Background

• Intertrigo is a common skin condition characterized by inflammation of the skin folds, most often occurring in areas where two skin surfaces rub or chafe against each other. This friction creates a warm, moist environment that promotes the growth of bacteria, fungi, or yeast, leading to irritation and inflammation. The condition predominantly affects the axillae (armpits), groin, under the breasts, and further areas with skin folds. Intertrigo typically presents as red, raw, and irritated skin, often accompanied by itching, burning, and sometimes pain.
• Several factors contribute to the development of intertrigo. Excessive sweating, poor air circulation in skin folds, and obesity can exacerbate the condition, creating a favorable environment for the proliferation of microorganisms. Other predisposing factors include diabetes, immunosuppression, and preexisting skin conditions such as eczema or psoriasis. Treatment for intertrigo usually involves keeping the affected areas clean and dry, using topical antifungal or antibacterial agents, and addressing underlying conditions if present. Preventive measures like weight management, proper hygiene, and wearing breathable clothing can help reduce the risk of intertrigo and its recurrence.

Epidemiology

• Intertrigo is a superficial inflammatory skin condition that primarily affects the flexural surfaces of the skin. Heat, moisture, friction, maceration, and poor ventilation in body folds causes it. These conditions create an environment conducive to the development of intertrigo. Erythematous patches of varying intensity characterize the condition and can often become secondarily infected, particularly with Candida, although other viral or bacterial factors can also contribute to its development.
• The prevalence of intertrigo has been studied in various settings. A multicenter study conducted in the Netherlands between 2013 and 2016 aimed to measure the prevalence of intertrigo in hospitals, care homes, and home care settings. The study involved skin examinations by trained nurse raters for subjects aged 18 and older. The research focused on identifying demographic and health characteristics associated with intertrigo.
• It has been observed that intertrigo is more common in obese individuals residing in humid climates due to increased friction and moisture in body folds.

Anatomy

Pathophysiology

The pathophysiology of intertrigo involves a combination of factors that contribute to the development of this skin condition. Intertrigo is primarily caused by the interaction of moisture, friction, and microorganisms in the skin folds, leading to inflammation and irritation.

• Moisture: One of the fundamental factors in the pathophysiology of intertrigo is excessive moisture in skin folds. These areas are prone to trapping sweat, urine, or other bodily fluids, creating a warm and damp environment.
• Friction: Skin-to-skin friction or skin-to-clothing friction in body folds can exacerbate the irritation caused by moisture. The constant rubbing of skin surfaces against each other or clothing can further damage the skin’s protective outer layer, promoting inflammation and increasing the risk of microorganisms entering the compromised skin.
• Microbial colonization: A warm and moist environment of skin folds provides an ideal breeding ground for microorganisms such as bacteria, fungi, and yeast. These microorganisms can readily colonize the area once the skin barrier is disrupted due to moisture and friction. Bacterial growth, particularly by Staphylococcus and Streptococcus species, and fungal overgrowth, especially Candida species, are commonly observed in intertrigo.
• Inflammation: As a response to irritants and invading microorganisms, the body’s immune system activates an inflammatory response in the affected skin folds. This immune reaction leads to redness, swelling, and discomfort experienced in intertrigo.
• Predisposing factors: Certain factors can increase the likelihood of developing intertrigo. Obesity plays a role by creating more skin folds and trapping more moisture. Other underlying conditions, such as diabetes or immunosuppression, can increase susceptibility to infections and skin irritation.

Etiology

The etiology of intertrigo involves multiple factors contributing to developing this skin condition.

Intrinsic factors:

• Skin folds and anatomy: Intertrigo typically occurs in areas where skin folds over on itself, creating warm, moist environments. Common sites include the axillae (armpits), groin, under the breasts, and abdominal folds. The skin-to-skin contact within these folds increases friction and maceration, making them more susceptible to irritation.
• Obesity: Excess body weight can lead to more pronounced skin folds, providing additional areas for moisture and friction to accumulate. Obese individuals risk developing intertrigo due to increased skin-to-skin contact and limited air circulation in these folds.

Extrinsic factors:

• Moisture and humidity: Prolonged exposure to moisture from sweat, urine, or other bodily fluids is a significant trigger for intertrigo. The moist environment facilitates the growth of microorganisms and weakens the skin’s protective barrier.
• Friction and rubbing: Friction between skin surfaces or skin and clothing can exacerbate the irritation and inflammation in skin folds. This friction damages the skin’s outer layer and contributes to the formation of intertrigo.
• Microbial colonization: Bacteria, fungi, and yeast can readily colonize skin folds’ warm and moist environment.

Predisposing conditions:

• Diabetes: People with diabetes may have elevated glucose levels in bodily fluids, which can provide a nutrient-rich environment for microbial growth in skin folds.
• Immunosuppression: Individuals with weakened immune systems, whether due to underlying medical conditions or medications, are more susceptible to infections, including intertrigo-associated infections.
• Skin conditions: Preexisting skin conditions like eczema, psoriasis, or atopic dermatitis can compromise the skin’s integrity, making it more susceptible to irritation and microbial invasion.
  Environmental factors:
• Heat and humidity: Hot and humid climates can exacerbate intertrigo, promoting sweating and moisture accumulation in skin folds.
• Poor ventilation: Wearing tight, occlusive clothing or living in environments with inadequate airflow can contribute to moisture buildup in skin folds.

Genetics

Prognostic Factors

The prognosis of intertrigo, which refers to the likely course and outcome of the condition, depends on various factors that can influence its severity, recurrence, and response to treatment.

• Hygiene and self-care: Maintaining good hygiene and practicing proper self-care can significantly impact the prognosis of intertrigo. Keeping the affected areas clean and dry helps prevent the accumulation of moisture and reduces the risk of microbial colonization and infection.
• Body weight and obesity: Obesity is a significant risk factor for intertrigo due to increased skin folds and the potential for more significant moisture and friction.
• Underlying medical conditions: Certain medical conditions, like diabetes and immunosuppression, can affect the prognosis of intertrigo. Properly managing these underlying conditions is crucial to prevent complications and improve healing.
• Severity of inflammation and infection: The extent of inflammation and the presence of secondary bacterial or fungal infections can influence the prognosis. Mild cases of intertrigo may resolve quickly with appropriate self-care, while severe or infected cases may require medical intervention and a more extended recovery period.
• Recurrent episodes: Individuals who experience recurrent episodes of intertrigo may require ongoing management and preventive measures to minimize the frequency and severity of flare-ups.
• Skin conditions and sensitivities: Preexisting skin conditions like eczema or psoriasis can complicate the prognosis of intertrigo, as they may exacerbate inflammation and delay healing. Identifying and managing these underlying skin conditions are essential for better outcomes.
• Patient compliance and education: Educating the patient about intertrigo, its causes, and preventive measures can lead to better outcomes.

Clinical History

Age group:

Intertrigo can occur at any age, but certain age groups may be more susceptible due to specific factors.

• Infants: In babies, intertrigo commonly appears in the diaper area (diaper rash) due to prolonged exposure to moisture from urine and feces, skin-to-skin contact, and friction.
• Children and adolescents: Children who are overweight or participate in activities that cause increased sweating or friction (such as sports) may be at higher risk of developing intertrigo in skin folds.
• Adults: Intertrigo is more prevalent in adults, particularly in those who are obese or have certain medical conditions that promote sweating and moisture retention.

Physical Examination

During a physical examination of intertrigo, a healthcare professional will assess the affected areas to identify the characteristic signs and symptoms of this skin condition.

Visual Inspection:

The healthcare provider will inspect the skin folds and areas prone to intertrigo.

Redness: Intertrigo typically presents as red, inflamed skin in the affected areas due to irritation and inflammation.

Moisture and Maceration: Moisture, especially in skin folds, is a common feature of intertrigo. The skin may appear wet or macerated due to prolonged exposure to sweat or other bodily fluids.

Rash: The affected skin may have a rash-like appearance characterized by diffuse redness or smaller red patches.

Erosions or Cracks: In more severe cases, intertrigo can lead to erosions or cracks in the skin folds, causing pain and discomfort.

Satellite Lesions: Secondary satellite lesions or smaller patches of inflammation may be observed around the main affected area, indicating possible secondary infection.

Palpation:

The healthcare provider may gently palpate (feel) the affected areas to assess for tenderness, warmth, and signs of secondary infection.

Patient History: The healthcare professional will also take a detailed patient history to understand relevant factors such as medical conditions, medications, recent changes in activity levels, hygiene practices, and any previous episodes of intertrigo.

Rule Out Secondary Infections: In some cases, secondary bacterial or fungal infections may complicate intertrigo. The healthcare professional will check for signs of infection, such as pustules, increased warmth, tenderness, or discharge. If suspected, they may consider taking swabs for culture to identify the specific microorganisms causing the infection.

Age group

Associated comorbidity

Associated activity

Certain medical conditions and activities can increase the risk of intertrigo or exacerbate its presentation. Some examples include:

• Obesity: Excess body weight creates more prominent skin folds, providing an environment conducive to intertrigo development.
• Diabetes: People with diabetes may have elevated glucose levels in bodily fluids, which can promote microbial growth and skin irritation in intertrigo-prone areas.
• Immunosuppression: Weakened immune systems may lead to a higher risk of infection in intertrigo-affected skin folds.
• Sports or physical activities: Engaging in sports or activities that cause increased sweating and friction can aggravate intertrigo, especially in body areas exposed to repeated rubbing.

Acuity of presentation

The acuity of intertrigo refers to how quickly the symptoms appear and how severe they are at the time of presentation. The clinical presentation can range from acute to chronic:

Acute: Acute intertrigo may develop rapidly and be associated with intense redness, swelling, pain, and tenderness in the affected skin folds. This can be triggered by excessive sweating, friction, or exposure to moisture.

Chronic: Chronic intertrigo refers to cases that persist or recur over an extended period. In chronic cases, the affected skin may become thickened, discolored, or have areas of fissuring due to long-term irritation and inflammation.

Differential Diagnoses

The clinical presentation of intertrigo can share similarities with other skin conditions, making it essential to consider various differential diagnoses during the evaluation.

• Candidiasis (Yeast Infection): Candidiasis is a fungal infection caused by Candida species, often presenting as red, moist, and itchy patches with satellite lesions. It can be mistaken for intertrigo due to its similar appearance in skin folds. Still, the presence of satellite lesions and a positive response to antifungal treatment can help differentiate it from intertrigo.
• Psoriasis: It is a skin condition which is characterized by red, scaly plaques that can occur in skin folds, including intertriginous areas. Unlike intertrigo, psoriasis typically has well-defined borders and thick, silvery scales.
• Contact Dermatitis: It occurs when the skin reacts to irritants or allergens. It can cause red, itchy, and inflamed skin, similar to intertrigo. However, contact dermatitis often has a clear cause related to exposure to a particular substance.
• Inverse Psoriasis: Inverse psoriasis is a subtype of psoriasis that specifically affects skin folds, including areas commonly affected by intertrigo. It can be challenging to distinguish from intertrigo based solely on appearance, and a biopsy may be required for a definitive diagnosis.
• Seborrheic Dermatitis: Seborrheic dermatitis can resemble intertrigo, especially in areas with skin folds, presenting as red, scaly, and inflamed patches.
• Erythrasma: Erythrasma is a bacterial skin infection caused by Corynebacterium minutissimum, resulting in reddish-brown, scaly patches in skin folds. It can be mistaken for intertrigo, but specific diagnostic tests, like Wood’s lamp examination, can help differentiate the two conditions.
• Tinea Corporis (Ringworm): Tinea corporis is a fungal infection that can occur on various body parts, including skin folds. It presents red, ring-like patches with a scaly border and can be mistaken for intertrigo. A skin scraping or culture can aid in the diagnosis.
• Hailey-Hailey Disease (Familial Benign Chronic Pemphigus): Hailey-Hailey disease is a rare genetic skin disorder that may initially resemble intertrigo, but it tends to have a more chronic and recurrent course, along with other distinguishing features like vesicles or bullae.
• Nummular Eczema: Nummular eczema can cause circular or coin-shaped plaques of red, inflamed skin that may resemble intertrigo. However, nummular eczema is not confined to skin folds and may have well-defined borders.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment paradigm of intertrigo involves a combination of self-care measures, lifestyle modifications, and medical interventions. The primary goal is to reduce moisture, friction, and microbial growth in skin folds while alleviating inflammation and promoting healing. The specific treatment approach may vary based on the severity of the condition and individual patient factors.

Self-Care and Hygiene:

• Keep the affected areas clean and dry. Gently wash the skin folds with mild soap and water, ensuring to dry them afterward thoroughly.
• Pat the skin folds dry instead of rubbing to avoid further irritation. Use absorbent powders or cornstarch in skin folds to help keep them dry. Wear loose-fitting, breathable clothing to reduce friction and promote air circulation.

Topical Agents:

• Over-the-counter (OTC) or prescription-strength barrier creams or ointments can protect the skin and help prevent further irritation.
• Topical corticosteroids may be prescribed to reduce inflammation and itching in more severe cases. Antifungal creams or powders may be used if a fungal infection is suspected or identified.

Management of Secondary Infections:

• If there is evidence of bacterial or fungal infection, topical or oral antimicrobial agents may be prescribed to treat the infection.
• Lifestyle Modifications:
• Weight management is crucial for individuals who are overweight or obese to reduce the number and size of skin folds, which can help prevent intertrigo development or recurrence.
• If certain physical activities increase sweating and friction, consider taking preventive measures like wearing moisture-wicking clothing and taking breaks to dry the affected areas.

Preventive Measures:

After resolving intertrigo, continue practicing good hygiene and preventive measures to reduce the risk of recurrence.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-the-non-pharmacological-therapy-for-modifying-the-environment

• Infectious Disease Specialists

Modifying the environment of intertrigo is a crucial aspect of managing and preventing this skin condition.

• Keep the Skin Folds Clean and Dry: Proper hygiene is essential in managing intertrigo. Regularly wash the affected skin folds with mild soap and water, thoroughly patting them dry instead of rubbing them to avoid further irritation. After washing, use absorbent powders or cornstarch in the folds to help keep them dry and prevent moisture buildup. Opt for cool showers instead of hot ones when feasible, as excessive heat can exacerbate sweating and moisture retention. After any activities that cause sweating, such as exercise or outdoor work, promptly change into dry clothing. Additionally, it’s essential to choose breathable, loose-fitting clothing made from natural fibers that allow for better air circulation, reducing the potential for friction and promoting a drier environment in the affected areas.
• Maintain a Comfortable and Ventilated Environment: Creating an environment that minimizes factors contributing to intertrigo is vital. Ensure that living and sleeping areas are adequately ventilated to promote air circulation and reduce humidity. Consider using fans or air conditioning during warmer months to keep indoor environments cool and dry. Avoid sitting or lying in positions that cause skin folds to press against each other, and try to maintain good posture to prevent unnecessary friction. For individuals engaged in physical activities that lead to sweating, take regular breaks to towel off and dry the skin folds. During prolonged sitting or immobility, such as during long flights or bedridden states, reposition the body occasionally to reduce pressure and moisture in skin folds.

Use of topical azole antifungal in treating Intertrigo

• Infectious Disease Specialists

Topical azole antifungal creams are commonly used to treat fungal infections, including those associated with intertrigo.

Azole antifungal creams work by inhibiting the growth and spread of fungi, such as Candida and dermatophytes. They are available over-the-counter and by prescription, depending on the strength and specific medication. Common azole antifungal creams include clotrimazole, miconazole, ketoconazole, and econazole.

When using a topical azole antifungal cream for treating intertrigo, follow these general guidelines:

• Clean and dry near the affected area: Before applying the cream, gently clean the affected skin with soap and water, then pat it dry with a clean towel.
• Apply a thin layer of the cream: Take a small amount of the antifungal cream and gently apply it to the affected area, making sure to cover the entire affected skin.
• Continue treatment as directed: Even if the symptoms improve, it is crucial to complete the full course of treatment as prescribed. This ensures that the infection is fully eradicated and helps prevent recurrence.
• Preventative measures: To prevent intertrigo from recurring, try to keep the affected areas clean, dry, and well-ventilated. Avoid tight-fitting clothing and consider using absorbent powders to reduce moisture.

Use of Oral antifungal therapy in treating Intertrigo

• Infectious Disease Specialists

Oral antifungal therapy can be an effective treatment option for intertrigo, a common skin condition caused by the inflammation of skin folds. Intertrigo often occurs in areas where skin rubs against skin, creating a warm, moist environment that is conducive to fungal growth.

Oral antifungal medications are systemic treatments that work throughout the body to combat fungal infections, including those affecting the skin. They can be beneficial in cases of severe or widespread intertrigo or when topical treatments alone are not sufficient.

• Fluconazole: This is a commonly prescribed antifungal medication that is generally well-tolerated and effective against Candida species.
• Itraconazole: Another antifungal medication that can be used for treating intertrigo, especially if fluconazole is not effective or not well-tolerated.
• Ketoconazole: Although less commonly used due to the availability of newer agents, ketoconazole can still be considered in some cases.

Use of topical corticosteroid therapy in treating Intertrigo

• Infectious Disease Specialists

Hydrocortisone is a topical corticosteroid commonly used in treating various skin conditions, including intertrigo. Intertrigo is a type of inflammatory skin rash that occurs in areas where the skin folds and rubs against itself, such as the armpits, groin, and between the toes.

Hydrocortisone works by reducing inflammation, itching, and redness in the affected area. It does so by suppressing the immune response and decreasing the production of inflammatory substances in the skin.

use-of-intervention-with-a-procedure-in-treating-intertrigo

• Infectious Disease Specialists

In severe or chronic intertrigo cases that do not respond to conservative management, a medical intervention called “Intertrigo Surgery” or “Intertrigo Excision” may be considered. This procedure aims to remove the affected skin folds to eliminate the source of friction and irritation, allowing the area to heal and preventing recurrence. It is typically performed by a dermatologist or a surgeon with expertise in skin surgery.

• Preparation: Before the procedure, the healthcare provider will thoroughly evaluate the intertrigo-affected area. They will review the patient’s medical history, assess the severity and extent of the intertrigo, and discuss the risks and also benefits of the surgery. The patient may be asked to stop certain medications that could interfere with healing or increase the risk of bleeding.
• Anesthesia: Local anesthesia is generally administered to numb the treated area. This ensures the patient does not experience pain or discomfort during the procedure.
• Excision: The surgeon carefully excises the affected skin folds once the area is numb. The excision may involve removing the entire fold or just a portion, depending on the extent of the intertrigo. The surgeon aims to create smooth wound edges to facilitate proper healing.
• Closure: After the excision, the wound is closed using sutures or stitches to bring the edges together. Sometimes, the secondary intention may leave the wound open to heal naturally.
• Dressing and Aftercare: The surgeon will apply a sterile dressing to the wound to protect it during the initial healing period. Patients will receive instructions on wound care, including how to keep the area clean, dry, and free from infection.
• Recovery and Follow-Up: The recovery time can vary depending on the extent of the excision and the patient’s overall health. Following the postoperative instructions and attending follow-up appointments as the healthcare provider advises is essential.

se-of-phases-in-managing-intertrigo

• Infectious Disease Specialists

The management of intertrigo typically involves several phases aimed at providing relief from symptoms, promoting healing, and preventing recurrence. These phases can be broadly categorized as acute management and long-term preventive measures:

• Acute Management Phase: In the acute phase of intertrigo management, the primary focus is alleviating the symptoms and reducing inflammation in the affected skin folds. This involves practicing good hygiene, keeping the area clean and dry, and using topical agents to address irritation and microbial overgrowth. The patient is advised to wash the affected areas gently with mild soap and water, pat them dry thoroughly, and apply barrier creams or ointments to protect the skin and prevent further friction. Antimicrobial agents may be prescribed to treat the infection if there are signs of secondary infection, such as pus or increased warmth. Additionally, topical corticosteroids can be used briefly to reduce inflammation and itching. During this phase, it is essential to avoid further aggravating the intertrigo by wearing breathable, loose-fitting clothing and avoiding activities that cause excessive sweating and friction.
• Long-Term Preventive Measures: After the acute symptoms are under control, the focus shifts to long-term preventive measures to diminish the risk of recurrence and maintain intertrigo-free skin. Lifestyle modifications generally play a significant role in this phase, including weight management for individuals who are overweight or obese to reduce the number and size of skin folds. Patients are educated on proper hygiene practices and encouraged to continue keeping the skin folds clean and dry. Regular use of absorbent powders or cornstarch can help maintain a dry environment. Furthermore, individuals are advised to wear breathable clothing and avoid tight-fitting apparel to reduce friction and promote air circulation. In cases where intertrigo is associated with underlying medical conditions (e.g., diabetes, immunosuppression), managing these conditions effectively becomes crucial in preventing intertrigo recurrence. Long-term follow-up with healthcare professionals allows for monitoring and further adjustments to the preventive measures as needed, ensuring the best possible outcomes for the patient.

Medication

Future Trends

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References

Intertrigo – PubMed (nih.gov)

Prevalence and associated factors of intertrigo in aged nursing home residents: a multi-center cross-sectional prevalence study – PMC (nih.gov)

Infectious Diseases Society of America 2023 Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections | Clinical Infectious Diseases | Oxford Academic (oup.com)

Prevalence of intertrigo and associated factors: A secondary data analysis of four annual multicentre prevalence studies in the Netherlands – PubMed (nih.gov)

Recurrent candidal intertrigo: challenges and solutions – PMC (nih.gov)