Intertrigo

Intertrigo is an inflammatory skin condition that develops in areas where skin folds rub together, such as the groin, armpits, under the breasts, and between the toes. These areas, characterized by warmth, moisture, and limited air circulation, create an ideal environment for the growth of bacteria and fungi.

This constant friction, trapped moisture and lack of ventilation can irritate the skin,resulting in a red, painful rash that appears in the skin folds. The resulting skin breakdown can further increase the risk of secondary infections caused by bacteria such as Streptococcus and Corynebacterium, and fungi such as Candida.

Intertrigo, also known as skin fold dermatitis, is depicted with red, irritated, and inflamed skin under the armpit. The rash has a burn-like appearance and causes itching, discomfort, and tenderness due to friction and moisture in skin folds

While intertrigo can affect individuals of all ages,from infancy to advanced age, certain factors increase the risk, including obesity, diabetes, and limited mobility. It is the most common in warm and moist climates.^[1]

Despite its potential for discomfort and complications, intertrigo is a treatable and preventable condition. In this article, we will discuss intertrigo, including its symptoms, causes and risk factors, complications, diagnosis, treatment, and most importantly, how to prevent its development.

Symptoms of Intertrigo

Intertrigo typically presents as a red, irritated rash in the affected skin folds. These areas may appear raw, and the skin can feel hot or tender to the touch.^[2]

• Appearance: The rash can vary in appearance, ranging from pink to deep red.
• Itching and Discomfort: Intense itching, burning, and stinging are common symptoms.
• Skin Breakdown: In severe cases, the skin may crack or break open, increasing the risk of infection.
• Unpleasant smell: In some cases, the affected area may develop an unpleasant smell, especially if a secondary infection is present.

Causes and Risk Factors of Intertrigo

Intertrigo arises from a combination of factors that disrupt the delicate balance of the skin in areas of skin folds.

Friction and Moisture

• Constant friction between skin surfaces, such as in the groin, armpits, and under breasts, creates irritation.
• Moisture trapped in these areas, from sweat, urine, or fecal incontinence, further softens and weakens the skin, making it more susceptible to damage.

Microorganism Overgrowth

• The warm, moist environment within skin folds provides an ideal breeding ground for microorganisms, including:
  • Candida: This yeast species commonly causes fungal intertrigo.
  • Staphylococci: These bacteria can lead to bacterial intertrigo.
  • Corynebacterium minutissimum: This bacterium is associated with erythrasma, a specific type of intertrigo.

Environmental Factors

• Heat and humidity: Warm, humid climates increase sweating and create a more favorable environment for microbial growth.

Risk Factors

• Obesity: Increased body weight leads to larger skin folds, trapping moisture and increasing friction.
• Diabetes or weak immune system: Diabetes can weaken the immune system and increase the risk of fungal infections.
• Incontinence: Urine or fecal incontinence increases moisture and the risk of skin irritation.
• Wearing braces or prosthetics: Reduced mobility can limit air circulation and increase the risk of skin breakdown.
• Infancy: Infants are particularly susceptible due to frequent diaper changes and the presence of skin folds.
• Older adults: Age-related changes in skin integrity and reduced mobility can increase susceptibility.

Medical Conditions: Conditions such as dermatitis, psoriasis, excessive sweating, poor hygiene, and malnutrition also contribute to the rash.^[3]

Types of Intertrigo

Intertrigo can manifest in various forms, each with its own characteristic presentation.

• Candidal Intertrigo: Caused by the overgrowth of Candida albicans, this type commonly affects skin folds such as the groin, armpits, and under the breasts. The warm, moist environment within these folds provides an ideal breeding ground for this fungus. Candidal intertrigo typically presents with red, irritated skin, often with small, satellite lesions.
• Toe Web Intertrigo: This form of intertrigo specifically affects the spaces between the toes, particularly between the fourth and fifth toes. It thrives in warm, moist environments, making it more common in individuals who wear tight, closed-toe shoes for prolonged periods. The affected skin may appear white, macerated, and thickened, sometimes resembling athlete’s foot.
• Diaper Dermatitis: This type of intertrigo commonly affects infants and individuals with incontinence. Candida albicans, often present in the gastrointestinal tract, can overgrow in the diaper area, leading to a red, irritated rash with potential satellite lesions. Prolonged diaper contact and infrequent diaper changes can increase the risk of diaper candidiasis.

Diagnosis of Intertrigo

The diagnosis of intertrigo primarily relies on a thorough clinical examination and patient history.

Medical History
A detailed medical history, including past medical conditions (such as diabetes, obesity, and immunodeficiency), medications, and recent changes in lifestyle, is crucial.

Prior use of topical steroids or antibacterial soaps should be noted as these can sometimes exacerbate skin irritation.

Physical Examination
A careful examination of the affected skin folds is essential.

The physician will look for characteristic features of intertrigo, such as redness, irritation, and the presence of satellite lesions (small, secondary lesions that may appear around the main area of inflammation).

Laboratory Investigations
To confirm the diagnosis or In cases of suspected infection, further investigations may be necessary

• Potassium hydroxide (KOH) preparation: To identify fungal infections such as Candida.
• Bacterial culture: To identify bacterial infections.
• Wood’s lamp examination: To detect certain fungal infections.

Differential Diagnosis 

It’s important to differentiate intertrigo from other skin conditions that may present similarly in skin folds. These include:

• Seborrheic dermatitis
• Irritant or allergic contact dermatitis
• Atopic dermatitis
• Inverse psoriasis
• Pemphigus
• Scabies

Other conditions to consider include metabolic derangements and malignancies.

Management and Treatment
of Intertrigo

The primary goal of intertrigo management is to reduce inflammation, prevent infection, and promote healing.

Home Care Measures

Keep Skin Dry:

• Air drying: Frequently expose affected areas to air. Use a hair dryer on a cool setting if necessary.

• Absorbent materials: Use powders such as zinc oxide (available in barrier creams) to absorb moisture. Avoid cornstarch as it may worsen fungal infections.

• Separate skin folds: Use clean gauze or soft cotton pads to keep folds apart and encourage airflow.

• Clothing: Wear loose, breathable, moisture-wicking clothing (preferably cotton) to reduce sweating.

• Barrier creams: Apply creams containing zinc oxide or petroleum jelly to reduce friction and protect the skin.

• Weight management: For those living with obesity, gradual weight reduction may reduce friction and moisture in skin folds.

Over-the-Counter Treatments 

• Mild topical corticosteroids (e.g. 1% hydrocortisone) may reduce inflammation. These are available at pharmacies and should be used short-term with pharmacist or GP advice.

• Antifungal creams such as clotrimazole or miconazole are available without a prescription and are often used if a fungal cause (e.g. Candida) is suspected.

• Barrier creams with zinc oxide can be used regularly to prevent further irritation.

• Antibacterial creams like fusidic acid or mupirocin are prescription-only medicines (POMs) in the UK and should be prescribed by a GP if a bacterial infection is suspected.

Medical Treatment (GP or Specialist Care)

• Severe cases: A GP may prescribe oral antifungals (e.g. fluconazole) or oral antibiotics if the infection is widespread or persistent.

• Steroid monitoring: If topical corticosteroids are prescribed, usage should be monitored to avoid skin thinning (atrophy) or stretch marks (striae).

• Address underlying conditions: Management of diabetes, weight, or incontinence is important to reduce recurrence.

Treating Secondary Infections

• Fungal infections: Topical antifungal treatment is usually first-line; oral treatment may be needed if topical therapies fail.

• Bacterial infections: May require topical or oral antibiotics as prescribed by a GP.

• Erythrasma: This superficial bacterial infection (caused by Corynebacterium) is typically treated with topical erythromycin; oral erythromycin may be used for widespread cases under medical advice.

Complications of Intertrigo

Complications of intertrigo can arise if left untreated or improperly managed.

• Secondary Infections: The moist, warm environment created by intertrigo can promote the growth of bacteria (such as Staphylococcus and Streptococcus) and fungi (such as Candida). These secondary infections can worsen the inflammation and may even spread to deeper tissues, potentially leading to cellulitis. In rare cases, severe infections can even progress to sepsis, a life-threatening condition.
• Skin Breakdown: Prolonged irritation can lead to skin breakdown, including cracks, fissures, and ulcers.
• Skin Thinning: Prolonged use of topical corticosteroids can weaken the skin, leading to skin thinning (atrophy) and the appearance of stretch marks (striae).
• Contact Dermatitis: Some individuals may develop contact dermatitis as a reaction to topical medications used to treat intertrigo.

these complications are more likely to occur in individuals with weakened immune systems, such as those with diabetes or those who are immunocompromised.

Prognosis

In most cases, intertrigo can be effectively managed with proper hygiene, lifestyle modifications, and appropriate treatment. However, the prognosis may vary depending on the severity of the condition and the presence of underlying medical conditions.

What Affects the Outlook?

• Managing underlying conditions: Keeping long-term conditions such as diabetes, obesity, or incontinence under control can help reduce the chances of intertrigo coming back.

• Following treatment advice: Regular use of prescribed creams or medications, along with maintaining clean, dry skin, is important to support healing and prevent recurrence.

Should I seek medical care?

Speak to your GP, pharmacist or another healthcare professional if:

• The rash is not improving with home treatment

• The affected area becomes increasingly red, swollen or painful

• You develop signs of infection, such as pus, fever or feeling generally unwell

• You’re unsure whether the rash is caused by intertrigo

Prompt medical advice can help ensure you receive the right diagnosis and treatment, and reduce the risk of complications or recurrent infections.