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Intertrigo Causes, Symptoms and Treatment

The term intertrigo comes from Latin inter, between and tergo, I rub. It therefore refers to dermatoses located in areas where two areas of skin touch and rub, called folds.

Definition of intertrigo

What is it ? 

Intertrigo is a dermatosis localized to skin folds, whether they are isolated or together, large (inguinal folds, intergluteal, axillary, sub-mammary) or small (interdigital-palmar, inter-arch, umbilicus, retro-auricular, labial commissures , belly button).

The different types of intertrigo

Intertrigos of infectious origin (mycoses, bacteria, etc.) are distinguished from non-infectious intertrigos which most often result from the location of dermatoses (eczema, psoriasis, etc.) at the folds.

Clinically, dry intertrigos are distinguished from wet and oozing intertrigos.

Causes of intertrigo

Infectious intertrigo

Mushroom intertrigo, mycosis of folds

Fungal infections are the first cause of intertrigo. There are two types of mushrooms:

  • Dermatophytes, often giving dry intertrigos
  • Candida, which are yeasts, most often causing a shiny and moist intertrigo

Intertrigo to bacteria

  • Corynebacterium minutissium intertrigo, erythrasma: Erythrasma is the most common bacterial intertrigo in the inguinal and axillary folds.
  • Pseudomonas aeruginosa intertrigo: Pseudomonas, also called pyocyanic bacillus, is a bacterium that lives in soil and water. It is contaminated by contact with the wet earth (gardening …) or in hot water (spa …) and it often complicates dermatophytic intertrigos through maceration and transpiration. It is therefore common in interortal spaces, which become brutally painful, erosive, oozing or even smelly.

Intertrigos to other pathogenic bacteria

They are due to staphylococci, streptococci and gram-negative bacilli (E. coli). These intertrigos are more common among obese, diabetic and defective patients, and generally complicate underlying dermatitis.

Non-infectious intertrigos

  • Psoriasis: Psoriasis of “inverted” folds or psoriasis is common in the intergluteal fold.
  • Irritation: It is secondary to the application of local care (antiseptic, cosmetic) or by accidental contact with a caustic substance.
  • Eczema: It may be allergy contact eczema to a deodorant in the armpits for example or atopic dermatitis preferentially reaching certain folds (retro-auricular furrows, folds of the knees, folds of the elbows …).

Rare causes

  • Hailey-Hailey’s disease is a rare hereditary dermatosis.
  • Paget’s disease is a malignant disease corresponding to an intraepidermal adenocarcinoma.
  • Crohn’s disease, an inflammatory bowel disease, can cause intergluteal and inguinal folds
  • Vegetative pemphigus is a rare clinical form of pemphigus vulgaris affecting large folds.
  • Secondary syphilis can affect large folds.
  • Langerhansian histiocytosis is a disease related to accumulation in Langerhans cell tissues.
  • Migratory necrolytic erythema is specific to glucagonomers, malignant tumors of the pancreas.
  • Corneal pustulosis of Sneddon and Wilkinson belongs to the group of neutrophilic dermatoses, characterized by the presence of neutrophils in the skin and affecting large folds.

Diagnosis of intertrigo

The diagnosis of intertrigo is easy: it is defined by a redness of the fold, which can itch, be painful, ooze … It is the diagnosis of the cause which is more delicate. The doctor will focus on characteristics that allow him to orientate himself to one or more causes: bilateral and possibly symmetrical or unilateral intertrigo, presence of desquamation, oozing, evolution by centrifugal extension, sharp limits or crumbled contours , presence of vesicles, pustules, and cracking at the bottom of the fold …

It is often necessary to perform mycological sampling (for direct examination and culture) or bacteriological and sometimes a skin biopsy.

Evolution and possible complications

Intertrigo rarely tends to heal spontaneously. It has a tendency to change and often worsen through the maceration, friction and sometimes local care that tend to irritate, can cause allergies or cause a complication (for example when applying a cream cortisonée on an infectious intertrigo).

Bacterial superinfection, pain and cracking are also classic complications.

Symptoms of intertrigo

The symptoms vary depending on the cause of the intertrigo:

Infectious intertrigos

fungal

Intertrigo with dermatophytes

At the level of large folds, they give dry and flaky red pink center, most often bilateral and symmetrical, which itch. The evolution is done by a centrifugal extension, with a clear border, polycyclic, vesicular and scaly. The classic lesion is the inguinal fold.

At the level of the small folds, it is intertrigo interorteil commonly called “athlete’s foot” because it is common among athletes, especially in the last space between toe-toe (between the last two toes). It forms a pink or red crack bordered by a maceration giving the skin a wet and whitish appearance.It can then extend on the back of the foot or the sole of the foot. It often itches.

Candida intertrigo

At the level of the large folds, they give a red varnished and wet intertrigo whose bottom is often cracked, even covered with a creamy white coating. The boundaries of intertrigo are crumbled with a whitish collar and some pustules. Again the site of predilection is the inguinal fold but it is also seen under the breasts.

At the level of the small folds, it is an intertrigo having the same characteristics as in the large folds, but sitting most often between the fingers or on the commissure of the lips (perleche).

bacteria

Intertrigo with Corynebacterium minutissium, erythrasma

Erythrasma takes the form of a well-rounded, well-defined brownish plaque. The light examination of Wood (UV lamp) colors it in red “coral”.

Pseudomonas aeruginosa intertrigo

Pseudomonas intertrigo often complicates dermatophytic intertrigos, especially between the toes through maceration and perspiration in shoes, which become abruptly painful, erosive, oozing or even smelly.

Intertrigos to other pathogenic bacteria

They also often complicate the intertrigos of obese people, diabetics and patients with poor personal hygiene: the intertrigo turns red, oozing with crusts or pustules.

Non-infectious intertrigos

Psoriasis

Psoriasis of the folds or psoriasis “inverted” gives an intertrigo sitting preferentially between the buttocks and on the navel, red, brilliant, well limited, and often cracked at the bottom of the fold.

Irritation

The irritation is often related to the application of antiseptics, cosmetics or irritants. The intertrigo is bright red, crumpled with sometimes vesicles or even wounds and it is common that it causes a burning sensation

Eczema

Folding eczema can have two origins:

  • allergic contact eczema that is often oozing, itchy and may include blisters. It comes from a contact allergy to a product applied in the fold and complicates an intertrigo that becomes oozing or even vesicular and can itch.
  • Atopic dermatitis, predominant in the creases of the elbows, knees, neck, behind the ears and often has a drier look

Rare causes

Hailey-Hailey’s disease is a rare hereditary dermatosis, characterized by the recurrent occurrence of vesicles or even bubbles on the neck, axillary hollows and groin grouped in well-defined cupboards, traversed by fissures in very characteristic parallel rhagades.

Paget’s disease is an intra-epidermal adenocarcinoma (form of cancer), most often vulvar, associated with visceral cancer (urinary or gynecological for example) in about 1/3 of the cases. It is presented as a red plaque of the vulva, groin or penis that extends gradually.

Crohn’s disease, a chronic inflammatory disease of the intestine, may have cutaneous localizations especially in intergluteal and inguinal folds. They present as fissures, ulcerations linear and deep in “stabbing”, abscesses complicating fistulas … which can precede the digestive manifestations of several months.

Vegetative pemphigus is a rare form of pemphigus affecting large folds, giving it vegetative and budding redness.

Secondary syphilis can give multiple plaques, swollen and erosive, sometimes vegetating in the folds.

Langerhansian histiocytosis is a disease linked to an accumulation in the skin of Langerhans cells. It gives rise to crusted and purpuric skin elevations, predominating at the level of the retro-auricular folds, even large folds.

Migratory necrolytic erythema is a cutaneous lesion due to glucagonome, a malignant tumor of the pancreas. It gives raised, squamous red plaques of centrifugal extension whose border is crusted or erosive and leaving a pigmented scar.

Corneal pustulosis of Sneddon-Wilkinson is a neutrophilic dermatosis, characterized by the presence of white blood cells called neutrophils in the skin. It gives pustules or superficial, flaccid bubbles that may have a characteristic fluid level called hypopion pustule. Pustules and bubbles are grouped by drawing arches or rings or circulating mainly on the trunk, at the root of the limbs and in the large folds.

Risk factors

The pleats have a risk of maceration, friction and heat that promote irritation and microbial proliferation whether mycotic or bacterial.

The acidity of wrinkles, obesity, immune deficiency, pregnancy, diabetes and some drugs (general corticosteroids, antibiotics) favor specifically candidiases of the folds.

Treatment and prevention

Prevention of intertrigo

Simple fold care measures can often reduce the risk of intertrigo:

  • wash daily and carefully dry folds
  • avoid too tight underwear, wool and synthetic fibers / favor cotton socks and underwear
  • fight against the contributing factors: diabetes, obesity, cortisone cream …

treatments

Treatment depends on the cause:

Infectious intertrigo

Intertrigos with dermatophytes

The treatment of dermatophytic intertrigos is carried out by the most often twice daily application of antifungals, cream, milk, spray, powder:

  • Imidazoles: econazole (Pevaryl), miconazole (Daktarin), oxiconazole (Fonx)
  • Allylamines: terbinafine (Lamisil)
  • Pyridone derivatives: ciclopiroxolamine (Mycoster)

In case of resistance to local treatment the doctor may prescribe an oral antifungal agent such as griseofulvin (Grisefuline) or terbinafine (Lamisil) for 3 to 4 weeks.

Intertrigos to candida

The treatment firstly fights the factors that promote candidiasis: avoid moisture, maceration, chemical or mechanical trauma. It is also necessary to treat underlying diabetes or an associated gastric or genital candidiasis

It is based on local antifungals, cream, milk, and spray, powder, applied twice a day:

  • Imidazoles: econazole (Pevaryl), miconazole (Daktarin), oxiconazole (Fonx)
  • Allylamines: terbinafine (Lamisil)
  • Pyridone derivatives: ciclopiroxolamine (Mycoster).

The general treatment can be proposed for 15 days in case of recurrence or associated digestive center (nystatin, Mycostatin, ketoconazole, Nizoral).

bacteria

Intertrigo with Corynebacterium minutissium, erythrasma

Erythrasma is treated with local erythromycin antibacterial lotion.

Pseudomonas aeruginosa intertrigo

Non-irritating antiseptic solutions are applied in the fold (chlorhexidine: Diaseptyl, polyvidone iodine: Betadine…) and / or silver sulfadiazine (Flammazine). The doctor is only rarely required to use oral antibiotics; in case of spread of infection or resistance to treatment, it is most often ciprofloxacin (Ciflox).

Intertrigos to other pathogenic bacteria

They regress most often with local antiseptics (chlorhexidine: Diaseptyl, polyvidone iodine: Betadine…), combined with local antibiotic treatment with fusidic acid (Fucidine cream).

Non-infectious intertrigos

Psoriasis

It generally responds well to a combination of corticosteroid and vitamin D gel (Daivobet…)

Irritation

The treatment of irritation requires local antiseptics (chlorhexidine: Diaseptyl, polyvidone iodine: Betadine…), emollients or even topical corticosteroids under medical control.

Eczema

The treatment of eczema requires emollients and dermocorticoids under medical control.

Rare causes

  • Hailey-Hailey’s disease requires drying of the folds to limit outbreaks and the risk of bacterial, mycotic and viral infections. Surgical excision of affected folds followed by skin grafting is often the only effective treatment.
  • Paget’s disease requires treatment of associated visceral cancer and excision of Paget’s disease plaque.
  • Vegetative pemphigus requires topical corticosteroids under medical control.
  • Secondary syphilis is treated by intramuscular pitting of penicillin.
  • Migratory necrolytic erythema requires the removal of the glucagonome in question.

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