Intertrigo

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].

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.

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 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.

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.

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.

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.

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.

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.

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.

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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)
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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)
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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.