Intertrigo and Secondary Skin Infections

April 1, 2014
◆
Volume 89, Number 7 www.aafp.org/afp American Family Physician 569
Intertrigo and Secondary Skin Infections
MONICA G. KALRA, DO, Methodist Health System of Dallas, Dallas, Texas
KIM E. HIGGINS, DO, Physician Senior Services, Dallas, Texas
BRUCE S. KINNEY, DO, Methodist Health System of Dallas, Dallas, Texas
I
ntertrigo is caused by cutaneous inflam-
mation of opposing skin surfaces. It
is more common in hot and humid
environments and during the sum-
mer. Skin folds, including inframammary
(Figure 1), intergluteal, axillary, and inter-
digital (Figure 2) areas, may be involved.
1

Intertrigo is more common in young and
older persons secondary to a weakened
immune system, incontinence, and immo-
bility, although it can occur at any age.
2-4

Etiology and Predisposing Factors
Intertrigo most often occurs in patients with
obesity (body mass index more than 30 kg
per m
2
), diabetes mellitus, or human immu-
nodeficiency virus infection, and in those
who are bedridden. It also occurs in patients
with large skin folds and those who wear
diapers or other items that trap moisture
against the skin. There is a linear increase
in the severity of obesity and the presence
of intertrigo.
5
Patients who are obese sweat
more profusely because of their thick layers
of subcutaneous brown fat, generating more
heat than persons with normal body mass.
6

This increases thermal, frictional, and mois-
ture components of the skin.
5
As the stratum corneum becomes macer-
ated because of hyperhydration, the friction
intensifies and further weakens and dam-
ages the epidermal tissue. The condition can
progress to severe inflammation and skin
breakdown. This erosion of the epidermal
barrier may create an entry point for micro-
organisms that cause secondary infections.
7
Clinical Manifestations
Intertrigo is often a chronic disorder that
begins insidiously with the onset of pruritus,
stinging, and a burning sensation in skin folds.
Physical examination of the skin folds usually
reveals regions of erythema with peripheral
scaling. Intertrigo associated with a fungal
superinfection may produce satellite papules
and pustules. Candidal intertrigo (Figure 3)
is often associated with a foul-smelling odor.
In the presence of a bacterial superinfection,
plaques and abscesses may form.
8
Intertrigo is a superficial inflammatory dermatitis occurring on two closely opposed skin surfaces as a result of mois-
ture, friction, and lack of ventilation. Bodily secretions, including perspiration, urine, and feces, often exacerbate
skin inflammation. Physical examination of skin folds reveals regions of erythema with peripheral scaling. Excessive
friction and inflammation can cause skin breakdown and create an entry point for secondary fungal and bacterial
infections, such as Candida, group A beta-hemolytic streptococcus, and Corynebacterium minutissimum. Candidal
intertrigo is commonly diagnosed clinically, based on the characteristic appearance of satellite lesions. Diagnosis
may be confirmed using a potassium hydroxide preparation. Resistant cases require oral fluconazole therapy. Bacte-
rial superinfections may be identified with bacterial culture or Wood lamp examination. Fungal lesions are treated
with topical nystatin, clotrimazole, ketoconazole, oxiconazole, or econazole. Secondary streptococcal infections are
treated with topical mupirocin or oral penicillin. Corynebacterium infections are treated with oral erythromycin.
(Am Fam Physician. 2014;89(7):569-573. Copyright © 2014 American Academy of Family Physicians.)
CME
This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See
CME Quiz Questions on
page 515.
Author disclosure: No rel-
evant financial affiliations.
▲
Patient informa-
tion: A handout on
this topic is available at
http://familydoctor.org/
familydoctor/en/diseases-
conditions/intertrigo.html.
Figure 1. Inframammary intertrigo appearing
as skin discoloration with no evidence of fun-
gal or bacterial superinfection.
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Intertrigo
570 American Family Physician www.aafp.org/afp Volume 89, Number 7
◆
April 1, 2014
Interdigital intertrigo (Figure 2) may be mild and
asymptomatic, but also may lead to intense erythema
and desquamation. The affected skin may have a foul
odor and may be macerated and ulcerated with copi-
ous or purulent discharge. Patients with interdigital
intertrigo and comorbidities such as obesity or diabetes
are at greater risk of cellulitis.
3
Interdigital intertrigo
can progress to a severe bacterial infection with pain,
mobility problems, erysipelas, cellulitis, abscess forma-
tion, fasciitis, and osteomyelitis causing pain so severe
that the patient is unable to ambulate.
3
Web space
infections are typically caused by gram-positive cocci
such as Staphylococcus and Streptococcus and may cause
ulceration, fever, and chills.
9
Foot care
and patient education are key in prevent-
ing interdigital infections in patients with
diabetes.
10
Diagnosis
Intertrigo may be difficult to distinguish
from other skin disorders, but the patient his-
tory will help in the diagnosis (Table 1).
8
The
history should include previous treatments,
especially topical steroids and antibacterial
soaps or ointments. Some steroids may cause
atrophy and maceration, and some soaps and
ointments may exacerbate skin inflamma-
tion. A visual inspection of the skin will help
identify lesions in other areas.
8
The diagnosis of secondary fungal infec-
tions is commonly made clinically, based
on the characteristic appearance and
distribution of satellite papules and pus-
tules.
11
The diagnosis may, however, be confirmed
with a potassium hydroxide preparation positive for
pseudohyphae and spores. Additionally, a potassium
hydroxide preparation, Wood lamp examination,
or culture of skin scrapings can diagnose conditions
such as Candida or dermatophyte infections. The
presence of hyphae on potassium hydroxide exami-
nation confirms dermatophytic lesions, including
tinea versicolor and tinea corporis, and the pres-
ence of pseudohyphae confirms Candida infection.
A video showing a potassium hydroxide examina-
tion of a fungal infection is available at http://www.
youtube.com/watch?v=ugeMsyEDJaw. The Wood
Figure 3. Candidal intertrigo in the inguinal fold.
Figure 2. Severe interdigital intertrigo with erythema
suggestive of cellulitis.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence
rating References
Intertrigo associated with Candida should be
managed with topical antifungals applied
twice daily until the rash resolves.
C 14
Fluconazole (Diflucan), 100 to 200 mg daily for
seven days, is used for intertrigo complicated
by a resistant fungal infection. Patients who
are obese may require an increased dosage.
C 14
Skin barrier protectants, such as zinc oxide
ointment and petrolatum, as part of a
structured skin care routine that also includes
gentle cleansing and moisturizing may reduce
recurrent intertrigo infections.
C 20, 21
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-
quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
practice, expert opinion, or case series. For information about the SORT evidence
rating system, go to http://www.aafp.org/afpsort.
Intertrigo
April 1, 2014
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Volume 89, Number 7 www.aafp.org/afp American Family Physician 571
lamp examination fluoresces green with
Pseudomonas infection and coral-red
with erythrasma (Figure 4), a bacterial
infection caused by Corynebacterium
minutissimum.
3
Treatment
Table 2 summarizes treatment options for
intertrigo.
3,11-18
BARRIER AGENTS
In uncomplicated intertrigo, numerous
agents and mechanisms can be used to keep
the skin folds dry, clean, and cool. Applying
barrier protectants reduces skin breakdown
and alleviates pruritus and pain. Skin pro-
tectants include zinc oxide ointment and
petrolatum.
12
Separating skin surfaces with
absorbent products, such as gauze, cotton,
and products with water vapor–permeable
sheets, may also help reduce friction.
DRYING AGENTS
Aluminum sulfate, calcium acetate solution,
and antiseptic drying agents (e.g., talcum
powder) may be used.
11,13
Powder drying
agents should not be applied at the same
time as antifungal creams or ointments
because this will create a tacky paste. If both
are used, they should be applied two to three
hours apart. If symptoms do not improve
after treatment, potassium hydroxide prepa-
ration, and bacterial culture and sensitivity
testing should be performed.
SECONDARY FUNGAL INFECTIONS
Intertrigo complicated by fungal infection
should be managed with topical antifun-
gals. Nystatin is effective only for candidal
intertrigo. Clotrimazole, ketoconazole, oxi-
conazole (Oxistat), or econazole may be
used for both Candida and dermatophyte
infections. Topical treatments are applied
twice daily until the rash resolves. Flucon-
azole (Diflucan), 100 to 200 mg daily for seven days, is
used for resistant fungal infections, although patients
who are obese may require an increased dosage. Oral
azoles may potentiate the effects of hypoglycemic agents,
leading to low blood glucose levels, and patients with
diabetes should be instructed to monitor their blood glu-
cose levels with concomitant use of these medications.
14
SECONDARY BACTERIAL INFECTIONS
The moist, damaged skin associated with intertrigo
provides an opportunistic environment for bacte-
rial microorganisms; therefore, secondary cutaneous
infections are common. Staphylococcus aureus infection
may occur independently or with group A beta-hemo-
lytic streptococcal infection.
15
Pseudomonas aeruginosa,
Table 1. Differential Diagnosis of Cutaneous Diseases
Resembling Intertrigo
Disease Characteristics
Infectious diseases
Candidiasis
(moniliasis)
Superficial erythematous infection, commonly affecting
moist, cutaneous areas of the skin; satellite pustules
Dermatophytosis
(tinea
corporis, tinea
versicolor)
Pruritic infections of nonviable keratinized tissues, such as
nails and hair; contains a leading scale
Erythrasma Small, red-brown macules that may coalesce into larger
patches with sharp borders; may be asymptomatic or
pruritic; fluoresces coral-red on Wood lamp examination
Pyoderma Aggressive infection with boggy, blue-red bullae that
progress to deep ulcers with hemorrhagic bases
Scabies Infection with intense pruritus and minimal cutaneous
manifestations, including intertriginous burrows and
papules; the head is spared in all age groups except
infants
Seborrheic
dermatitis
Yellow, greasy, scaly plaques with overlying erythema;
most often affects the face, postauricular region, and
chest
Noninfectious inflammatory diseases
Atopic dermatitis Red or brownish patches with intense pruritus; personal
and/or family history of seasonal allergies and asthma is
common
Pemphigus
vulgaris
Serious, often fatal, autoimmune disease; flaccid bullae,
Nikolsky sign (i.e., disruption of the epidermal layer with
lateral pressure, leading to ulceration)
Psoriasis Chronic scaling papules and plaques; often affects
extensor surfaces of the elbows and knees; associated
with silvery scale
Noninflammatory diseases
Acanthosis
nigricans
Hyperpigmentation with velvety, thickened skin,
predominantly on posterior neck and body folds
Hidradenitis
suppurativa
Chronic condition of apocrine gland–bearing skin in the
axillae or anogenital region; deep abscesses and old scars
Intertrigo Pruritic regions of erythema and peripheral scaling
between skin folds
Lichen sclerosus Well-demarcated, hypopigmented, atrophic plaques on
the genitalia, trunk, and axillae
Neoplasms
Bowen disease Solitary, enlarging, erythematous, well-defined plaque
Paget disease Erythematous plaques with scaling, crusting, and/or
exudation; affects the breast, axillae, or anogenital
region; may represent a neoplastic process
Superficial basal
cell carcinoma
Most common skin cancer; pink or flesh-colored papule
often containing a telangiectatic vessel
Information from reference 8.
Intertrigo
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April 1, 2014
Proteus mirabilis, or Proteus vulgaris also may be present
independently or simultaneously.
The optimal treatment for patients with intertrigo
and group A beta-hemolytic streptococcal infections
includes single or multiple regimens of topical therapies
(e.g., mupirocin [Bactroban], erythromycin); oral anti-
biotics (e.g., penicillin, first-generation cephalosporins);
and low-potency topical steroids (e.g., hydrocortisone
1% cream).
3,15
Low-potency topical steroids can also be
useful to treat intertrigo associated with seborrheic or
atopic dermatitis.
16
Cutaneous erythrasma is best managed
with erythromycin (topical, applied twice
daily until rash resolves, or oral, 250 mg four
times daily for two weeks).
3,17,18
Oral eryth-
romycin is more effective than a topical regi-
men, but it can cause adverse reactions, such
as nausea, vomiting, abdominal pain, and
diarrhea.
3,17,18
Topical clindamycin, Whit-
field ointment, and antibiotic soaps may also
be beneficial.
17
Preventing Recurrent Infections
Keeping the area affected by intertrigo dry
and exposed to air can help prevent recur-
rences. Weight loss should be encouraged
if obesity is a predisposing factor. Some
patients with large, pendulous breasts may
benefit from reduction mammoplasty.
19
Skin maceration and irritation from
incontinence can be minimized or pre-
vented by avoiding or reducing skin expo-
sure to stool or urine. A structured skin care
routine based on gentle cleansing, moistur-
izing (preferably with an emollient), and
application of a skin barrier protectant may
help.
20,21
A B
Figure 4. (A) Erythrasma in the inguinal fold appearing as coalesced red-brown macules. (B) Erythrasma lesions fluo-
resce coral-red on Wood lamp examination.
Table 2. Treatment Options for Inflammatory and
Infectious Intertrigo
Condition Treatments
Intertrigo Topical: zinc oxide ointment, petrolatum, talcum
powder, aluminum sulfate, calcium acetate solution
Intertrigo complicated
by secondary
bacterial infections

Erythrasma Topical: erythromycin, clindamycin, Whitfield
ointment, chlorhexidine
Oral: erythromycin
Group A beta-
hemolytic
streptococcus
Topical: mupirocin (Bactroban), erythromycin, low-
potency steroids
Oral: penicillin, cephalexin (Keflex), ceftriaxone
(Rocephin), cefazolin, clindamycin
Intertrigo complicated
by secondary fungal
infections

Candida Topical: nystatin, clotrimazole, ketoconazole,
oxiconazole (Oxistat), econazole
Oral: fluconazole (Diflucan; used for resistant cases)
Dermatophytes Topical: clotrimazole, ketoconazole, oxiconazole,
econazole
Information from references 3, and 11 through 18.
Intertrigo
April 1, 2014
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Volume 89, Number 7 www.aafp.org/afp American Family Physician 573
Data Sources: In conducting our literature search, we used Cochrane,
UpToDate, PubMed, and Google Scholar. We used the keywords inter-
trigo, fungal infections, and secondary skin infections. Search dates: July
2012 and January 2014.
The authors thank Brenda Iyamu, MD; Eric South, DO; and Mark Hand,
DO, for their contribution to this article.
The Authors
MONICA G. KALRA, DO, is research director of the family medicine resi-
dency at Methodist Health System of Dallas (Tex.). She is also an assistant
professor at the Texas College of Osteopathic Medicine in Fort Worth and
a clinical adjunct professor at the University of Texas Southwestern Medi-
cal School in Dallas.
KIM E. HIGGINS, DO, is medical director and owner of Physician Senior
Services in Dallas. She is also medical director of Envoy Hospice in Fort
Worth, Tex.
BRUCE S. KINNEY, DO, is chief resident for the family medicine residency
at Methodist Health System of Dallas.
Address correspondence to Monica G. Kalra, DO, Methodist Health
System of Dallas, 3500 W. Wheatland, Dallas, TX 75237 (e-mail:
[email protected]). Reprints are not available from the authors.
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