Intertrigo

Medically reviewed by The Dermatologists and written by Dr. Alexander Börve

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.
• Foul Odor: In some cases, the affected area may ooze or sore and develop a foul odor due to bacterial or fungal overgrowth.

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

• Maintain Skin Dryness
  • Air Drying: Frequently expose the affected areas to air. Use a hair dryer on the cool setting to gently dry the skin folds.
  • Absorbent Materials: Use absorbent powders (such as cornstarch or zinc oxide powder) to absorb excess moisture.
  • Separate Skin Folds: Gently separate skin folds with clean gauze or cotton pads to improve air circulation.
• Moisture-Wicking Fabrics: Wear loose-fitting, breathable clothing made from cotton or moisture-wicking fabrics to minimize sweat accumulation.
• Skin Barrier Creams: Apply barrier creams containing zinc oxide or petrolatum to protect the skin and reduce friction.
• Weight Management: If obesity is a contributing factor, weight loss can significantly reduce the risk of intertrigo.

Over-the-counter Medications 

• Mild Topical Corticosteroids: Low-potency hydrocortisone cream can help reduce inflammation.but they should be used with caution and under the guidance of a healthcare professional.
• Antifungal Creams: Over-the-counter antifungal creams containing clotrimazole or miconazole can be used to treat fungal infections.
• Barrier Creams: Applying barrier creams containing zinc oxide or petrolatum can help protect the skin from further irritation and promote healing.
• Antibacterial Creams: In cases of bacterial infection, topical antibiotics such as mupirocin may be prescribed.

 Medical Interventions

• Severe Cases: In severe cases, oral medications may be necessary, such as oral antifungals for fungal infections or antibiotics for bacterial infections.
• Close Monitoring: Patients receiving topical steroids should be closely monitored for the development of skin atrophy or striae, which can occur due to prolonged use
• Underlying Conditions: Addressing underlying medical conditions, such as diabetes and obesity, is crucial for long-term management of intertrigo.
• Addressing Secondary Infections
  • Fungal Infections: Intertrigo complicated by fungal infections should be treated with topical antifungals.
  • Bacterial Infections: Intertrigo complicated by bacterial infections, such as those caused by Staphylococcus aureus or Streptococcus, may require treatment with topical or oral antibiotics.
  • Erythrasma: Erythrasma, a skin infection caused by Corynebacterium minutissimum, is typically treated with topical or oral erythromycin.

Prevention of Intertrigo

Preventing intertrigo primarily focuses on minimizing the factors that contribute to its development: moisture, friction, and the growth of microorganisms.

Maintaining Skin Dryness
Keeping the affected areas dry is crucial. This can be achieved through:

• Frequent air exposure: Exposing the affected areas to air as often as possible allows them to dry thoroughly.
• Absorbent materials: Using absorbent powders like cornstarch or zinc oxide powder can help absorb excess moisture.
• Moisture-wicking fabrics: Wearing loose-fitting, breathable clothing made from cotton or moisture-wicking fabrics can help minimize sweat accumulation.

Reducing Friction

• Keeping skin folds separated with soft, absorbent materials like cotton pads can significantly reduce friction and irritation.
• Avoiding tight-fitting clothing and minimizing activities that cause excessive sweating can also help.

Addressing Underlying Conditions

• Weight management is crucial for individuals with obesity, as it reduces skin folds and minimizes moisture accumulation.
• Effective management of conditions like diabetes and incontinence is essential to prevent complications.

Skin Care Routine

• A regular skin care routine is vital, including gentle cleansing with mild, fragrance-free soaps, thorough drying of the skin, and the application of emollients to maintain skin hydration.

By implementing these preventive measures, individuals can significantly reduce their risk of developing intertrigo and improve their overall skin health.

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.

Factors Affecting Prognosis

• Effective management of underlying conditions: Addressing conditions like obesity, diabetes, and incontinence is crucial for preventing recurrences.
• Adherence to treatment: Consistent adherence to treatment recommendations, including the use of prescribed medications and maintaining good hygiene, is essential for successful management.

Should I seek medical care?

Consult a dermatologist if,

• Home care measures fail to improve the condition.
• The rash worsens or spreads beyond the initial area.
• You experience fever, chills, or signs of a systemic infection.
• You have concerns about the severity of the condition or are unsure of the diagnosis.

Prompt medical attention can help ensure proper diagnosis and treatment, preventing potential complications and promoting a faster recovery.