Symptoms, Causes, Diagnosis, Treatment & Prevention

What is intertrigo?

Intertrigo is a rash that usually affects the folds of the skin, where the skin rubs together or where it is often moist. This rubbing can cause a breakdown in the top layers of the skin, causing inflammation and a rash. The breakdown of skin makes it easier for bacteria or fungus to develop in this area. It can make the rash worse.

Intertrigo is most common in people who are overweight or who have diabetes. People who have splints, braces, or artificial limbs are also more likely to develop this rash.

Symptoms of intertrigo

Symptoms include a red or reddish-brown rash that can appear anywhere skin rubs together or traps wetness. This rash may burn or itch. The most common areas include:

• Between toes
• In the armpits
• In the groin area
• On the underside of the belly or breasts
• In the crease of the neck

Intertrigo can also affect the skin between the buttocks. The affected skin will often be very raw and may itch or ooze. In severe cases, intertrigo may cause a foul odor, and the skin may crack and bleed.

What causes intertrigo?

Skin folds sitting together and rubbing together causes intertrigo. This skin-on-skin friction creates a warm, moist environment. This environment invites an overgrowth of yeast, fungus, and bacteria. Intertrigo is not contagious. You cannot catch it from or pass it to another person.

How is intertrigo diagnosed?

The best way to know for sure is to ask your doctor. Your doctor will be able to tell if you have the rash by looking at your skin. No special tests are needed but your doctor may take a sample to determine what type of bacteria or fungus may be present.

Can intertrigo be prevented or avoided?

You can help prevent intertrigo by doing these things:

• Keep skin cool and dry.
• Do not wear tight shoes or clothing. Wear a bra that has good support.
• Wear clothes made with absorbent fabrics, such as cotton. Avoid nylon or other synthetic (manmade) fibers.
• If you are overweight, try to lose weight.
• After exercising, shower and dry off completely. Use a hair dryer with a cool setting to dry areas that can trap wetness, such as under your arms or breasts.

Intertrigo treatment

For mild cases, your doctor will tell you to keep the affected area of your skin dry and exposed to air. Your doctor may also want to prescribe a topical steroid cream. For certain cases, your doctor may prescribe an antibiotic or antifungal cream. There are also antifungal powders that may help dry the skin. Talk to your doctor about which treatment is right for you.

Living with intertrigo

Intertrigo may come and go. If you know that you are predisposed to getting this type of rash, take precautions. Before physical activity, treat the area with deodorant or with petroleum jelly. Do what you can to keep skin folds dry.

Questions to ask your doctor

• What is the best way to keep from getting intertrigo again?
• Do I need to make any changes to my lifestyle?
• Do I need to use a cream or ointment?
• What side effects could I have from my medicine?
• Do I need to take an antibiotic?
• Is there anything I can do on my own to help myself get better?

Resources

U.S. National Institutes of Health, MedlinePlus: Intertrigo

Copyright © American Academy of Family Physicians

This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.

Causes, Images, and More — DermNet

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.

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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:

• Genetic tendency to skin disease
• Hyperhidrosis (excessive sweating)
• Age
• Diabetes
• Smoking
• Alcohol.

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

Intertrigo due to candida infection

Erythrasma: Corynebacterium minutissimum

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

Erythrasma

Axillary 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

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

Bullous 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

Folliculitis in axilla

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

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

Intertrigo due to 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

Flexural eczema

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 irritant dermatitis due to urine. Napkin dermatitis in adult.

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 

Intertrigo due to hidradenitis suppurativa in axilla

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

Intertrigo due to Hailey-Hailey disease

Granular parakeratosis

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

Granular parakeratosis

granular parakeratosis 02

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

Axillary 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

Athlete’s foot

What investigations should be done?

Investigations may be necessary to determine the cause of intertrigo.

• A swab for microscopy and culture of bacteria (microbiology)
• A scraping for microscopy and culture of fungi (mycology)
• A skin biopsy may be performed for histopathology if the skin condition is unusual or fails to respond to treatment.

What is the treatment for intertrigo?

• Treatment depends on the underlying cause if identified, and on which micro-organisms are present in the rash. Combinations are common.
• Zinc oxide paste can be used for napkin dermatitis or incontinence-associated irritant contact dermatitis.
• Physical exertion should be followed by bathing and completely drying skin flexures. A hairdryer on cool setting is an effective approach for drying underarms and breasts.
• Sweating can be reduced with an antiperspirant cream or powder.
• Bacterial infection may be treated with topical antibiotics such as fusidic acid cream, mupirocin ointment, or oral antibiotics such as flucloxacillin and erythromycin.
• Yeasts and fungi may be treated with topical antifungals such as clotrimazole and terbinafine cream or oral antifungal agents such as itraconazole or terbinafine.
• Inflammatory skin diseases are often treated with low potency topical steroid creams such as hydrocortisone. More potent steroids are best avoided in the flexures because they can cause skin thinning, resulting in stretch marks (striae atrophicae) and rarely, ulcers. Calcineurin inhibitors such as tacrolimus ointment or pimecrolimus cream are also effective in skin folds.

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

On DermNet

• Skin diseases and conditions affecting body folds
• Occupational skin disorders in homemakers

Other websites

• Intertrigo — Medscape Reference

Books about skin diseases

• Books about the skin
• Dermatology Made Easy book

Atopic dermatitis or skin inflammation

What is atopic dermatitis or skin inflammation?

Atopic dermatitis is a chronic skin disease with exacerbations and improvements, the main symptom of which is itching.

In atopic dermatitis, the formation of the natural protective layer of the skin is disrupted. Characterized by dry and flaky skin. During an exacerbation, inflamed red and scaly (scaly) or weeping patches appear.

Where is the atopic dermatitis rash located?

The location of the rash on the body depends on age. In infants, young children, adolescents, and adults, the location of the rash varies.

Baby (infant):

• The face and cheeks are red and rough.
• Inflammation covers the chest, back and folds of the limbs.
• The rash is symmetrical.
• Under eyes, area around mouth and nose mostly without rash.

Small child:

• The rash is located on the folds of the elbow and knee joints.
• Often rash on the neck, wrists, back of the hand, ankle.
• The skin pattern is strongly pronounced, the skin is often thickened.
• Skin shows scratch marks.

Adolescents and adults:

• The rash is localized on the elbows and knees, wrists and palms.
• The skin pattern is strongly pronounced, the skin is thickened.
• Characteristic skin fold under the eyes.

What are the complaints caused by atopic dermatitis

• Symptoms range from short and mild to severe itching and rash causing sleep disturbance.
• Due to sleep disturbances, children are tired during the day, their attention is distracted, their academic performance and ability to work are reduced.
• One of the main risk factors for exacerbation of atopic dermatitis is stress. At the same time, a visible rash and excruciating itching, in turn, lead to psychological stress, which makes it difficult to control the disease.

What is the cause of atopic dermatitis and its exacerbation

The cause of the disease is still unclear, although heredity and human environment play an important role. Exacerbation of dermatitis can cause physical and chemical irritants that get on the skin. For example, rough clothes (wool and synthetics), smelly detergents, hot water, wiping with a hard towel, cold and hot weather.

Exacerbation of atopic dermatitis can cause a general illness, which can be caused by severe respiratory tract infections or severe purulent inflammation of the skin.

Exacerbation of the rash of atopic dermatitis can cause a state of mental irritation or an allergen contained in food or air. About a third of children with atopic dermatitis are allergic to food or air allergens.

What to use for atopic dermatitis

Atopic dermatitis cannot yet be cured, but the disease can be controlled with daily skin care. To improve the elasticity of the skin, to avoid cracks, reduce itching and flaking of the skin, increase the protective function of the skin, you can smear softening base creams on dry areas of the skin several times a day. When choosing a base cream, it is very important that it is suitable for the patient and does not cause burning and redness. Zinc-containing creams reduce inflammation and soothe, but at the same time dry the skin. Zinc-containing creams can be alternated with base creams.

Creams with a high fat base generally need to be applied less frequently than water-based creams.

Considerations for atopic dermatitis

• For especially sensitive skin, use a base cream.
• Short periods of time may be spent in the shower, bath or pool
• Oils may be added to the water while taking a bath.
• Skin irritation can be avoided by using fragrance-free and color-free detergents.
• Wipe the skin with a soft towel, blotting lightly and then immediately apply the cream.
• Avoid sweating as much as possible, as this can irritate the skin.
• Choose a cool room for sleeping, as coolness reduces itching.

Compiled by: sister of the children’s clinic Tiija Kõivist

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What is atopic dermatitis?

“Dermatitis” means inflammation of the skin. And the term “atopic” is understood as a hereditary predisposition to allergies.

Most often, this disease first manifests itself in childhood. In most patients, by the age of five, atopic dermatitis goes into stable remission, but often the disease can continue in adults. The exact causes of the disease have not been established, but modern medicine believes that atopic dermatitis is a multifactorial disease, which is based on a genetic predisposition to atopic diseases.

IMPORTANT! Information from the article cannot be used for self-diagnosis and self-treatment! Only a doctor can prescribe the necessary examinations, establish a diagnosis and draw up a treatment plan for a consultation!

A tendency to atopic dermatitis can be realized when there are provoking factors in your life:

• psycho-emotional stress;
• disturbance in the functioning of internal organs;
• unfavorable environment.

It has been noticed that atopic dermatitis worsens more often in the cold season, so if skin problems arise with the onset of cold weather, there is reason to think about visiting a dermatologist.

The main symptom of atopic dermatitis is itching of varying intensity. Sometimes so strong that it can disturb the sleep of the patient. Inflammation and dryness of the skin, a variety of rashes that often accompany the disease, cause very unpleasant sensations.

There are several stages of the disease:

• Infantile (up to two years of age).

During this period, rashes, as a rule, are edematous redness, peeling on the skin of the face, on the extensor surfaces of the arms and legs. In more severe cases, blisters, weeping, and crusts may appear. In this stage, as a rule, there is a clear connection with food irritants.

• Children (from two to 12 years).

At the age of two years, atopic dermatitis in children manifests itself in the form of rashes on the skin of the elbows, popliteal fossae, and the back of the neck. The tendency to get wet decreases, nodular inflammatory elements are more often present, increased dryness of the skin, its peeling and irritation persists.

• Adult (over 12 years old).

In most patients, by this age, the disease goes into stable remission (no manifestations of the disease). With the continuation of the disease in adulthood, intense pruritus comes to the fore. Severe dryness of the skin, peeling persists. Rashes on the skin can be varied (bubbles, nodules, foci of redness). Most patients have a clear connection between exacerbations and psycho-emotional factors.

The above symptoms refer to periods of exacerbation of atopic dermatitis. During the “lull” the disease can manifest itself only as increased dryness of the skin.

Advice for people with atopic dermatitis

• People with atopic dermatitis have very sensitive skin. Such people do not want frequent water procedures, and they need to wash themselves with the use of special emollients and moisturizers, do not use a washcloth. After washing, it is better to remove water from the surface of the skin with blotting movements, and not with the usual wiping.
• Emollient and moisturizing cream for atopic dermatitis must be used daily. In clothes, preference should be given to cotton and skin contact with wool, synthetic and coarse fabrics should be avoided.
• For those suffering from atopic dermatitis, it is better to keep carpets, as well as items and furniture that contribute to the accumulation of dust, in the house. Books and clothes are best kept in lockable cabinets and vacuumed regularly. Pillows and blankets are better to use not down, but from synthetic materials.
• This disease imposes some dietary restrictions. Especially in infancy. It is very important that parents keep a food diary for their baby. It will help to clearly trace the connection between the use of a particular product and the exacerbation of atopic dermatitis.
• Many children have an increased sensitivity to milk and egg whites, which disappears with age. In the future, the significance of food allergies decreases. In adults, true food allergies are extremely rare.

However, adults with atopic dermatitis should also avoid foods that are rich in histamine or increase its release in the body:

• fermented cheeses cheeses
• cheeses
• marinades
• brewer’s yeast
• alcohol, etc.

In addition, if the patient notices a deterioration in the skin condition after consuming a particular product, then this product should also be excluded from the diet. During an exacerbation of the disease, a more stringent diet is required, excluding all irritating foods: spicy, smoked, spicy, marinades, fatty, sweet, muffin, fried, citrus fruits, honey, nuts, chocolate, alcohol. The sun is a powerful factor influencing the condition of the skin.

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Is it possible sunbathing with atopic dermatitis?

Yes, but the skin should still be protected from excess UV radiation. For example, using creams with a high degree of protection (SPF30+ and above). Apply the cream to the skin every two hours. In addition, it is better not to spend the “hottest” hours in the open sun. Even people without skin problems are advised to sunbathe either before 11 am or after 4 pm.

How to treat atopic dermatitis?

• The first step in the treatment of atopic dermatitis is the identification and elimination of triggers. At the same time, antihistamines are prescribed to eliminate the itching that bothers the patient. When choosing a drug, it is strongly recommended to consult a doctor so that he can help not only choose a medicine, but also calculate the dose corresponding to the age of the patient and the nature of the course of the disease.
• In addition, local anti-inflammatory drugs (creams, ointments), including hormonal ones, are used in the treatment of atopic dermatitis. The choice of drug should be approached very carefully, especially for infants.