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Intertrigo

Intertrigo is a common superficial inflammatory dermatosis that occurs in areas where skin surfaces rub against each other, such as the axillae, inframammary folds, abdominal creases, groin, and gluteal cleft, primarily due to friction, heat, and moisture leading to skin irritation and potential secondary infections.^[1]^[2] The condition arises from mechanical factors like skin-on-skin friction exacerbated by maceration in warm, humid environments, which disrupt the skin barrier and promote microbial overgrowth.^[1] Risk factors include obesity, diabetes mellitus (due to elevated skin pH and impaired immunity), hyperhidrosis, incontinence, and immobility, with higher prevalence in infants (as diaper dermatitis), the elderly in long-term care (16-38% incidence), and individuals in hot climates.^[1]^[2] There is no specific gender or ethnic predisposition, though it affects all ages.^[1] Clinically, intertrigo presents as erythematous, macerated plaques that may be pruritic, painful, or burning, progressing to erosions, fissuring, or weeping if untreated; secondary infections often introduce satellite pustules, foul odor, or crusting.^[3] Common pathogens include Candida species (causing candidal intertrigo with characteristic satellite lesions), bacteria such as Staphylococcus aureus or Streptococcus pyogenes, and occasionally dermatophytes or Corynebacterium minutissimum (leading to erythrasma).^[1]^[3] Diagnosis is typically clinical based on history and examination, but may involve potassium hydroxide (KOH) preparation for fungi, bacterial cultures, or Wood's lamp for confirmation of specific infections.^[1]^[2] Management focuses on eliminating predisposing factors through weight reduction, glycemic control, and hygiene practices like gentle cleansing and thorough drying, alongside barrier protection with absorbent powders or zinc oxide.^[3] Topical therapies target inflammation and infection: low-potency corticosteroids (e.g., hydrocortisone 1%) for simple cases, antifungals (e.g., clotrimazole or miconazole) for candidal involvement, and antibiotics (e.g., mupirocin) for bacterial superinfection; severe or refractory cases may require oral agents or referral.^[1]^[3] Prevention emphasizes moisture control with breathable clothing, antiperspirants, and regular skin inspections, yielding excellent prognosis with low recurrence when addressed promptly.^[2]

Characteristics

Definition

Intertrigo is an inflammatory dermatosis that develops in areas of skin-to-skin contact, particularly within skin folds, where friction is intensified by heat and moisture, resulting in maceration and disruption of the skin barrier.^[1] This condition arises primarily from mechanical irritation rather than an initial infectious process, leading to superficial inflammation of the affected cutaneous surfaces.^[3] It commonly affects flexural regions such as the axillae, inframammary folds, abdominal creases, groin, gluteal cleft, neck folds in infants, and interdigital spaces.^[4] These sites are predisposed due to their warm, occluded environment that traps perspiration and promotes ongoing irritation.^[5] Unlike deeper dermatoses or primary infectious conditions, intertrigo is characterized by superficial involvement without extension into subcutaneous tissues and is initially noninfectious, though it is highly susceptible to secondary bacterial or fungal colonization.^[1] The term "intertrigo" derives from the Latin words inter (meaning "between") and terere (meaning "to rub"), reflecting the frictional etiology central to its pathogenesis.^[1]

Epidemiology

Intertrigo is a common condition, though precise prevalence in the general population remains elusive due to underreporting and variability in diagnostic criteria. Studies indicate rates ranging from 2% to 10% across community and outpatient settings, with a prospective study in Senegal reporting 2.5% among adults attending dermatology units. In healthcare environments, prevalence is notably higher: approximately 2% in hospitals, 6.7% in aged care facilities, and 9.6% in home care, based on multicenter data from the Netherlands. Among institutionalized elderly, rates can reach 16% to 38%, underscoring its burden in long-term care.^[6]^[7]^[2] Demographically, intertrigo affects individuals across all ages, with no overall ethnic or gender predilection, though some nursing home studies show a slight increase among females (odds ratio 1.29). It peaks in infants due to diaper-related moisture in the groin area, in obese adults with BMI greater than 30 kg/m² owing to increased skin folds, and in the elderly due to immobility and dependency. The condition is more prevalent in warm, humid climates and during summer months, as heat exacerbates moisture retention and friction in skin folds. Global distribution reflects this, with higher reports from tropical and subtropical regions.^[1]^[8]^[2]^[9] Associated comorbidities significantly elevate risk, particularly diabetes mellitus, where intertrigo accounts for up to 20.5% of non-candidal skin conditions in patients with diabetes, with cutaneous manifestations overall affecting 30-70% of individuals and infections being common (31.7%). Immunosuppression and incontinence further increase incidence, often co-occurring with obesity in up to 50% of cases in high-risk groups. Temporal trends show no major shifts in baseline incidence over decades, but rising global obesity rates correlate with increased occurrences, as evidenced by studies linking BMI trends to higher intertrigo prevalence; recent studies as of 2025 continue to highlight high prevalence in severe obesity (e.g., 15.9% in patients with mean BMI 46.4 kg/m²).^[10]^[9]^[11]^[12]

Clinical manifestations

Signs

Intertrigo primarily manifests as symmetrical erythematous plaques in opposing skin folds, characterized by ill-defined borders and a shiny, moist appearance due to maceration from trapped moisture and friction.^[1]^[13]^[3] These plaques often appear red or reddish-brown and may progress to superficial erosions, fissures, or crusting if untreated.^[4]^[14] Secondary features include satellite papules or pustules surrounding the main lesion, particularly in cases of candidal superinfection, along with possible weeping, additional crusting, or a foul odor indicative of bacterial overgrowth.^[1]^[13]^[3] Infectious contributions, such as fungal or bacterial involvement, can alter the appearance by adding pustules, vesicles, or purulent discharge.^[11] Site-specific variations are notable; for instance, lesions in the groin tend to exhibit more weeping and maceration due to higher moisture levels, while those in the axillae may show scaling alongside erythema.^[4]^[13] In infants, intertrigo often presents as a bright red rash in the diaper area or skin folds, initially without prominent satellite lesions.^[4] Severity can be graded as mild, featuring superficial erythema without breakdown; moderate, with erosions and fissuring; or severe in neglected cases, potentially leading to ulceration and localized necrosis from secondary infections.^[3]^[11]^[14]

Symptoms

Patients with intertrigo commonly report pruritus, or itching, along with sensations of burning, stinging, tingling, or soreness in the affected skin folds.^[1]^[4]^[3] These symptoms often intensify with factors such as skin friction from movement, increased sweating, or exposure to heat and humidity, which exacerbate moisture accumulation and irritation in the flexural areas.^[1]^[4]^[3] The pain associated with intertrigo is typically described as a dull ache in mild cases but can become sharp or more intense with ongoing friction or the development of secondary infections.^[1]^[3] Complications such as cellulitis can further intensify the pain.^[1] Intertrigo usually has an insidious onset, developing chronically over days to weeks, though acute exacerbations frequently occur during periods of hot weather or illness, leading to heightened symptom severity.^[1]^[3] The condition significantly impacts quality of life, with persistent itching often causing sleep disturbances and, in cases involving the groin, difficulty with walking due to discomfort and functional limitations.^[3]^[4] Additionally, the unpleasant odor arising from maceration or secondary infections can lead to embarrassment and social withdrawal.^[3]^[4]

Etiology

Mechanical factors

Intertrigo primarily arises from mechanical irritation in areas where skin folds oppose each other, such as the axillae, groin, inframammary regions, and abdominal folds. The core mechanism involves skin-on-skin friction that generates heat and shear forces, which trap moisture from sweat, urine, or feces, leading to epidermal maceration and breakdown of the skin barrier.^[1]^[2]^[4] Environmental factors exacerbate this process by promoting excessive perspiration and moisture retention. High humidity and elevated temperatures increase sweating in intertriginous areas, while occlusive clothing or bedding further impedes evaporation and airflow, intensifying the maceration effect.^[1]^[2]^[3] Biomechanical elements amplify friction and pressure in susceptible individuals. Obesity deepens skin folds, thereby increasing the surface area for contact and elevating local skin temperature, which heightens the risk of irritation. In bedridden or immobile patients, prolonged pressure from dependent positioning sustains shear forces and moisture accumulation, particularly when combined with incontinence.^[1]^[3]^[4] The initial inflammatory response stems from this mechanical disruption of the epidermal barrier, triggering the release of cytokines that promote erythema and edema independent of microbial involvement.^[3]^[4]

Infectious factors

Intertrigo, while primarily resulting from mechanical irritation, is frequently complicated by secondary infections that exacerbate inflammation and tissue damage. The most common infectious agents are fungal, with Candida albicans accounting for the majority of cases, often thriving in the occluded, warm, and moist skin folds to produce characteristic satellite papules or pustules adjacent to the primary erythematous area.^[3] ^[1] Bacterial superinfections are also prevalent, primarily involving gram-positive organisms such as Staphylococcus aureus and group A beta-hemolytic Streptococcus (Streptococcus pyogenes), which can lead to the formation of pustules, erosions, or deeper tissue involvement with increased erythema and exudate.^[3] ^[14] Less frequently, gram-negative bacteria like Pseudomonas aeruginosa may colonize highly macerated areas, such as interdigital spaces, resulting in a green discoloration and foul odor due to bacterial overgrowth.^[3] Dermatophyte infections, such as those caused by Trichophyton species, are rare in intertrigo but can occur in interdigital variants, while viral superinfections, including herpes simplex virus, are uncommon and typically limited to immunocompromised individuals.^[1] ^[3] The pathogenic process is facilitated by initial skin maceration from prolonged moisture and friction, which compromises the epidermal barrier and permits microbial invasion; Candida species, in particular, adhere to and penetrate the damaged stratum corneum in these humid microenvironments, promoting further inflammation and lesion spread through satellite pustules.^[1] ^[3] Secondary superinfection develops in a significant proportion of cases, particularly among individuals with diabetes mellitus, where hyperglycemia impairs neutrophil function and elevates skin pH, creating an optimal niche for opportunistic pathogens; notably, intertrigo lacks a primary infectious origin and arises instead from noninfectious triggers.^[3] ^[15]

Diagnosis

Clinical evaluation

The clinical evaluation of intertrigo begins with a detailed history taking to identify risk factors and contextualize the presentation. Clinicians inquire about the onset, which is often insidious and chronic, accompanied by pruritus, burning, or pain in affected skin folds, with acute exacerbations potentially signaling secondary infection.^[1] Aggravating factors such as exposure to heat, humidity, friction from skin-on-skin contact, and hyperhidrosis are explored, alongside comorbidities like obesity, diabetes mellitus, incontinence, or immunosuppression that predispose individuals to the condition.^[9] Hygiene practices, including cleaning and drying routines in intertriginous areas, are assessed, as poor hygiene exacerbates moisture retention, while prior treatments such as topical steroids, antibacterial agents, or ointments are reviewed to gauge response and potential complications.^[4] Physical examination focuses on direct inspection and palpation of skin folds, including the axillae, inframammary regions, abdominal creases, groin, and intergluteal cleft. Affected areas typically show symmetrical erythematous plaques with peripheral scaling, maceration, erosions, or weeping due to trapped moisture, often accompanied by a foul odor in cases of secondary candidal involvement.^[9] Palpation evaluates for tenderness, induration, or warmth, which may indicate deeper inflammation or infection, while the distribution and symmetry are noted—bilateral involvement supports uncomplicated intertrigo, whereas unilateral lesions warrant further scrutiny.^[1] Typical signs such as satellite pustules or vesicles, as described in clinical manifestations, aid in recognizing potential superinfections during this assessment.^[3] Red flags during evaluation include systemic symptoms such as fever, chills, or lymphadenopathy, which suggest cellulitis or deeper bacterial involvement beyond superficial intertrigo.^[9] Asymmetry in lesion distribution or atypical features like intense erythema with purulent discharge may indicate alternative or complicated diagnoses, prompting escalation of care.^[1] Diagnosis of intertrigo is primarily clinical, relying on characteristic location in flexural areas, morphological appearance, and initial response to basic hygiene measures, without a formal scoring system.^[4] In most cases, no additional testing is required if the history and examination align with these features.^[3]

Laboratory investigations

Laboratory investigations for intertrigo are generally unnecessary when the clinical diagnosis is straightforward but become essential in cases of diagnostic uncertainty, suspected secondary infection, or treatment failure. These tests help confirm microbial involvement and guide therapy while ruling out alternative conditions.^[16]^[1] Skin scrapings represent the primary laboratory approach for detecting infectious etiologies. Material is collected from the lesional scale and examined microscopically after treatment with 10-20% potassium hydroxide (KOH) solution, which dissolves keratin to reveal fungal elements such as pseudohyphae, hyphae, or budding yeast forms indicative of Candida species. This method aids in identifying cutaneous candidiasis, though false negatives can occur due to low fungal burden or improper sampling. For suspected bacterial superinfection, Gram staining of the scrapings can identify gram-positive organisms like Staphylococcus aureus or Streptococcus species, providing rapid preliminary insights into the microbial profile.^[1]^[17]^[3] Microbial cultures are indicated for refractory, severe, or atypical presentations to enable precise identification and antimicrobial susceptibility testing. Swabs from the affected skin folds are cultured on appropriate media for bacteria (e.g., blood agar) and fungi (e.g., Sabouraud dextrose agar), which can confirm pathogens such as Candida albicans, dermatophytes, or bacteria and inform targeted therapy selection, particularly in polymicrobial cases. While swabs are convenient, they may yield lower recovery rates for certain fungi compared to scrapings or biopsies, emphasizing the need for optimal collection techniques.^[16]^[3]^[18] Wood's lamp examination may be used for suspected erythrasma, revealing a characteristic coral-red fluorescence due to Corynebacterium minutissimum.^[9] Skin biopsy is infrequently performed, reserved for scenarios where intertrigo mimics more serious disorders such as cutaneous malignancy, psoriasis, or autoimmune conditions like pemphigus. A punch or shave biopsy reveals nonspecific histopathological features, including acanthosis, parakeratosis, spongiosis, and a mixed inflammatory infiltrate, without pathognomonic changes for intertrigo itself. Biopsy is particularly warranted if lesions persist despite adequate treatment or exhibit atypical morphology.^[16]^[3]^[1] Beyond direct skin assessments, fasting blood glucose testing is recommended in recurrent or unexplained intertrigo to screen for underlying undiagnosed diabetes mellitus, which predisposes individuals through impaired immunity and increased skin moisture. No routine imaging studies, such as ultrasound or MRI, are advised unless there is clinical evidence of deeper extension like cellulitis.^[1]^[16]

Treatment

Nonpharmacological approaches

Nonpharmacological approaches to managing intertrigo primarily focus on alleviating the mechanical factors that exacerbate skin fold irritation, such as moisture accumulation and friction, to promote healing and prevent worsening. These strategies emphasize supportive care to restore the skin barrier and reduce environmental contributors to the condition. Initial steps involve gentle skin cleansing using a mild, fragrance-free soap followed by thorough patting dry with a soft towel to remove excess moisture without causing further abrasion.^[4] ^[3] For enhanced drying, patients can use a hairdryer on a cool setting several times daily or apply talc-free absorbent powders such as antifungal powders (e.g., miconazole-containing) to absorb residual dampness in the folds.^[4] ^[14] Barrier creams containing zinc oxide can also be applied to create a protective layer that minimizes moisture contact with the skin while allowing it to breathe.^[19] ^[1] Reducing friction between opposing skin surfaces is essential, particularly in areas like the groin, axillae, or inframammary folds, where constant rubbing perpetuates inflammation. Recommendations include wearing loose-fitting, breathable clothing made from natural fibers such as cotton to allow air circulation and prevent occlusion.^[3] ^[20] To physically separate skin folds, cotton wicks, gauze, or soft linen cloths can be placed between affected areas, especially during periods of prolonged contact like sitting or sleeping.^[19] ^[21] For obese individuals, where excess skin weight contributes to persistent friction, gradual weight loss through diet and exercise is advised as a long-term supportive measure to reduce fold depth and improve access for care; innovative options like moisture-wicking fabrics may aid in severe cases.^[3] ^[20]^[12] Environmental modifications play a key role in controlling ambient conditions that promote perspiration and humidity. Patients should avoid hot, humid environments and utilize fans, air conditioning, or dehumidifiers to maintain cooler, drier air around the body.^[19] ^[1] For bedbound individuals, frequent position changes every two hours help prevent prolonged pressure and moisture buildup in dependent folds.^[21] In cases of excessive sweating, absorbent towels placed under areas like the breasts can wick away moisture during daily activities.^[21] When intertrigo progresses to erosions or superficial ulcerations, wound care involves protecting the damaged skin to facilitate re-epithelialization without adhesion. Nonadherent dressings, such as silicone-based or petrolatum-impregnated gauze, can be applied to eroded areas to shield them from friction while allowing drainage if needed.^[19] ^[1] These measures, combined with the aforementioned drying and friction reduction techniques, typically lead to noticeable improvement within 1 to 2 weeks, provided underlying mechanical triggers like moisture are consistently addressed.^[4] ^[14]

Pharmacological interventions

Pharmacological interventions for intertrigo primarily target the underlying infectious and inflammatory components, guided by clinical evaluation and laboratory confirmation of pathogens such as Candida species or bacteria.^[1] Topical antifungals serve as first-line therapy for candidal involvement, with azole agents like clotrimazole 1% cream applied twice daily for 2 weeks being preferred due to their broad efficacy against Candida and potential dermatophytes, outperforming nystatin in cases of mixed infections.^[9]^[21] Nystatin ointment or powder, applied similarly, achieves clinical cure rates of approximately 85% in uncomplicated candidal diaper dermatitis but is limited to Candida-specific cases.^[21] For resistant infections, oral fluconazole at 100-200 mg daily for 7 days may be used, particularly in obese patients requiring dose adjustment.^[9]^[1] Antibacterial agents address superinfections, with topical mupirocin applied twice daily recommended for mild bacterial involvement, such as staphylococcal or streptococcal overgrowth.^[9]^[1] In cases of associated cellulitis, oral antibiotics like cephalexin 500 mg four times daily for 7-10 days provide effective coverage against gram-positive pathogens.^[22]^[1] Low-potency topical corticosteroids, such as hydrocortisone 1% cream applied once or twice daily for short durations (up to 1-2 weeks), offer relief from inflammation and pruritus without significant risk of skin atrophy in flexural areas.^[9]^[1] Combination therapies integrating antifungals and low-potency corticosteroids are supported for inflamed, infected intertrigo, though monotherapy is preferred in uninfected cases to minimize resistance risks; apply antifungals and low-potency steroids separately if needed.^[9]^[21]

Prevention

Hygiene measures

Maintaining proper hygiene is essential for preventing intertrigo by reducing moisture accumulation and friction in skin folds. Daily cleansing of affected areas, such as the axillae, groin, and abdominal folds, should involve washing with lukewarm water and a mild, fragrance-free soap to gently remove sweat and debris without irritating the skin.^[1]^[4] Harsh antiseptics or antibacterial soaps should be avoided in uninfected cases, as they can disrupt the skin's natural barrier and promote dryness or further irritation.^[23] After cleansing, the skin must be patted dry immediately using a soft, clean towel rather than rubbed, to minimize friction and ensure thorough removal of moisture.^[4] Effective drying techniques further aid in prevention by promoting an environment less conducive to microbial growth. Applying moisture-wicking or absorbent powders, such as those containing cornstarch or aluminum acetate, after drying can help absorb residual sweat and reduce humidity in the folds.^[1] Additional methods include using a fan or a hairdryer on the cool setting several times daily to enhance evaporation in hard-to-reach areas.^[4] Clothing choices play a key role in hygiene routines by facilitating airflow and reducing skin-on-skin contact. Opt for loose-fitting garments made from breathable, absorbent fabrics like cotton, which allow moisture to escape and minimize irritation from synthetics or tight materials.^[1]^[4] In patients with incontinence, clothing and undergarments should be changed promptly after soiling to prevent prolonged exposure to urine or feces, which exacerbates moisture buildup.^[23] For infants, who are particularly susceptible to intertrigo in areas like the neck, thighs, or diaper region, hygiene measures emphasize frequent diaper changes—ideally every 2 to 3 hours or immediately after soiling—to limit moisture contact.^[4] At each change, apply a barrier cream containing zinc oxide or petrolatum to protect the skin and monitor folds daily for early signs of redness or irritation.^[1]^[24]

Lifestyle modifications

Lifestyle modifications play a crucial role in reducing the recurrence of intertrigo by addressing underlying factors that promote skin fold irritation and moisture accumulation. For individuals with obesity, a major risk factor linked to higher intertrigo prevalence—such as 44.7% in obese versus 6.8% in those with normal BMI—gradual weight loss through balanced diet and regular exercise is recommended to decrease skin folds and friction.^[11] Post-bariatric weight loss has been associated with intertrigo resolution in cases where excess skin is reduced, highlighting the potential for risk mitigation through sustained BMI decreases.^[25] Managing comorbidities is essential for intertrigo prevention. In patients with diabetes, optimizing glycemic control to an HbA1c level below 7% can lower the risk of secondary skin infections that exacerbate intertrigo, as poor control impairs skin barrier function and immunity.^[26] For those with urinary or fecal incontinence, using absorbent pads or undergoing behavioral therapy reduces moisture exposure in skin folds, thereby minimizing irritation and infection risk.^[9] Adjusting daily activities helps alleviate mechanical stress on susceptible areas. Avoiding prolonged sitting, which can trap heat and moisture in gluteal or abdominal folds, and opting for loose-fitting clothing reduce friction; similarly, wearing well-supportive bras minimizes rubbing in inframammary regions.^[27] Environmental adaptations further support intertrigo management, particularly in humid settings. Maintaining a cool, dry indoor environment through air conditioning or fans prevents sweat accumulation, while using dehumidifiers in high-humidity climates like tropical regions can significantly lower recurrence by controlling ambient moisture levels.

References

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Intertrigo is a common inflammatory skin condition that is caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture.
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Oct 14, 2024 · Intertrigo is inflammation of the skin folds. It tends to occur in warm, moist areas of the body where two skin surfaces rub or press against each other.
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Apr 15, 2019 · In a prospective study in two dermatology units in Senegal, the prevalence of intertrigo was reported to be 2.5% for adults with an average age ...
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The prevalence of intertrigo was highest in home care (9.6% (95% CI 8.6% to 10.6%)) followed by aged care facilities (6.7% (95% 6.4 to 7.0)) and hospitals (2% ...
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