skinfolds, a flexed posture, chubbiness, and a tendency to drool.33 Secondary infections with Candida albicans, GAS, S. aureus, and mixed organisms can occur. Bright red, well-demarcated, weeping patches and plaques are seen in the folds of the neck, axillae, antecubital fossa, inguinal area, or popliteal fossae (Fig. 68.3). Satellite lesions suggest Candida infection, whereas streptococcal intertrigo commonly is associated with a foul odor. Affected infants usually appear well but can have associated fever, fussiness, or malaise.33,34

The differential diagnosis of intertriginous dermatitis includes seborrheic dermatitis, atopic dermatitis, irritant or allergic contact dermatitis, erythrasma, inverse psoriasis, scabies, and Langerhans cell histiocytosis. The diagnosis is confirmed by culture of a lesion.

Treatment of candidal intertrigo consists of topical antifungal agents such as nystatin, econazole, or ketoconazole, whereas streptococcal intertrigo can be treated with a 10-day course of penicillin or cephalexin in combination with topical mupirocin. Anti-inflammatory agents (e.g., topical 1% hydrocortisone) can be used for associated erythema. Using barrier ointments and ensuring that skinfolds are completely dry reduces the friction and moisture of intertriginous areas, helping to prevent intertrigo.33

Intertrigo

This common skin condition affects any site in which skin surfaces are in close proximity and provide a warm, moist environment.97 It begins as vesicopustules, which enlarge and rupture, causing maceration and fissuring. The area of involvement has a scalloped border with a white rim consisting of necrotic epidermis, which surrounds an erythematous, macerated base. Frequently, satellite lesions are found that may coalesce and extend the affected area. A variant form of cutaneous candidiasis in the intertriginous region has a miliary appearance resembling miliaria rubra with erythematous macules or vesicopustules.

▪ Mykosen der Haut

Bei vielen Tropenrückkehrern ist eine Pityriasis versicolor (Kleieflechte), meist im Brust- und mittleren Rückenbereich vorzufinden. Diese durch den Hefepilz Malassezia furfur hervorgerufene oberflächliche Mykose wird durch Schwitzen begünstigt und bessert sich unter intensiver Besonnung. Die rundlichen, scharf begrenzten, zart schuppenden Läsionen wirken auf nicht gebräunter Haut dunkler; auf gebräunter Haut erscheinen sie durch Abschilfern pigmenttragender Epidermisschichten dagegen als hell.

Als wirksam erweist sich bei der harmlosen, allenfalls ästhetisch störenden Dermatose die lokale Anwendung eines antimykotischen Shampoos (wie z.B. Terzolin®) oder die Applikation von Elz-Surrex®-Paste.

Die Tinea cutis wird vorwiegend durch Fadenpilze (Trichophyten) hervorgerufen, die sich in feucht-warmem Milieu, insbesondere an Füßen (sog. Athletenfuß) oder im Inguinalbereich rasch entwickeln können. Es entstehen rötliche schuppende, unregelmäßig begrenzte Läsionen unterschiedlicher Größe mit häufig zentrifugalem Wachstum und zentraler Abblassung. Bei Befall der Zehenzwischenräume sind zusätzlich weißliche Mazerationen zu finden. Durch Juckreiz, Nässen, Rhagadenbildung und bakterielle Superinfektion kann es zu erheblichen Beschwerden kommen.

In der Therapie haben sich azol-haltige Lösungen oder Cremes bewährt; bei massiver Ausprägung ist auch eine systemische Behandlung mit Itraconazol (z.B. Sem-pera®) oder Terbinafin (z.B. Lamisil®) in Betracht zu ziehen.

Intertrigo

Intertrigo is a superficial inflammatory dermatitis that occurs in areas where the skin is in apposition (Fig. 3-40; see also Fig. 17-38). As a result of friction, heat, and moisture, the affected areas become intensely erythematous in a well-demarcated pattern, macerated, and often secondarily infected by bacteria or Candida, or in adolescents by dermatophytes (see Chapter 17). Intertrigo with secondary streptococcal infection often presents with oozing and can be associated with bacteremia.282,283 Treatment is directed toward elimination of the macerated skin. Open wet compresses, dusting powders (such as ZeaSORB), topical corticosteroid lotions, and when indicated, appropriate antibiotics or fungicidal agents may be used.

Intertrigo

Intertrigo is a superficial inflammatory dermatitis that occurs in areas where the skin is in apposition (Figs 3.37; Fig. 17. 32). As a result of friction, heat, and moisture, the affected areas become erythematous, macerated, and secondarily infected by bacteria or Candida, or in adolescents by dermatophytes (see Ch. 17). Treatment is directed toward elimination of the macerated skin. Open wet compresses, dusting powders (such as ZeaSorb), topical corticosteroid lotions, and when indicated, appropriate antibiotics or fungicidal agents may be used.

Skin Problems

Intertrigo, seborrheic eczema, and thrush are common in the thick heavy skinfolds of severely obese children. Pink or pale cutaneous striae, distinct from the purplish striae resulting from thinning of subcutaneous tissues in Cushing's syndrome, are common on the abdomen and upper limbs and may be a source of embarrassment. Hirsutes (abnormal facial and body hair) occurs particularly in adolescent girls with polycystic ovarian syndrome, which is associated with obesity and insulin resistance. Acanthosis nigricans, a velvety, pigmented, thickening of the skin usually at the back of the neck, is another important marker for insulin resistance, affecting up to 90% of children with type 2 diabetes mellitus.

Work-up

Intertrigo is a clinical diagnosis based on a physical examination and history. A skin biopsy may be done to exclude other potential conditions but is generally not indicated.

A full skin examination is recommended to identify the involved areas.

KOH can be used to confirm the presence of a superimposed infection. If pustules, crusting, abscesses, or vesicles are present, a culture from the affected areas should be done to identify the cause of secondary infection.

A Wood lamp test can also be used to rule out erythrasma. The latter would show a bright coral red fluorescence when the lamp is shone over the affected area.

A history of contactants, such as past creams, used to rule out a primary or secondary ACD is also recommended.