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Intertrigo

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, 1998. Revised and updated August 2015. Updated by Janet Dennis, November 2018. Technical Editor: Mary Elaine Luther, Medical Student, Ross University, Barbados. DermNet Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. January 2020.


Intertrigo — codes and concepts
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What is intertrigo?

Intertrigo describes a rash in the flexures, such as behind the ears, in the folds of the neck, under the arms, under a protruding abdomen, in the groin, between the buttocks, in the finger webs, or in the toe spaces. Although intertrigo can affect only one skin fold, intertrigo commonly involves multiple sites. Intertrigo is a sign of inflammation or infection.

Who gets intertrigo?

Intertrigo can affect males or females of any age. Intertrigo is particularly common in people who are overweight or obese (see metabolic syndrome).

Other contributing factors are:

In infants, napkin dermatitis is a type of intertrigo that primarily occurs due to skin exposure to sweat, urine, and faeces in the diaper area.

Toe-web intertrigo is associated with closed-toe or tight-fitting shoes. Lymphoedema is also a cause for toe-web intertrigo.

What are the clinical features of intertrigo?

Intertrigo can be acute (recent onset), relapsing (recurrent), or chronic (present for more than six weeks). The exact appearance and behaviour depend on the underlying cause(s).

The skin affected by intertrigo is inflamed, reddened, and uncomfortable. The affected skin can become moist and macerated, leading to fissuring (cracks) and peeling.

Intertrigo with secondary bacterial infection (eg, pseudomonas) can cause a foul odour.

What causes intertrigo?

Intertrigo is due to genetic and environmental factors.

  • Flexural skin has a relatively high surface temperature.
  • Moisture from insensible water loss and sweating cannot evaporate due to occlusion.
  • Friction from the movement of adjacent skin results in chafing.
  • Intertrigo occurs more easily in environments that are hot and humid.
  • Diabetes, alcohol, and smoking increase the likelihood of intertrigo, especially the infectious form.

The microbiome (microorganisms normally resident on the skin) on flexural skin includes Corynebacterium, other bacteria, and yeasts. Microbiome overgrowth in warm moist environments can cause intertrigo.

Intertrigo is classified into infectious and inflammatory origins, but they often overlap.

  • Infections tend to be unilateral and asymmetrical.
  • Atopic dermatitis is usually bilateral and symmetrical, affecting the flexures of the neck, knees and elbows.
  • Other inflammatory disorders also tend to be symmetrical affecting the armpits, groins, under the breasts, and the abdominal folds.

Infections causing intertrigo

Thrush: Candida albicans

  • Characterised by its rapid development
  • Itchy, moist, peeling, red and white skin
  • Small superficial papules and pustules

Candida albicans

Erythrasma: Corynebacterium minutissimum

  • Persistent brown patches
  • Minimal scale
  • Asymptomatic (painless and non-itchy)

Erythrasma

Tinea: Trichophyton rubrum + T. interdigitale

  • Tinea cruris (groin) and athletes foot (between toes)
  • Slowly spreads over weeks to months
  • Irregular annular plaques
  • Peeling, scaling

Tinea cruris

Impetigo: Staphylococcus aureus and Streptococcus pyogenes

  • Rapid development
  • Moist blisters and crusts on a red base
  • Contagious, so other family members may also be affected

Impetigo

Boils: Staphylococcus aureus

  • Rapid development
  • Very painful follicular papules and nodules
  • Central pustule or abscess

Boil

Folliculitis: Staphylococcus aureus

  • Acute or chronic
  • Superficial tender red papules
  • Pustules centred on hair follicles
  • Can be provoked by shaving, waxing, epilation.

Folliculitis

Skin inflammations causing intertrigo

Flexural psoriasis

  • Well-defined, smooth or shiny red patches
  • Very persistent
  • Common in submammary and groin creases
  • Symmetrical involvement
  • May fissure (crack) in the crease
  • Red patches on other sites are scaly

Flexural psoriasis

Seborrhoeic dermatitis

  • Ill-defined salmon-pink thin patches
  • Common in axilla and groin creases
  • Fluctuates in severity
  • May be asymmetrical
  • Often unnoticed
  • Red patches on the face and scalp tend to be flaky.

Seborrhoeic dermatitis

Atopic dermatitis

  • First occurs in infancy
  • Common in elbow and knee creases
  • Characterised by flares
  • Very itchy
  • Acute eczema is red, blistered, swollen
  • Chronic eczema is dry, thickened, lined (lichenified).

Atopic dermatitis

Contact irritant dermatitis

  • Acute, relapsing or chronic

Irritants include:

  • Body fluids: sweat, urine
  • Friction due to movement and clothing
  • Dryness due to antiperspirant
  • Soap
  • Excessive washing.

Irritant contact dermatitis

Contact allergic dermatitis

  • Acute or relapsing
  • The allergen may be:
    • Fragrance, preservative or medicament in deodorant, wet-wipe or other product
    • Component of underwear (rubber in elastic, nickel in bra wire).

Allergic contact dermatitis

Hidradenitis suppurativa

  • Chronic disorder
  • Boil-like follicular papules and nodules
  • Discharging sinuses and scars

Hidradenitis suppurativa 

Hailey-Hailey disease

  • Intermittent painful shallow blisters that quickly break down
  • Rare inherited condition
  • Often starts age 20–40 years
  • Most troublesome during summer months

Hailey-Hailey disease

Granular parakeratosis

  • Red-brown scaly rash
  • Can be itchy
  • Rare
  • A biopsy is essential for diagnosis.

Granular parakeratosis

Fox-Fordyce disease

  • Dome-shaped follicular papules in armpits
  • Often persistent
  • Asymptomatic or itchy
  • Reduced sweating
  • Excoriations and lichenification eventually occur as a result of scratching.

Fox-Fordyce disease

Toe-web intertrigo

  • Common in persons wearing tight-fitting shoes
  • Pseudomonas aeruginosa is the most common organism
  • Mild toe-web intertrigo presents with erythema and scaling (athlete's foot)
  • Chronic intertrigo (longer than six months) causes burning pain, exudation, maceration, and inability to move the toes
  • A serious complication is cellulitis, often spreading to ankles and knees.

Toe-web intertrigo

What investigations should be done?

Investigations may be necessary to determine the cause of intertrigo.

What is the treatment for intertrigo?

See smartphone apps to check your skin.
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Related information

 

References

  • Janniger CK, Schwartz RA, Szepietowski JC, Reich A. Intertrigo and common secondary skin infections. Am Fam Physician 2005; 1; 72: 833–8. Journal
  • Tüzün Y, Wolf R, Baglam S, Engin B. Diaper (napkin) dermatitis: a fold (intertriginous) dermatosis. Clin Dermatol 2015; 33: 477–82. PubMed
  • De Britto LJ, Yuvaraj J, Kamaraj P, Poopathy S, Vijayalakshmi G. Risk factors for chronic intertrigo of the lymphedema leg in southern India: a case-control study. Int J Low Extrem Wounds 2015; 14: 377–83. doi: 10.1177/1534734615604289.PubMed
  • Martín EG, Sánchez RM, Herrera AE, Umbert MP. Topical tacrolimus for the treatment of psoriasis on the face, genitalia, intertriginous areas and corporal plaques. J Drugs Dermatol 2006; 5: 334–6. PubMed
  • Weidner T, Tittelbach J, Illing T, Elsner P. Gram‐negative bacterial toe web infection–a systematic review. J Eur Acad Dermatol Venereol 2018; 32: 39–47. PubMed

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