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Intertrigo


Presentation

Clinical history of intertrigo starts as an insidious onset of burning, itching and stinging sensation on the intertrigionus areas of the body. In temperate regions, intertrigo may be seasonal occurring in seasons with high humid heat like the summers. The physical appearance of the Intertrigo is highly dependent on the stage where it is brought to medical attention.

Early symptoms may only show erythematous skin folds which may progress to erosion and maceration with weeping. Pustules and vesicles may appear connoting secondary bacterial infection.

Fungal infections may cause chaffing, crusting and lichenification of the affected skin. Foot intertrigo may present with crusting or chafing lesions in between toes may be easily confused with Tinea pedis and eczematous dermatitis which are not responsive to anti-fungal therapy [5].

Lymphedema
  • Rich clinical experiences indicate that toe web intertrigo is a major predisposing condition for cellulitis/acute dermatolymphango adenitis (ADLA) and the number of lesions is the strongest predictor of frequency of ADLA in lymphedema (LE) patients.[ncbi.nlm.nih.gov]
  • Some skin modifications, such as chronic lymphedema, plantar hyperkeratosis and interdigital desquamation, may be associated with consequent impairment of the local immunosurveillance and increased risk of some bacterial or mycotic infections.[ncbi.nlm.nih.gov]
  • Obesity is associated with the incidence of stretch marks, acanthosis nigricans, lymphedema, cellulitis, hirsutism, and intertrigo .[diki.pl]
  • Risk Factors for Chronic Intertrigo of the Lymphedema Leg in Southern India: A Case-Control Study. Int J Low Extrem Wounds. 2015 Dec;14(4):377-83. doi: 10.1177/1534734615604289. Epub 2015 Sep 8. PubMed PMID: 26353823. PubMed .[dermnetnz.org]
Rigor
  • As this mould is potentially dangerous for immunodepressed subjects, early diagnosis and rigorous follow-up of skin diseases caused by this agent are advisable.[ncbi.nlm.nih.gov]
  • All things considered, this means that almost all of the 68 included studies lacked scientific rigor and all the results have to be considered with great caution. Applied Interventions No study addressed the prevention of intertrigo.[link.springer.com]
Recurrent Infection
  • Patients should be instructed about proper foot hygiene, which is important to prevent recurrent infections.[ncbi.nlm.nih.gov]
  • Infections Keeping the area affected by intertrigo dry and exposed to air can help prevent recurrences.[aafp.org]
Exanthema
  • "Systemic drug-related intertriginous and flexural exanthema (SDRIFE)". Dermatol Online J. vol. 15. 2009 15. pp. 3.[clinicaladvisor.com]
Plantar Hyperkeratosis
  • Some skin modifications, such as chronic lymphedema, plantar hyperkeratosis and interdigital desquamation, may be associated with consequent impairment of the local immunosurveillance and increased risk of some bacterial or mycotic infections.[ncbi.nlm.nih.gov]
Agalactia
  • The most common microrganisms among KS patients were T. mentagrophytes (16%), S. aureus (14.9%), P. aeruginosa (13.9%), S. marcescens (5,9%), while among non-KS patients were S. aureus (26,9%), C. albicans (22%), S. agalactiae (7.7%) and E. coli (9.9%[ncbi.nlm.nih.gov]
Urinary Incontinence
  • Generally, intertrigo is more common in people with a weakened immune system including children, the elderly, and immunocompromised people. [1] The condition is also more common in people who experience urinary incontinence and decreased ability to move[en.wikipedia.org]
Tingling
  • Analysis of local risk factors revealed that topical application of oil, tingling and numbness of the extremities were associated independently with chronic intertrigo.[ncbi.nlm.nih.gov]

Workup

The diagnosis of intertrigo is mainly based on clinical history and appearance of lesion as it is presented by the patients.

A Potassium Hydroxide smear may be performed by a dermatologist to demonstrate the fungal mycelia that may be propagating in the lesion.

Culture and sensitivity testing from the lesions may help clinician determine the best anti-bacterial and anti-fungal medications available for the patient.

Staphylococcus Aureus
  • Pseudomonas aeruginosa, Enterococcus facealis and Staphylococcus aureus were the most common pathogens. Autoeczematization was present in 50% of the 32 disease episodes.[ncbi.nlm.nih.gov]
  • aureus each in 11.9%; beta-hemolytic streptococcus in 2.4%; and Proteus mirabilis in 1.2%.[ncbi.nlm.nih.gov]
  • aureus and Streptococcus pyogenes Rapid development Moist blisters and crusts on red base Contagious, so other family members may also be affected Impetigo Boils : Staphylococcus aureus Rapid development Very painful follicular papules and nodules Central[dermnetnz.org]
  • 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.[explainmedicine.com]
Human Papillomavirus
  • Human papillomavirus (HPV) type 6 was identified by in situ DNA hybridization, in the submammary lesions. This is an unusual manifestation of both intertrigo and wart virus infection. HPV-6 is classically found in anogenital warts.[ncbi.nlm.nih.gov]
Gram-Positive Bacteria
  • Foot intertrigo, occurring in the interdigital space, is mostly caused initially by dermatophytes and yeasts and less frequently by gram-negative and gram-positive bacteria.[ncbi.nlm.nih.gov]

Treatment

Treatment of uncomplicated intertrigo may only need to modify environmental factors like the alteration of heat and humidity with an air conditioning unit. Areas that are involved may be treated with weak steroids like 1% hydrocortisone cream and a thick layer of drying ointments like zinc oxide.

Appropriate anti-fungals may be used for secondary mycoses like Miconazole and Clotrimazole. Patients with pruritic intertrigo in the inguinal folds with secondary Candida infection may respond rapidly with a topical combination of Isoconazole nitrate and Diflucortolone valerate [6].

The use of Honey barrier creams have also proven to be efficacious in relieving pruritus in intertrigo [7].

Infants may benefit from absorbent diapers and barrier pastes (Desitin) in preventing diaper rash in the gluteal folds of the buttocks.

Immunosuppressants like Tacrolimus and Pimecrolimus may be used to control inflammation in intertrigo with fewer long term side-effects [8].

Prognosis

Prognosis in intertrigo is usually good, for primary inflammation does not cause the morbidity and mortality. In lesions harboring the source of secondary bacterial and fungal infections, immunocompromised patients and the elderly may complicate in to full blown sepsis which could have a grim outlook. The change in the patient’s habits and other modifiable risk factors like obesity and proper hygiene can lead to the spontaneous resolution of the disease.

Complications

The most common complications of intertrigo is secondary infections. Fungal infection may result from the propagation of a resident fungal flora in an immunecompromised host like diabetics, rheumatoid arthritis and long term steroid users.

Bacterial infections may either be opportunistic or invading pyogenic bacteria which may cause pruritus, pustules or abscess. In interdigital intertrigo with onychomycoses, can lead to severe bacterial infection and may complicate to erysipelas, cellulitis, fasciitis and osteomyelitis [3].

In severe maceration of the skin surface, bleeding may ensue. Disydrosis or pompholyx is a chronic and recurrent dermatosis of the plantar foot which complicates from interdigital intertrigo with mycosis [4]. Strong topical agents used to treat bacterial infections may complicate to contact dermatitis if used injudiciously. The formation of streak lines in the skin or “Striae” can be a chronic complication of continuous topical steroid use for its treatment.

Etiology

The dermatitis in intertrigo is caused by simple friction, moisture and heat. Irritation in intertrigo may be initiated by allergic reaction to contact chemical agents, or intake of allergenic food or medicines.

Primary bacterial infection, dermatophytic fungal infection and yeasts may cause the initial irritation of the intertriginous areas.

Epidemiology

Internationally, intertrigo is very common in obese patients and diabetics especially in warm and humid climates. The common diaper rash in the groin and the buttocks in infants are in part caused by intertrigo.

Mortality or morbidity may not be directly caused by intertrigo but it is considered one of the primary source of bacterial infections. Older patients are more prone to intriginous inflammation because of prolonged immobilization, reduced immunity and incontinence issues.

Sex distribution
Age distribution

Pathophysiology

The main pathophysiology of intertrigo is the mechanical friction of the two skin causing skin erosion and maceration of the contacting surfaces. The opposing skin surfaces are aggravated by heat and moisture making it sore and painful.

The dent in the integrity of the skin will propagate the growth of secondary bacterial and fungal infection of the intertriginous areas. Secretions of urine, fecal fluid, vaginal fluids and sweat may propagate more inflammation in intertrigo.

Prevention

Intertrigo is easily preventable in most cases. Intertriginous areas may be greased with lubricating emollients like petroleum jelly and topical barriers like zinc oxide prior to strenuous activities to prevent friction of the skin.

The frequent bathing in warm and humid climate may wash off perspiration in the skin folds. Weight reduction is one of the most effective way to prevent intertrigo by eliminating the unnecessary skin folds and fat folds (panniculus) where the disease may propagate.

Summary

Intertrigo is an inflammatory condition of the skin where there is constant friction like the axilla, groins, perineum, breast creases and fat folds in obese people [1]. The word intertrigo originated from the Latin word “inter” meaning in between and “terere” to rub translates to the constant rubbing of skin which causes irritation and maceration [2].

Areas of the body that are in constant skin to skin contact are generally referred to as “intertriginous areas”, thus inflammation of these skin areas are sometimes referred to as Intertrigionus dermatitis. The inflammation is aggravated by friction, heat and high moisture where it may lead to a painful erythema, pruritus, and oozing sore. Intertrigo may easily harbor bacterial and fungal infection of the skin.

Patient Information

Physicians emphasize to patients the importance of weight reduction in the prevention of Intertrigo [9]. Intertrigo should be seen as a common complication of diabetics and obese people [10]. Frequent and consistent personal hygiene is also a good practice which may also groom a healthy well-being.

Extra effort on the daily care of the skin folds and creases may reduce the emergence of Intertrigo and its secondary infections. Patients on prescribed medications should do regular monitoring of the lesion and should openly communicate to their physicians any changes they may notice on the progression of the lesion.

References

Article

  1. Weston WL, Lane AT, Weston JA. Diaper dermatitis: current concepts. Pediatrics. Oct 1980; 66(4):532-6.
  2. Wolf R, Oumeish OY, Parish LC. Intertriginous eruption.Clin Dermatol. 2011; 29(2):173-9 (ISSN: 1879-1131)
  3. Vanhooteghem O, Szepetiuk G, Paurobally D, Heureux F. Chronic interdigital dermatophytic infection: a common lesion associated with potentially severe consequences. Diabetes Res Clin Pract. 2011; 91(1):23-5 (ISSN: 1872-8227)
  4. Pitché P, Boukari M, Tchangai-Walla K. Factors associated with palmoplantar or plantar pompholyx: a case-control study. Ann Dermatol Venereol. 2006; 133(2):139-43 (ISSN: 0151-9638)
  5. Lin JY, Shih YL, Ho HC. Foot bacterial intertrigo mimicking interdigital tinea pedis.
  6. Chang Gung Med J. 2011; 34(1):44-9 (ISSN: 2309-835X), Veraldi S. Rapid relief of intertrigo-associated pruritus due to Candida albicans with isoconazole nitrate and diflucortolone valerate combination therapy. Mycoses. 2013; 56 Suppl 1:41-3 (ISSN: 1439-0507)
  7. Nijhuis WA, Houwing RH, Van der Zwet WC, Jansman FG. A randomised trial of honey barrier cream versus zinc oxide ointment. Br J Nurs. 2012; 21(20):9-10, 12-3 (ISSN: 0966-0461)
  8. Martin Ezquerra G, Sanchez Regana M, Herrera Acosta E, Umbert Millet P. Topical tacrolimus for the treatment of psoriasis on the face, genitalia, intertriginous areas and corporal plaques. J Drugs Dermatol. Apr 2006;5(4):334-6.
  9. American Academy of Family Physicians. Information from your family doctor. Intertrigo: what you should know. Am Fam Physician. Sep 1 2005;72 (5):840.
  10. Hahler B. An overview of dermatological conditions commonly associated with the obese patient. Ostomy Wound Manage. Jun 2006;52(6):34-6, 38, 40 passim.

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Last updated: 2017-08-09 17:56