Introduction

Intertrigo, also known as intertriginous dermatitis (ITD), is a common inflammatory skin illness caused by skin-on-skin friction in skin folds, which results in moisture becoming trapped due to inadequate air circulation.¹ 

This can occur anywhere on the body when two skin surfaces come into close contact, including the interdigital regions, although it is more common in the body's natural big skin folds, such as the axillary, inframammary, umbilical, perianal, and inguinal areas .²

Intertrigo begins as moderate mirror-image erythema in the skin folds, but it can proceed to more severe inflammation, including erosion, leaking, exudation, maceration, and secondary infection. Moist, injured skin can get secondary infected with bacteria, yeast, and fungi. Visual manifestations of intertrigo include redness in a minor format and moist skin. Patients may complain of itching, burning feeling, pain and odour.^1,3

Diagnosis

Intertrigo, a prevalent skin issue in skin folds, can occasionally mimic other skin disorders. Doctors examine the skin and inquire about symptoms to distinguish between them. They consider the issue's location, duration, and factors that either contribute to or worsen it. They also inquire about pain, burning, itchiness, and smell.³ 

To aid in diagnosis, doctors also look for any family history of skin conditions or drug allergies. Asking questions and checking the skin to ensure something else isn't the issue are the main steps in diagnosing intertrigo. Inverse psoriasis may be diagnosed based on a personal history of psoriasis. Compiling a complete medication history is always a good strategy to rule out cutaneous drug responses.^{1, 3}

The typical physical features of mirror-image erythema, coupled with inflammation and erosion in the skin folds, are typically sufficient to make the diagnosis of intertrigo.¹ Physical examinations with obese patients can be challenging and necessitate the patient lying flat. Assistance may be needed to fully check the depth of the skin folds. A physical examination entails a thorough inspection of the skin, which involves checking the mucous membranes, and the entire skin, evaluating any problems from intertrigo, including secondary infections, and screening for any skin conditions that may be related. Every element that may be contributing should be assessed, including the skincare routine currently followed and the sources of excessive moisture (such as sweating and/or faecal incontinence).^{3, 4}

Even though secondary infections are typically diagnosed clinically and treated empirically, confirmation can be acquired by using a microscope to examine skin scrapings that have been treated with a potassium hydroxide solution. Dermatophytic lesions are confirmed by the presence of hyphae, while Candida is confirmed by the presence of pseudohyphae.⁵

Samples may also be sent for formal mycological examination and specific stains used, such as periodic acid–Schiff stain, particularly if an unusual species is suspected and given the rise in antifungal resistance. The use of a Wood's lamp may be useful in the simple determination of secondary bacterial infection, producing a green fluorescence with Pseudomonas and coral red with Corynebacterium minutissimum.^{3, 4} Skin scrapings and swab samples may also be sent for bacteriological culture and sensitivity reporting, particularly in cases unresponsive to initial therapy and treatment, guided by local antimicrobial policy.¹

Treatment

The standard method for intertrigo management is to reduce moisture and friction with absorptive powders like cornflour or barrier lotions. Patients should dress in light, non-constricting, absorbent clothing and avoid wool and synthetic fibres. Physicians should educate patients on heat, humidity, and outdoor activities. Physical exercise is normally recommended, but patients should shower and thoroughly dry their intertriginous areas afterwards. Wearing open-toe shoes can help with toe web intertrigo. Secondary bacterial and fungal infections should be treated with antiseptics, antibiotics, or antifungals, depending on the pathogen.⁶

Candidal intertrigo, which primarily affects the fourth and fifth interdigital spaces of the foot, is common in those who work in moist environments and wear occlusive footwear. The infection improves with topical antifungals but recurs until the triggering conditions are eliminated. Because it is critical to keep the area dry, several ways, such as utilising cork or a gauze piece rolled and placed between the toes, are tested.⁶

Castellani's paint is an effective treatment for tinea cruris and moniliasis in intertriginous areas. We dampened normal blotting paper with Castellani's paint and allowed it to dry. The magenta-coloured blotting paper was cut into strips and applied to the interdigital region (Figure 2) once a day before bedtime for five days. Although any antifungal lotion could have been investigated, we chose Castellani's paint because it is coloured. Visual knowledge of skin colouration and drug release into water was critical for the investigation.⁶

Gramme staining verified the presence of Candida intertrigo in four cases. All of the patients improved with treatment. Blotting paper was employed to keep the interdigital region dry, and Castellani's paint was applied to manage the infection. The use of magenta-coloured paper resulted in discolouration of the treatment site, confirming dye release. 

We recommend using blotting paper soaked in an antifungal solution and dried to deliver the medicine while also drying the infected interdigital area. As previously indicated, we used paint to see the drug on the paper and its diffusion across the treated region. The same treatment is predicted to be effective even with colourless antifungal solutions that are currently available.⁶

Antimyocytes (anti-fungal medication)

Antifungal drugs operate by identifying and eradicating the fungus that causes the illness, thereby lowering inflammation, itching, and discomfort associated with intertrigo. These drugs come in a variety of formulations, including lotions, ointments, powders, and oral tablets or capsules.⁷

Topical antifungal creams or ointments are commonly used as the first line of treatment for intertrigo. Once the area has been thoroughly washed and dried, these medications are applied directly to the affected skin folds, usually once or twice daily. Topical antifungals work by penetrating the skin and attacking fungus in the affected area. Terbinafine, clotrimazole, miconazole, econazole, and ketoconazole are all topical antifungal medicines.Oral antifungal medications may be advised in more severe or chronic episodes of intertrigo. Typical oral antifungal medications include itraconazole, fluconazole, and itraconazole.^{7, 8}

Amphotericin-b lotion

Amphotericin B lotion has demonstrated encouraging benefits in lowering fungal infections and easing related symptoms when used to treat monilial intertrigo. Usually, patients with monilial intertrigo are told to follow their doctor's recommendations and apply Amphotericin B lotion to the afflicted skin folds. The way this antifungal drug functions is by specifically identifying and getting rid of the fungus causing the infection. Amphotericin B lotion's antifungal qualities serve to improve the health of the afflicted skin by reducing symptoms, including redness, itching, and irritation. Amphotericin B lotion is a good therapeutic choice for people suffering from monilial intertrigo, as clinical trials have proven its efficiency in treating this ailment.⁹

Corticosteroids

Corticosteroids were used in 17 studies to treat intertrigo, with only four utilising them alone. One study randomly assigned patients. The average study size was 28, ranging from 7 to 78 individuals. While corticosteroids demonstrated a modest impact, insufficient comparison data and the absence of placebo-controlled trials necessitate additional research to evaluate their true value.⁷

Antiseptics

Five trials used a topical antiseptic to treat skin fold concerns, although only one of them focused on the antiseptic as the primary treatment. The study examined two different antiseptics, eosine and cicalfate, in 49 patients who had comparable skin fold issues. However, the patients were not randomly randomised to receive either antiseptic. Cicalfate was found to be extremely efficient in curing 40 out of 49 lesions, while eosine was effective in 31 out of 49 lesions.⁷

Overall, because there was insufficient research and the one comparative study was not randomised, we cannot safely state how beneficial antiseptics are for treating skin fold concerns. More research is required to reach a firm conclusion.

Treatment with surgery

15 studies focused on surgical treatment for women with macromastia, a disorder in which the breasts are abnormally enormous. All of these trials involved reduction mammaplasty, which is a type of surgery that reduces breast size. While no research compared this operation to other therapies, the majority of them found that the number of women experiencing intertrigo under the breasts fell dramatically following the surgery. Despite the lack of robust comparison groups or placebo treatments, all of these investigations yielded comparable results: a significant reduction in intertrigo following surgery. This shows that reduction mammaplasty may alleviate intertrigo in women with macromastia, but more research with more rigorous study designs is required to confirm this.¹⁰

Summary

To conclude, intertrigo is a common skin disorder caused by friction and moisture in skin folds, which can result in irritation and infection. Diagnosis involves examining symptoms and skin appearance, ruling out other disorders, and possibly providing testing. Treatment options include antifungal medications, corticosteroids, antibiotics, and antiseptics, as well as, in some cases, surgical techniques. While certain treatments show promise, more research is needed to fully evaluate their effectiveness.⁹ Overall, controlling intertrigo necessitates a multimodal approach suited to each individual's needs, with a focus on prevention, adequate cleanliness, and timely medical intervention as needed.⁸

Furthermore, there has been little research into treating intertrigo. Although there have been attempts to treat intertrigo in large skin folds, the designs of these studies have been unsatisfactory, and we need better-designed studies to provide more accurate data. Without more evidence, it is impossible to create clear clinical guidelines for managing this illness.⁹