Overview

Intertrigo is a prevalent skin condition triggered by friction between skin surfaces and exacerbated by warmth and humidity. It typically appears as a red rash. Excess moisture, often from perspiration, leads to skin surfaces adhering (sticking) together in areas where your skin folds over itself. The presence of moisture results in higher levels of friction, causing damage and inflammation to the skin.

Damage to the skin in intertrigo can lead to an overgrowth of bacteria and fungi usually found on the skin's surface. The perfect conditions for bacteria and fungi to thrive are created by the combination of trapped moisture, warmth, and skin damage caused by friction. The excess bacteria and fungi cause your immune system to react, leading to additional inflammation and a noticeable rash. In more serious instances, the bacterial and/or fungal overgrowth is prominent enough to lead to a secondary infection.¹

Sites of intertrigo

Intertrigo is a skin condition characterized by a rash located in flexures. This means intertrigo rash can be seen in these areas:²

• Near neck bends
• Behind the ears
• Underarms
• Below the chest 
• Groin
• Between the toes
• Between the buttocks
• Between the fingers
• Beneath the skin creases on the abdomen

Infants are particularly susceptible to intertrigo due to their sensitive skin and increased likelihood of having damp skin from drool or nappy usage. 

Types of intertrigo

Intertrigo has various names, such as intertriginous dermatitis, which depend on factors like its location and whether it is associated with an infection. One or more of these terms may be used by your healthcare provider to describe intertrigo.¹

• Acute intertrigo: when intertrigo appears suddenly it is referred to as acute intertrigo
• Recurrent intertrigo: occurs when someone experiences intertrigo multiple times over a longer period of time
• Chronic intertrigo: intertrigo becomes chronic when it lasts for six weeks or longer
• Uncomplicated intertrigo: an uncomplicated intertrigo indicates that there is no infection present in the affected area
• Interdigital intertrigo: the term used to describe intertrigo occurring between the fingers or toes
• Candidal intertrigo: occurs when Candida yeast infects the intertrigo. Candida is the primary reason for intertrigo infections
• Nappy rash: also called napkin dermatitis, is a type of intertrigo

Causes of intertrigo

The main factor that leads to intertrigo is skin irritation from rubbing against itself. This rubbing usually happens within skin creases, producing a moist, warm setting that doesn't get much air. This setting encourages the excessive growth of yeast, fungi, bacteria, and other microorganisms to gather in the impacted region. 

Babies are more prone to developing intertrigo due to their extremely sensitive skin. Infants and toddlers may also experience skin-to-skin rubbing in areas like the folds of their necks. Infants frequently have moist skin due to drooling and wearing diapers, which raises their chances of getting intertrigo as well. 

Sometimes, chemotherapy treatment can lead to intertrigo as a side effect.³

These are some common risk factors for developing intertrigo:

• Weakened immune system
• Sagging skin
• Diabetes
• Using nappies or incontinence pads
• Inadequate personal cleanliness practices
• Excessive body weight
• Lack of movement
• Lack of control over bladder or bowels
• Excess sweating (hyperhidrosis)
• Undernourishment
• Tight clothing or shoes
• Environments with high temperatures and humidity levels

Fungal infection

Candidal intertrigo is an infection of the skin folds that occurs as a result of a secondary intertrigo. Candida albicans, a type of yeast, is the fungus usually linked to this condition, it is the primary reason for all yeast infections relating to the skin. Many people have Candida albicans on their skin, and this yeast can increase in numbers and spread, especially in skin creases and similar areas of the body. A rash caused by Candida is usually characterized by intense itching and a bright red, raw appearance.

Bacterial infection

Bacterial intertrigo is a type of secondary infection that occurs when bacteria infect areas of the body with intertrigo. Staphylococcus aureus, Proteus mirabilis, Proteus vulgaris, Pseudomonas aeruginosa, and group A beta-hemolytic streptococci are bacteria linked to intertrigo.

Viral infection

Viruses can also impact the part of the body with intertrigo, leading to a secondary infection. Some of the main viruses linked to intertrigo are Poxviridae, Papillomaviridae, Picornaviridae, Retroviridae, Herpesviridae, Togaviridae, and Parvoviridae. 

Clinical features 

• Identified mainly by red patches, which are frequently mirrored
• The redness can develop into a more severe inflammation with ulcers, cracks, oozing, crusts, and softening
• Candidal intertrigo can appear as satellite macules, papules, or pustules
• Intertrigo between the toes can range from mild and symptom-free to severe with marked redness and peeling, potentially becoming erosive, foul-smelling, and soaked
• Patients may also experience excessive or pus-filled discharge and have difficulty walking. Advanced gram-negative infections can result in the presence of green discolouration at the site of infection in patients. People who are obese or have diabetes and severe toe web intertrigo are more likely to develop cellulitis (infection of the deeper layers of the skin)⁴

Diagnosis

Diagnosis of intertrigo in infants and children is mainly made by physical examination.

In severe cases, the doctor may perform some tests such as:

1. Skin scraping
2. Wood’s lamp examination
3. Skin biopsy

Treatment

A simple method for treating intertrigo in infants:^{5 1}

• Wash the area two to three times daily using gentle soap (such as unscented Dove) and water
• Use a hairdryer on a low heat setting to dry the area
• Dress your child in loose-fitting clothes, preferably made with cotton and avoid synthetic materials
• Use a drying agent preparation. Mix cornstarch powder with an aluminium hydroxide antacid product (like Mylanta, or Maalox) to create a paste, which can be applied to the affected area and left to dry. Using the Domeboro solution as a wet compress is also effective. Let the space dry naturally after finishing the application
• If you think there might be fungal involvement, consider sprinkling Mycostatin powder in the area instead. Warning: be cautious when using powder. Apply a small quantity onto your finger and rub it in by hand. Prevent sprinkling powder directly onto the baby's neck to avoid the risk of the infant inhaling the fine particles and developing reactive pneumonitis
• Build a tangible obstruction: depending on where the intertrigo is located, your child might find it helpful to put up a physical barrier around the affected area. Consider using a light cotton or gauze layer to create a barrier between your child's skin creases
• Your doctor may prescribe antifungal and antibiotic creams to apply to affected areas

Prevention

Practice these preventive measures to avoid the risk of intertrigo and keep your child's skin free from any irritation:

• Ensure that the skin remains clean and dry: remember to thoroughly clean and dry the skin, particularly in skin creases where moisture may accumulate
• Apply a barrier cream or ointment to the affected area to shield the skin from irritation and friction
• Make sure to change nappies often: to maintain cleanliness and dryness in the nappy area, change nappies frequently, ideally every 2-3 hours or immediately when they are soiled
• Ensure your child wears loose and breathable garments made from materials like cotton to promote airflow and minimize irritation
• Do not choose clothing that is too tight: do not dress your child in tight clothing, as it can lead to friction and irritation on the skin
• Use a mild soap: use a mild, gentle soap to cleanse your child's skin to prevent additional irritation
• Watch for any signs of skin irritation: pay attention to your child's skin for indications of redness, swelling, or discomfort, and respond accordingly
• If your child develops intertrigo or if the condition does not improve with home care, it is recommended to seek medical advice from a healthcare provider for additional treatment options¹

Summary

Intertrigo is a prevalent skin problem that occurs when skin surfaces rub against each other, and is exacerbated by heat and humidity. It appears as a red rash and can be made worse by factors such as too much moisture, an increase in bacteria and fungus, and weakened immune systems. Intertrigo often occurs in regions where the skin creases, like the neck, groin, and underarms. It may present as acute, recurring, chronic, simple, or linked to particular infections such as candidal intertrigo or nappy rash. Reasons for this condition can be attributed to skin irritation, compromised immune systems, diabetes, tight clothing, and various other factors. The treatment includes maintaining cleanliness and dryness in the affected area, using drying agents, applying barrier creams, and wearing breathable clothing. Preventive measures consist of staying clean, changing nappies often, wearing loose attire, using gentle soap, and consulting a doctor if necessary.