eMedicine Specialties > Dermatology > Environmental
Intertrigo
Updated: Aug 12, 2009
Introduction
Background
Intertrigo is an inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation. Intertrigo frequently is worsened or colonized by infection, which most commonly is candidal but also may be bacterial, fungal, or viral. Intertrigo commonly affects the axilla, perineum, inframammary creases, and abdominal folds.1,2 Diaper dermatitis shows significant overlap with intertrigo. Intertrigo is a common complication of obesity and diabetes.3
Pathophysiology
Intertrigo develops from mechanical factors and secondary infection. Heat and maceration are central to the process. Opposing skin surfaces rub against each other, causing erosions that become inflamed. Sweat, feces, urine, and vaginal discharge may aggravate intertrigo in both adults and infants.
Frequency
International
Intertrigo is common, especially in hot humid environments. Intertrigo is a common complication of diabetes, and it affects most infants as a component of diaper dermatitis.
Mortality/Morbidity
As a complication of more serious disease, intertrigo should be considered a comorbidity. Intertrigo becomes most serious as a source of secondary infection.
Race
Intertrigo has no racial predilection.
Sex
Intertrigo has no sex predilection, other than that from anatomic differences.
Age
Intertrigo affects people who are very old and very young because of reduced immunity, immobilization, and incontinence.
Clinical
History
- Intertrigo usually is chronic with insidious onset of itching, burning, and stinging in skin folds.
- When acute discomfort is noted, consider secondary infection.
- Intertrigo commonly is seasonal, associated with heat and humidity or strenuous activity in which chafing occurs.
- In addition to obesity and diabetes, hyperhidrosis may be a risk factor for intertrigo.
- Additional factors that predispose individuals to perineal intertrigo include urinary or fecal incontinence, vaginal discharge, or a draining wound.
Physical
- The appearance of intertrigo is dependent on the skin area involved and the duration of inflammation. Erythema and weeping may progress to maceration and crusting. Fissuring may follow erosion. Pustules or vesicles may herald infection. In the perineum, depths of the skin folds are involved compared to purely irritant diaper dermatitis in which only convex surfaces are involved.
- Any skin fold may be involved with intertrigo. In adults or infants who are obese, skin folds are accentuated, and inflammation may occur under pendulous abdominal folds, in neck creases, or in popliteal or antecubital fossae.
- As the mandible shrinks in elderly persons and the vertical dimensions decrease around the mouth, inflammation and candidiasis can occur under the accentuated nasolabial fold that develops.
Causes
- Initiating factors include friction, perspiration, maceration, or irritation from stool, urine, drainage, or topical agents.
- Autoeczematization and infection also may be factors in intertrigo.
- Whether infectious agents play a primary role in intertrigo or simply are common secondary agents is controversial.4
Differential Diagnoses
| Acanthosis Nigricans | Granuloma Gluteale Infantum |
| Acrodermatitis Enteropathica | Granuloma Inguinale (Donovanosis) |
| Bowen Disease | Impetigo |
| Candidiasis, Mucosal | Lymphogranuloma Venereum |
| Cellulitis | Paget Disease, Mammary |
| Contact Dermatitis, Allergic | Scabies |
| Contact Dermatitis, Irritant | Seborrheic Dermatitis |
| Erythrasma | Syphilis |
| Familial Benign Pemphigus (Hailey-Hailey
Disease) |
Other Problems to Be Considered
Differential diagnoses for intertrigo
In the adult, consider inflammatory diseases (common or rare) including contact dermatitis, inverse psoriasis, seborrheic dermatitis, pemphigus, metabolic diseases, and malignancies.
Primary or secondary infections may be related to dermatophytes, candidal organisms, bacteria, or viruses. Possibilities involving bacteria include infection by Streptococcus and Staphylococcus species and lymphogranuloma venereum and granuloma inguinale infections.5
Metabolic disorders include toxic epidermal necrolysis, acrodermatitis enteropathica, acanthosis nigricans, and migratory epidermal necrolysis.
Malignancies include metastatic carcinoma, Paget disease, or Bowen disease.
Differential diagnosis for intertrigo by body site
Toe and finger web spaces: Consider mycotic infections, termed erosio interdigitalis blastomycetica between fingers and dermatophytosis complex between toes. Exclude interdigital hair sinuses, inverse psoriasis, gram-negative infection, or erythrasma.
Vulva: Vulvitis can occur from erythrasma, plasma cell vulvitis, adult diaper dermatitis, candidal infection, seborrheic dermatitis, psoriasis, contact dermatitis, or Jaquet "pseudowarts" resulting from chronic maceration.6
Umbilicus: Inflammation in this location is termed navelitis. Exclude seborrheic dermatitis, psoriasis, endometriosis, scabies, or the ominous Sister Mary Joseph sign (umbilical metastasis), especially if associated with blue-black induration.
Postauricular fold: Consider infectious eczematoid dermatitis, sebopsoriasis, allergic contact dermatitis, or trauma resulting from wearing glasses (granuloma fissuratum).
Axillae: Consider inverse psoriasis, erythrasma, seborrheic dermatitis, irritant or allergic contact dermatitis from deodorants, shaving, or benign familial pemphigus (Hailey-Hailey disease), or axillary granuloma parakeratosis.
Lips: Synonyms include angular stomatitis and perlèche. Consider seborrheic dermatitis; candidal infection; perioral dermatitis; irritation or allergic dermatitis from dentifrice, gum, or mouthwash; lip licker's eczema; excessive salivation from orthodontic devices; or herpes simplex labialis.
Perianal/natal cleft: Consider pruritus ani, candidal infection, contact dermatitis, anal fissures, essential fatty acid deficiency, acrodermatitis enteropathica, extramammary Paget disease, psoriasis, pilonidal cyst, decubitus dermatitis, or baboon syndrome from contact allergy systemic antibiotics, or hypovitaminosis B.
Crural fold: Alternative diagnoses include inverse psoriasis, candidal infection, adult diaper dermatitis, granuloma inguinale, pemphigus vegetans, benign familial pemphigus (Hailey-Hailey disease), toxic epidermal necrolysis, and extramammary Paget disease. A form of extensive papulonodular and eroded dermatitis in women appears to be related to overuse of topical preparations such as Vagisil.
Inframammilae: Consider inverse psoriasis, candidal infection, inflammatory metastatic breast cancer, Paget disease, or benign familial pemphigus (Hailey-Hailey disease).
Infantile intertrigo: Intertrigo in infants often is synonymous with diaper dermatitis. Exclude seborrheic dermatitis, candidal infection, psoriasis, nutritional abnormalities (biotin deficiency, acrodermatitis enteropathica from zinc deficiency, aminoaciduria related), Letterer-Siwe disease (especially if papular, eroded, or purpuric), granuloma gluteal infantum (from topical corticosteroids), impetigo, cellulitis, cystic fibrosis, congential syphilis, or hereditary neuroepithelial dysplasia.7
Workup
Laboratory Studies
- Potassium hydroxide (KOH) test, Gram stain, or culture is useful to exclude primary or secondary infection and to guide intertrigo therapy.
- Wood lamp examination can exclude erythrasma.
- Perform appropriate workup if systemic disease is suspected along with the intertrigo (diabetes, acrodermatitis enteropathica, necrolytic migratory erythema secondary to glucagonoma) or if intertrigo responds poorly to treatment.
Procedures
- Skin biopsy may help exclude inverse psoriasis, Bowen disease, Paget disease, or metastatic carcinoma.
Treatment
Medical Care
Correcting the causative factors of intertrigo is critical.
- Take steps to eliminate friction, heat, and maceration by keeping folds cool and dry.
- These steps can be accomplished by using air conditioning and absorbent powders and by exposing skin folds to the air.
- Compresses with Burow solution 1:40, dilute vinegar, or wet tea bags often are effective, especially if followed by fanning or cool blow-drying.
- Skin surfaces in deep folds can be kept separated with cotton or linen cloth; however, be sure to avoid tight, occlusive, or chafing clothing or dressings. Moisture-wicking undergarments are helpful.
- Where appropriate, antimycotic agents (miconazole, clotrimazole) are helpful, especially if used with a mild- to mid- potency (class III-VI) steroid for a short duration. Avoid using stronger topical steroids because the occlusive effect of skin folds can accelerate the development of skin atrophy and striae.
- Castellani paint (carbol-fuchsin paint) also can be helpful.
- Formulations combining protective agents, antimicrobials, and topical steroids may be helpful, including the following:
- Triple Paste comprises petrolatum, zinc oxide paste, and aluminum acetate (Burow) solution applied qs ad (in a sufficient quantity).
- Greer goo is composed of nystatin (Mycostatin) powder 4 million U, hydrocortisone powder 1.2 g, and zinc oxide paste 4 oz applied qs ad (in a sufficient quantity).
- A thick coat of these protective barrier creams should be applied.
- Commercially available barrier pastes sold for diaper dermatitis (eg, Desitin) can be helpful, as can absorbent diapers.
- Open-toed shoes or sandals may help reduce toe web-space moisture.
Medication
The goals of pharmacotherapy for intertrigo are to reduce morbidity and to prevent complications.
Protective agents
Used to protect skin against contact irritants.
Petrolatum, zinc oxide, and aluminum acetate (Triple Paste)
Consists of petrolatum, zinc oxide paste, and aluminum acetate solution.
Dosing
Adult
Apply thick coat as a protective barrier prn
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if irritation develops; for external use only
Mycostatin, hydrocortisone, zinc oxide (Greer goo)
Consists of nystatin (Mycostatin) powder, 4 million U, hydrocortisone powder, 1.2 g, and zinc oxide paste, 4 oz qs ad (in a sufficient quantity).
Dosing
Adult
Apply thick coat as a protective barrier prn
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if irritation develops; for external use only
Zinc oxide, cod liver oil, and talc (Desitin)
For relief of rash, superficial wounds, and burns.
Dosing
Adult
Apply thick coat as a protective barrier prn
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Discontinue if irritation develops; for external use only
Dimethicone (ProShield Plus)
Hydrophobic barrier cream.
Dosing
Adult
Apply a thick coat as a protective barrier prn
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Discontinue if irritation develops; for external use only
Antifungal agents
Exert fungicidal effect by altering permeability of fungal cell membrane. Mechanism of action may also involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide toxic to fungal cells.8
Carbol-Fuchsin (Castellani Paint)
First aid antiseptic and drying agent. Active ingredient is phenol 1.5%. Inactive ingredients are water, SD alcohol 40B (13%), resorcinol, acetone, and basic fuchsin.
Dosing
Adult
Apply qd or bid as drying agent
Pediatric
Apply qd or bid as drying agent
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid getting on clothes; stain will slowly wear off skin
Miconazole (Micatin, Monistat-Derm, Monistat) cream
Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, resulting in fungal cell death.
Lotion is preferred in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.
Dosing
Adult
Apply to affected areas bid for 2-6 wk
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; not recommended in first trimester of pregnancy
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes; local reactions 0.5-1.5% include dyspareunia, mild vaginal or vulvar erythema, burning, pruritus, urticaria, and rash
Clotrimazole (Lotrimin, Mycelex, Gyne-Lotrimin)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.
Dosing
Adult
Gently massage into affected area and surrounding skin areas bid for 2-6 wk
Pediatric
Children: Not established
Adolescents: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity, not recommended in first trimester of pregnancy
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external use only; avoid contact with eyes; if irritation or sensitivity develops, discontinue use; local reactions 0.5-1.5% include dyspareunia, mild vaginal or vulvar erythema, burning, pruritus, urticaria, and rash
Immunosuppressant agents
These agents exert anti-inflammatory effect by inhibiting T-lymphocyte activation. Safer than topical steroids for prolonged use or in skin folds.9
Tacrolimus ointment (Protopic)
Nonsteroidal anti-inflammatory agent. Should not cause steroid-type skin atrophy.
Currently indicated only for atopic dermatitis in nonimmunocompromised patients >2 y.
Dosing
Adult
0.1% ointment: Apply to affected areas bid for 2-6 wk
Pediatric
0.03% ointment: Apply as in adults
Interactions
None reported; use caution if using oral treatments with CYP3A4 inhibitors
Contraindications
Documented hypersensitivity; not recommended in immunocompromised persons
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use with occlusive dressings; may be associated with an increased risk of folliculitis in adults; may cause local burning sensation, stinging, soreness, or pruritus (typically improve as lesions heal); for external use only; minimize exposure to natural or artificial sunlight (eg, tanning beds or UVA/B treatment); be sure skin is completely dry before application; product insert for tacrolimus revised in January 2006 and contains a black box warning stating the long-term safety of calcineurin inhibitors has not been established; although a causal relationship has not been established, rare cases of malignancy (eg, skin, lymphoma) reported; only 0.03% ointment is indicated for use in children aged 2-15 y
Pimecrolimus (Elidel cream 1%)
Nonsteroidal anti-inflammatory agent. Should not cause steroid-type skin atrophy. Currently indicated only for atopic dermatitis in nonimmunocompromised patients >2 y. Use cream sparingly to avoid maceration in skin folds.
Dosing
Adult
Apply to affected areas bid for 2-6 wk
Pediatric
Apply as in adults; indicated for >2 y
Interactions
None reported; use caution if using oral treatments with CYP3A4 inhibitors
Contraindications
Documented hypersensitivity; not indicated in immunocompromised patients; efficacy and safety in geriatric patients not tested
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use with occlusive dressings; may be associated with an increased risk of folliculitis in adults; may cause local burning sensation, stinging, soreness, or pruritus (typically improve as lesions heal); for external use only; minimize exposure to natural or artificial sunlight (eg, tanning beds or UVA/B treatment); be sure skin is completely dry before application; product insert for pimecrolimus revised in January 2006 and contains a black box warning stating the long-term safety of calcineurin inhibitors has not been established; although a causal relationship has not been established, rare cases of malignancy (eg, skin, lymphoma) reported
Follow-up
Complications
- Since intertrigo frequently is colonized or secondarily infected, acute cellulitis is a threat.
- Potential complications of therapy include contact dermatitis from topical agents and striae from topical steroids.
Prognosis
- With therapy, the prognosis for each episode of simple intertrigo is excellent. Recurrence is common.
Patient Education
- During patient instruction, emphasize topics such as weight loss, glucose control (in patients with diabetes), good hygiene, and the need for daily care and monitoring.10
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize and diagnose an infectious intertrigo may result in serious cellulitis, especially in patients who are diabetic
- Failure to monitor patients closely for the development of striae or a hidden infection if topical steroids are needed to control an inflammatory intertrigo
- Failure to consider biopsy if the intertrigo fails to respond to treatment or if severe skin or systemic disorders must be excluded, although skin biopsies are not necessary to diagnose uncomplicated intertrigo
- Failure to notice skin fissuring and breakdown/ulcers possibly hidden in the deep skin folds of persons who are obese, which can lead to pain, disability, and, potentially, sepsis
Special Concerns
- Intertrigo most often involves persons who are helpless or dependent on others, ie, older persons and infants. Since intertrigo in the perineum often is complicated by incontinence, new breakthroughs in absorbent diapers have made diaper dermatitis easier to avoid. However, contact dermatitis in reaction to these diapers, whether irritant or allergic, can occur; therefore, monitor waistlines and leg openings for intertrigo.
References
Weston WL, Lane AT, Weston JA. Diaper dermatitis: current concepts. Pediatrics. Oct 1980;66(4):532-6. [Medline].
English JC III, Derdeyn AS, Wilson WM, Patterson JW. Axillary granuloma parakeratosis. J Cutan Med Surg. 2003;7(4):330-332.
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. [Medline].
Mistiaen P, Poot E, Hickox S, Jochems C, Wagner C. Preventing and treating intertrigo in the large skin folds of adults: a literature overview. Dermatol Nurs. Feb 2004;16(1):43-6, 49-57. [Medline].
Honig PJ, Frieden IJ, Kim HJ, Yan AC. Streptococcal intertrigo: an underrecognized condition in children. Pediatrics. Dec 2003;112(6 Pt 1):1427-9. [Medline].
Mommers JM, Seyger MM, van der Vleuten CJ, van de Kerkhof PC. Interdigital psoriasis (psoriasis alba): renewed attention for a neglected disorder. J Am Acad Dermatol. Aug 2004;51(2):317-8. [Medline].
Bjornsdottir S, Gottfredsson M, Thorisdottir AS, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis. Nov 15 2005;41(10):1416-22. [Medline].
Dogan B, Karabudak O. Treatment of candidal intertrigo with a topical combination of isoconazole nitrate and diflucortolone valerate. Mycoses. Sep 2008;51 Suppl 4:42-3. [Medline].
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. [Medline].
American Academy of Family Physicians. Information from your family doctor. Intertrigo: what you should know. Am Fam Physician. Sep 1 2005;72(5):840. [Medline].
Arnold HL, Odom RB, James WD. Intertrigo. In: Andrew's Diseases of the Skin: Clinical Dermatology. 8th ed. Philadelphia, Pa: WB Saunders; 1990:285.
Clark RA, Hopkins TT. Dermatology. 3rd ed. Philadelphia, Pa: WB Saunders; 1992:485-89.
Jansen GT, Dillaha CJ, Honeycutt WM. Intertrigo. In: Clinical Dermatology. Hagerstown, Md: Harper & Row; 1979.
Kaya TI, Delialioglu N, Yazici AC, Tursen U, Ikizoglu G. Medical pearl: Blue underpants sign--a diagnostic clue for Pseudomonas aeruginosa intertrigo of the groin. J Am Acad Dermatol. Nov 2005;53(5):869-71. [Medline].
White GM. Regional Dermatology. Chicago, Ill: Mosby-Wolfe; 1994.
Keywords
intertrigo, skin inflammation, obesity, diabetes, heat rash, friction rash, diaper dermatitis, maceration rash
Contributor Information and Disclosures
Author
Samuel Selden, MD, Assistant Professor, Department of Dermatology, Eastern Virginia Medical School
Samuel Selden, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Astellas Pharma US, Inc. Honoraria Consulting; Galderma Laboratories, L.P. Honoraria Review panel membership
Medical Editor
Franklin Flowers, MD, Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, University of Florida College of Medicine
Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.
Pharmacy Editor
Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.
Managing Editor
Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.
CME Editor
Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.
Chief Editor
Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
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