Intertrigo

INTRODUCTION — 

Intertrigo, or intertriginous dermatitis, is a common inflammatory condition of skin folds characterized by moist erythema, malodor, weeping, pruritus, and tenderness (picture 1A-D). Initiating factors include moisture and friction associated with an absence of air circulation in deep skin folds. In addition, candidal or bacterial infection may initiate or aggravate intertrigo.

The diagnosis is usually straightforward and based on the clinical findings. Intertrigo usually responds rapidly to treatment but typically recurs if contributory factors persist.

The clinical features, diagnosis, and management of intertrigo will be reviewed here. Intertrigo involving the diaper area of young children and the diagnostic approach to intertriginous skin disorders are reviewed separately:

●(See "Diaper dermatitis".)

●(See "Approach to the patient with an intertriginous skin disorder".)

PATHOGENESIS — 

The pathophysiology of intertrigo involves predisposing factors that often coincide to promote inflammation within deep skin folds. Moisture and friction are the primary predisposing factors. Skin infections and contact dermatitis may also play a role in intertrigo.

●Moisture and friction – Rubbing of warm, moist skin against opposing moist skin leads to maceration and denudes the stratum corneum [1]. This may expose Langerhans cells to irritants and pathogens, such as Candida and bacteria, stimulating an immune reaction [1].

●Infection or colonization – Fungal or bacterial infection or colonization of the skin may contribute to intertrigo through initiating innate or acquired immune-mediated inflammatory cascades. Candidal infection is common in intertrigo and may exacerbate or induce its development. Secondary bacterial infection may also occur, particularly in areas of excoriated skin.

Seborrheic dermatitis, an inflammatory disorder in which fungi in the genus Malassezia are thought to play a role, may present with findings consistent with intertrigo. (See 'Clinical features' below.)

●Contact dermatitis – Concomitant irritant contact dermatitis, allergic contact dermatitis, or incontinence-associated dermatitis may worsen symptoms in patients with intertrigo. The chronically irritated skin in intertrigo increases susceptibility to contact dermatitis.

•Allergic contact dermatitis – Common causes of allergic contact dermatitis include fragrances in perfumes, colognes, and moisturizers; preservatives in moisturizers and diaper wipes (eg, methylchloroisothiazolinone and methylisothiazolinone); and topical medications (including topical corticosteroids). (See "Allergic contact dermatitis: Clinical features and diagnosis" and "Common allergens in allergic contact dermatitis".)

•Irritant contact dermatitis – Irritant contact dermatitis may result from soaps, detergents, and other irritants that are not thoroughly rinsed from the skin in the involved areas. (See "Irritant contact dermatitis in adults".)

•Incontinence-associated dermatitis – Incontinence-associated dermatitis describes moisture-associated skin inflammation and breakdown due to prolonged contact with urine or feces [2].

RISK FACTORS — 

The chronic presence of moisture within deep skin folds and skin friction predisposes to intertrigo. Examples of related risk factors include:

●Age – Intertrigo can affect individuals of all ages. However, it is most common in infants and bedridden older adults because of immobility and minimal aeration of intertriginous areas.

Data from studies of patients in nursing homes and hospitals support the frequent occurrence of intertrigo in older adults and seriously ill populations [3,4]. In a study of data from over 40,000 patients from four cross-sectional studies in the Netherlands, almost 10 percent of patients receiving nursing care at home and 7 percent of patients in nursing homes had intertrigo [3].

●Medical conditions predisposing to moisture or friction in skin folds – Medical conditions that contribute to moisture and/or friction within skin folds may promote intertrigo. Examples include obesity, incontinence, and hyperhidrosis.

In addition, significant weight loss may lead to excessive, sagging skin and deep skin folds, thereby increasing the risk for intertrigo [5,6]. (See 'Surgical reduction of skin folds' below.)

●Wet work involving the hands – Erosio interdigitalis blastomycetica (picture 1D), a variant of candidal intertrigo that occurs in web spaces of the digits, typically occurs in association with frequent wet work involving the hands (eg, dishwashing).

●Athletics – Frequent exercise may increase the risk for intertrigo [7]. Repetitive movements and sweating can cause the accumulation of the effects of heat, humidity, and frictional stress from clothing in intertriginous areas, leading to skin maceration.

●Infections – Cutaneous infections, particularly Candida infection, may initiate or exacerbate intertrigo. Examples of factors that may increase risk for skin infection include poor hygiene and immune deficiencies (eg, diabetes mellitus, HIV [human immunodeficiency virus] infection, chemotherapy, or malnutrition).

CLINICAL FEATURES — 

Intertrigo can occur in any area where skin opposes skin.

Classic features

●Skin lesions – The hallmark clinical finding is a moist, erythematous, dyspigmented, homogenous patch within deep skin folds (picture 1B and picture 1A, 1C-D). Patients with moderately to darkly pigmented skin are most likely to exhibit hyperpigmentation (picture 1A). Hypopigmentation may also occur.

●Distribution – Most cases of intertrigo occur in the deep folds of the groin, though it is also common in the axillary area, inframammary area, umbilicus, and under the panniculus. Neck fold involvement is common in infants, often due to the moisture associated with drooling, and may also occur in individuals with torticollis (picture 2). The antecubital fossae and popliteal fossae can be involved in patients with limb contractures.

●Symptoms – Patients with intertrigo may complain of burning, tenderness, pruritus, and/or a malodorous discharge within the affected areas. When fissuring occurs, the involved areas can be painful. Scratching can lead to excoriations and bruising.

Clinical variants

●Candidal intertrigo – Inflamed satellite papules and pustules occurring in association with the moist erythematous or dyspigmented patches of intertrigo suggest candidal involvement (picture 3). However, satellite papules and pustules may be few or absent.

●Erosio interdigitalis blastomycetica – Erosio interdigitalis blastomycetica (candidal intertrigo of the finger or toe web spaces) presents with moist erythema and fissuring in the deepest part of the web space (picture 1D). On the feet, it usually involves the third and fourth or fourth and fifth web spaces. Despite the name, there is no relationship to infection with the Blastomycetes fungal organism.

●Seborrheic dermatitis-associated intertrigo – Intertrigo may occur in association with seborrheic dermatitis in infants and adults (picture 4A-B). These patients usually exhibit erythema and scale in other areas characteristic for seborrheic dermatitis, such as the face, retroauricular skin, and scalp. (See "Seborrheic dermatitis in adolescents and adults", section on 'Clinical manifestations' and "Cradle cap and seborrheic dermatitis in infants", section on 'Clinical manifestations'.)

COURSE AND COMPLICATIONS — 

Intertrigo typically persists without interventions to eliminate or reduce contributory factors. Although intertrigo usually improves with appropriate treatment, recurrence is common.

Potential complications include secondary infection and cellulitis. (See 'Treatment' below.)

DIAGNOSIS

General approach — The physical examination is usually sufficient for diagnosis. Supplemental tests are generally reserved for patients with features that suggest alternative diagnoses or complications. (See 'Supplemental tests to assess for other diagnoses' below.)

Physical examination — Supportive physical findings include erythematous or hyperpigmented, moist patches limited to intertriginous skin. A full skin examination is helpful for identifying additional sites of involvement and detecting findings that suggest other disorders.

Examples of findings that should prompt consideration of other disorders include vesicles, bullae, extensive erosions, and vegetative plaques, and involvement of nonintertriginous skin. (See 'Differential diagnosis' below and "Approach to the patient with an intertriginous skin disorder".)

Supplemental tests to assess for other diagnoses — Certain features may prompt consideration of additional testing.

●Satellite papules and pustules – This finding suggests candidal intertrigo (picture 3). However, testing to confirm Candida infection is not typically necessary because intertrigo is usually treated with topical antifungal drugs with anticandidal activity. If desired, candidal intertrigo can be confirmed with a potassium hydroxide (KOH) preparation of skin scrapings from a satellite pustule or skin fold or fungal culture (picture 5). (See 'Initial treatment' below.)

●Raised border of patches or plaques – This feature may occur in tinea cruris (a dermatophyte infection) (picture 6A-B). A KOH preparation can help to distinguish tinea cruris from intertrigo (picture 7). (See 'Differential diagnosis' below.)

●Overlying fine scale or fine wrinkling – These features may occur in intertriginous erythrasma. Examination with a Wood lamp is helpful for distinguishing intertrigo from erythrasma (picture 8A-C). (See 'Differential diagnosis' below.)

●Purulence, crusting, or pain – These features may suggest secondary bacterial infection. A bacterial culture should be obtained. Perianal involvement should raise concern for perianal streptococcal infection, particularly in children (picture 9). (See "Diaper dermatitis", section on 'Complications'.)

●Uncertain diagnosis – Skin biopsies are not usually indicated and are reserved for patients in whom the diagnosis is uncertain and a disorder requiring a biopsy diagnosis is in the differential diagnosis (eg, Hailey-Hailey disease or pemphigus vegetans). (See 'Differential diagnosis' below and "Skin biopsy techniques".)

DIFFERENTIAL DIAGNOSIS — 

Intertriginous skin inflammation can occur in a variety of other inflammatory disorders. (See "Approach to the patient with an intertriginous skin disorder".)

The differential diagnosis of intertrigo in the diaper area of infants is reviewed separately. (See "Diaper dermatitis", section on 'Differential diagnosis'.)

Disorders commonly in the differential diagnosis for older children or adults include psoriasis, tinea cruris, erythrasma, and allergic contact dermatitis:

●Inverse psoriasis – Inverse psoriasis is a variant of psoriasis characterized by the development of well-demarcated, shiny plaques on intertriginous skin (picture 10A-B) [8,9]. There is minimal to no overlying scale. Common sites include the groin, axillae, and inframammary skin.

Friction and maceration are postulated to contribute to the development of intertriginous manifestations in patients with psoriasis through the Koebner phenomenon (development of new skin disease lesions in sites of cutaneous trauma) [8]. The identification of other cutaneous or nail manifestations of psoriasis (eg, psoriatic plaques, nail pits, onychomycosis) aids in distinguishing inverse psoriasis from intertrigo. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Inverse (intertriginous) psoriasis'.)

●Tinea cruris – Tinea cruris is a dermatophyte infection involving the groin, proximal medial thighs, perineum, or buttocks. The classic presentation consists of a centrifugally expanding, erythematous or hyperpigmented patch with partial central clearing and a slightly elevated, sharply demarcated border (picture 6A-B). Concomitant tinea pedis is common.

A potassium hydroxide (KOH) preparation demonstrating septate hyphae characteristic of dermatophytes confirms the diagnosis (picture 7). (See "Dermatophyte (tinea) infections", section on 'Tinea cruris'.)

●Erythrasma – Erythrasma is a cutaneous corynebacterial infection that typically presents as macerated, scaly plaques between the toes or as an intertriginous eruption of erythematous to brown patches or thin plaques with fine scale (picture 8A-B, 8D). The moist maceration of intertrigo is typically absent in areas other than the feet.

Examination of erythrasma with a Wood lamp demonstrates coral-red fluorescence and is useful for distinguishing erythrasma from intertrigo (picture 8C). (See "Erythrasma".)

●Allergic contact dermatitis – Allergic contact dermatitis to substances that come in contact with intertriginous skin, such as methylisothiazolinone used as a preservative in diaper "wet" wipes, can mimic intertrigo or represent a secondary complicating factor in patients with intertrigo (picture 11A-D) (see 'Pathogenesis' above). Features that may suggest contact dermatitis include sparing of the deep, hair-bearing vault of the axilla, an asymmetric distribution, and linear areas of dermatitis.

The patient history of exposure to products or substances is helpful for the diagnosis of allergic contact dermatitis. In addition, unlike intertrigo, the dermatitis usually extends out beyond the intertriginous skin. (See "Allergic contact dermatitis: Clinical features and diagnosis" and "Common allergens in allergic contact dermatitis".)

Less common disorders in the differential diagnosis are Hailey-Hailey disease, pemphigus vegetans, malignant intertrigo, Langerhans cell histiocytosis, and symmetrical drug-related intertriginous and flexural exanthema (SDRIFE):

●Hailey-Hailey disease – Hailey-Hailey disease, also known as benign familial pemphigus, is a rare genetic disorder that presents with blistering, erosions, maceration, and frequent secondary infection primarily on flexural skin. Patients often present with large, macerated, exudative plaques with superficial erosions and crusting (picture 12A-C). Vegetative, malodorous plaques with painful fissures may also occur. Many patients also have longitudinal white bands on the nails.

A skin biopsy is needed to confirm the diagnosis. (See "Hailey-Hailey disease (benign familial pemphigus)".)

●Pemphigus vegetans of Hallopeau – Pemphigus vegetans of Hallopeau is a variant of pemphigus that presents with vegetating plaques on intertriginous skin (picture 13A-B) [10].

Skin biopsies for routine histologic examination and direct immunofluorescence are necessary to confirm the diagnosis. Direct immunofluorescence testing reveals intercellular deposition of immunoglobulin G in the epidermis. (See "Pathogenesis, clinical manifestations, and diagnosis of pemphigus", section on 'Pemphigus vulgaris'.)

●Malignant intertrigo – Malignant intertrigo is a distinct subset of toxic erythema of chemotherapy affecting the intertriginous area [11]. Malignant intertrigo is more painful and tender than classic intertrigo and is not associated with satellite papules or pustules at the periphery. It has been described in association with a variety of chemotherapies [12].

●Langerhans cell histiocytosis – Langerhans cell histiocytosis is a rare, histiocytic disorder that most commonly occurs in young children but may also occur in adults. Cutaneous findings may include erythematous to brown papules and plaques on intertriginous skin (picture 14A-B). Scale, weeping, crusts, ulcerations, and petechiae may occur in involved areas. Langerhans cell histiocytosis can also affect bone, lymph nodes, lungs, and other internal organs.

A skin biopsy can confirm the diagnosis. (See "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis", section on 'Clinical manifestations'.)

●Symmetrical drug-related intertriginous and flexural exanthema – SDRIFE is a drug reaction characterized by sharply-demarcated areas of erythema in the gluteal area, inguinal area, and/or other flexural areas (picture 15). Common causes include penicillins (particularly amoxicillin), cephalosporins, and other antibiotics.(See "Drug eruptions", section on 'Symmetrical drug-related intertriginous and flexural exanthema'.)

TREATMENT — 

Treatment of intertrigo is advised to improve symptoms and minimize the risk for complications related to secondary infection.

Although intertrigo is common, data on treatment are limited. The few randomized trials performed have methodologic flaws and considerable risk of bias [13]. A systematic review found insufficient evidence to confirm efficacy of any particular approach to treatment [13].

Initial treatment — Our typical approach to treatment of intertrigo involves the simultaneous implementation of skin care measures and topical azole antifungal drug therapy (algorithm 1). In our experience, this regimen leads to marked improvement in signs and symptoms of intertrigo within a few weeks. (See 'Skin care and other measures to reduce skin moisture and friction' below and 'Topical antifungal therapy' below.)

Occasionally, patients require adjunctive treatment for pruritus. (See 'Adjunctive interventions for pruritus' below.)

Skin care and other measures to reduce skin moisture and friction — Skin care measures aim to reduce moisture and friction in the involved area(s). We typically advise:

●Daily cleansing of intertriginous skin with a mild cleanser followed by drying of the affected area with a hair dryer on a cool setting.

●Aeration of affected area when feasible.

●Daily application of drying powders, such as powders composed of microporous cellulose.

●Use of absorbent material or clothing, such as cotton or merino wool, to separate skin in folds.

●Selection of athletic clothes designed to decrease friction and wick moisture away from the skin.

●Application of barrier creams (eg, zinc oxide, petrolatum, or dimethicone), particularly for areas that may contact urine or feces.

Other considerations for patients with specific contributing factors include:

●Treatment of hyperhidrosis in the affected area. (See "Primary focal hyperhidrosis", section on 'Treatment'.)

●Weight loss in persons who are overweight or obese. (See "Obesity in adults: Overview of management".)

●Appropriate treatment of coexisting diabetes mellitus. (See "Overview of general medical care in nonpregnant adults with diabetes mellitus".)

●Barrier creams in conjunction with super absorbent diapers or incontinence products for patients with incontinence-related intertrigo. Super absorbent diapers can wick moisture away from the skin. Treatment of incontinence may also be helpful. (See "Female urinary incontinence: Treatment" and "Urinary incontinence in males", section on 'Management'.)

Topical antifungal therapy

Preferred agents — We typically prescribe a topical azole antifungal drug (eg, clotrimazole 1 % cream, ketoconazole 2 % cream, or econazole 1 % cream) for initial treatment. Topical antifungal powder formulations may also be effective.

Topical azole antifungal drugs are our preferred antifungal agents because of efficacy against Candida infection, which is common in intertrigo, and the additional antibacterial and anti-inflammatory effects of azole antifungal drugs [14,15].

●Administration – Patients apply the antifungal drug once or twice daily to affected areas for two to four weeks.

●Efficacy – Our routine use of azole antifungal therapy is primarily based on relatively few small uncontrolled or comparative studies that suggest benefit for intertrigo, and clinical experience; sufficient data to confirm benefit in the absence of clear signs of fungal infection are lacking [13].

Alternative agents — We primarily reserve treatment with other antifungal agents for patients in whom azole antifungal therapy is not feasible. Antifungal alternatives to azole antifungal drugs include benzylamines, such as butenafine 1 % cream, and allylamines, such as naftifine 2 % cream and terbinafine 1 % cream. These drugs also have anti-inflammatory properties [16,17]. However, compared with azoles, allylamines have lesser anti-Candida activity [18].

Although nystatin is an option for treating candidal involvement in intertrigo, we favor other antifungal agents because of their anti-inflammatory and antibacterial effects. In addition, unlike nystatin, azole, benzylamine, and allylamine antifungal drugs are also effective for tinea cruris, a common condition that may be mistaken for intertrigo. (See 'Differential diagnosis' above.)

Adjunctive interventions for pruritus — Although not required for most patients, low-potency topical corticosteroids or the topical antipruritic agent pramoxine may be helpful for patients with significant pruritus. In our experience, topical corticosteroid therapy is not typically necessary for resolution of intertrigo.

●Low-potency topical corticosteroids – We usually reserve adjunctive topical corticosteroid therapy for patients with marked pruritus because of the risk of skin atrophy from long-term topical corticosteroid use in intertriginous areas.

We typically prescribe a very low-potency (ie, group 7 (table 1)) topical corticosteroid, such as hydrocortisone 2.5%, applied twice daily for one week, once daily for one week, and every other day for one week. If symptoms improve rapidly, the topical corticosteroid can be tapered and stopped more quickly.

•Avoidance of combination products with higher potency topical corticosteroids – Commercial combination antifungal/corticosteroid creams with medium or high potency topical corticosteroids, such as betamethasone-clotrimazole containing betamethasone dipropionate 0.05% and nystatin-triamcinolone containing triamcinolone 0.1%, should be avoided. The corticosteroids in these products are excessively potent, increasing the likelihood of local adverse effects. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects'.)  

●Pramoxine – Pramoxine 1% lotion is an alternative nonsteroidal topical agent that may reduce pruritus. Patients apply pramoxine as needed, up to three to four times per day. Unlike topical corticosteroids, pramoxine does not induce cutaneous atrophy.

Refractory disease — Intertrigo typically responds to treatment. Therefore, clinicians should consider potential reasons for treatment failure prior to assuming refractory disease. Apparent treatment failure may occur due to factors such as an incorrect diagnosis or inadequate adherence to the treatment regimen. (See 'Differential diagnosis' above.)

Interventions such as oral antifungal therapy and surgery may be helpful for select patients in whom intertrigo does not improve with standard therapy.

Refractory candidal intertrigo — Oral antifungal therapy is typically reserved for known or suspected candidal intertrigo that does not respond to topical therapy.

Our preferred regimen for adults is fluconazole 150 mg once weekly for four weeks. However, a wide variety of dose regimens for fluconazole have been reported in the literature [19-23]. In a trial in which patients with cutaneous dermatophyte or candidal infections were randomly assigned to fluconazole 150 mg per week or 50 mg per day for up to four weeks, 10 of 11 and 12 of 13 patients treated for candidal infections with weekly or daily dosing, respectively, achieved clinical or mycologic cure by the end of treatment [20].

Oral ketoconazole should not be used for the treatment of intertrigo because of risk for hepatotoxicity and adrenal insufficiency. (See "Ketoconazole (systemic): Drug information".)

Surgical reduction of skin folds — Although typically not the sole indication for this intervention, surgical reduction of skin folds may lead to improvement in intertrigo. Reduction mammoplasty has been associated with reduced intertrigo in patients with macromastia in uncontrolled studies [13].

Recurrent disease

●Treatment – The initial treatment regimen can be repeated for recurrent intertrigo. (See 'Initial treatment' above.)

●Prevention – In general, skin care measures to minimize moisture and friction within skin folds should be continued after successful treatment to minimize the risk for recurrence. (See 'Skin care and other measures to reduce skin moisture and friction' above.)

In our experience, some patients with frequent recurrences, especially patients with deep skin folds associated with obesity, may also benefit from indefinite, once-weekly application of a topical azole antifungal cream or powder.

In one trial performed in 17 nursing homes in Germany (n = 314), patients randomly assigned to regular skin assessments and individually tailored skincare nursing routines designed to minimize moisture in deep skin folds had a lower cumulative incidence of intertrigo after six months (27 percent, 95% CI 18.4-37.7) compared with patients in the control group (37.8 percent, 95 % CI 27.5-49.4) [24].

Other interventions — Additional treatments have been used for intertrigo.

Topical calcineurin inhibitors (eg, topical tacrolimus, pimecrolimus) are alternatives to topical corticosteroids that lack the risk for cutaneous atrophy. In one series, 10 adults with intertrigo (without associated infection) applied tacrolimus 0.1% ointment twice daily for six weeks [25]. After one week, seven patients had clearance or at least 75 percent clearance of intertrigo; after six weeks, eight patients had clearance. Burning at the site of application was the most common adverse effect. One patient withdrew from the study due to burning and discomfort associated with drug application. The cost of topical tacrolimus is often higher than common topical antifungal or corticosteroid therapies.

Primarily historical treatments include topical iodochlorhydroxyquin and Castellani paint [26,27].

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Intertrigo (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Etiology and pathogenesis – Intertrigo is a common cutaneous disorder characterized by inflammation of intertriginous skin. Moisture and friction within skin folds contribute to the development of this condition. (See 'Introduction' above and 'Pathogenesis' above.)

●Epidemiology and risk factors – Intertrigo may occur at any age but most often occurs in older adults with limited mobility and infants. Additional risk factors include obesity, incontinence, poor hygiene, hyperhidrosis, and immune deficiencies. Potential exacerbating factors include skin infection and contact dermatitis. (See 'Risk factors' above.)

●Clinical presentation – The classic clinical findings of intertrigo are moist, erythematous, or hyperpigmented patches within skin folds (picture 1A-D).

The groin is the most common site of involvement. Examples of other sites are the axilla, inframammary skin, umbilicus, neck folds in infants, under the panniculus, and finger and toe web spaces (erosio interdigitalis blastomycetica (picture 1D)). Burning, tenderness, pruritus, and malodor may accompany the physical manifestations. (See 'Clinical features' above.)

Candidal skin infection commonly coexists with intertrigo. Satellite papules and pustules suggest candidal infection (picture 3). (See 'Pathogenesis' above and 'Clinical features' above.)

●Diagnosis – Intertrigo usually can be diagnosed based on the physical findings. When the diagnosis is uncertain, a Wood lamp examination, potassium hydroxide (KOH) preparation, or skin biopsy can aid with differentiating intertrigo from other conditions. A bacterial culture should be obtained if there are signs of secondary bacterial infection. (See 'Diagnosis' above and 'Differential diagnosis' above.)

●Management – Our approach is provided in the algorithm (algorithm 1).

•All patients – For all patients with intertrigo, initial therapy involves simultaneous implementation of skin care measures (to minimize moisture and friction in skin folds) and topical antifungal drug therapy. In our experience, this regimen typically leads to marked improvement in signs and symptoms of intertrigo within a few weeks. (See 'Skin care and other measures to reduce skin moisture and friction' above and 'Topical antifungal therapy' above.)

We suggest topical azole antifungal drugs (eg, clotrimazole, ketoconazole, econazole) (table 2) over other antifungal agents (Grade 2C). We prefer topical azole antifungal drugs because of their efficacy against Candida infection, which is common in intertrigo, and their antibacterial and anti-inflammatory effects. (See 'Topical antifungal therapy' above and 'Preferred agents' above.)

•Adjunctive therapy for patients with pruritus – For patients with intertrigo and marked pruritus, we suggest adjunctive very low-potency (ie, group 7 (table 1)) topical corticosteroid therapy over other agents (Grade 2C). Topical pramoxine is an alternative. Medium- and high-potency topical corticosteroids should be avoided. (See 'Adjunctive interventions for pruritus' above.)

●Prevention of recurrence – Intertrigo may recur after treatment. Measures to minimize moisture within skin folds should be continued after treatment to minimize the risk of recurrence. (See 'Recurrent disease' above.)