Intertrigo is inflammation in skin folds from friction, moisture, and heat. It is not a single diagnosis — it is a location. The cause determines the treatment. Moisture control is the foundation regardless of cause.
CLINICAL PRINTABLE
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1 · Interpretation Framework
- Intertrigo: inflammatory skin condition affecting skin folds (intertriginous areas) — groin, axillae, inframammary folds, abdominal pannus, perianal area, neck folds, and toe web spaces. Caused by friction, moisture, heat, and maceration.
- Irritant intertrigo: the baseline — moisture and friction cause skin barrier breakdown. Presents with erythema, maceration, and superficial erosions in the skin fold. No satellite lesions, no pustules, no odor. Resolves with moisture control and barrier protection.
- Candidal intertrigo: Candida superinfection of irritant intertrigo. The characteristic finding is satellite papules and pustules beyond the main erythematous plaque. Pruritic. Common in diabetes, obesity, immunosuppression, and antibiotic use.
- Bacterial intertrigo: most commonly caused by Staphylococcus aureus or group A Streptococcus. Presents with erythema, maceration, and often a malodorous discharge. Erythrasma (Corynebacterium minutissimum) is a common cause of intertrigo in the groin and axillae — coral-red fluorescence under Wood's lamp is diagnostic.
- Mixed intertrigo: irritant + Candida + bacterial superinfection can all coexist. Treat all components. Failure to improve with antifungal alone should prompt consideration of bacterial superinfection.
- Psoriasis inverse (flexural psoriasis): psoriasis in skin folds presents as well-demarcated, non-scaly (moisture prevents scale formation), erythematous plaques. May be mistaken for intertrigo. Look for psoriasis elsewhere (scalp, nails, elbows, knees) and family history.
2 · Nuance That Changes Interpretation
Satellite lesions are the key to Candida
The presence of satellite papules and pustules beyond the main erythematous plaque is the hallmark of cutaneous Candida. Irritant intertrigo does not have satellite lesions. When satellite lesions are present, add antifungal treatment regardless of other findings.
Erythrasma
Erythrasma (Corynebacterium minutissimum) causes well-demarcated, brown-red, slightly scaly plaques in the groin, axillae, and toe web spaces. It fluoresces coral-red under Wood's lamp (due to porphyrin production). Treatment is topical erythromycin or clindamycin, or oral erythromycin for extensive disease.
Moisture control is the foundation
Regardless of the cause, moisture control is the cornerstone of intertrigo management. Absorbent powders (cornstarch-based), moisture-wicking fabrics, barrier creams (zinc oxide), and addressing incontinence are essential. Without moisture control, recurrence is inevitable.
Diabetes and obesity
Poorly controlled diabetes and obesity are major risk factors for recurrent intertrigo and Candidal superinfection. Optimizing glycemic control and addressing obesity reduce recurrence. Candidal intertrigo in a patient without known diabetes should prompt glucose screening.
Toe web intertrigo
Toe web intertrigo (maceration and fissuring between the toes) is the most common portal of entry for lower extremity cellulitis. Treating toe web intertrigo and tinea pedis is part of cellulitis prevention. Look between all toe web spaces in patients with recurrent lower extremity cellulitis.
3 · What Should Raise Concern
- Rapidly spreading erythema beyond the skin fold with systemic signs (fever, tachycardia) — consider cellulitis or necrotizing fasciitis. Intertrigo does not cause systemic toxicity.
- Intertrigo not responding to appropriate treatment — reassess the diagnosis. Consider psoriasis inverse, contact dermatitis, extramammary Paget's disease (perianal/genital), or Hailey-Hailey disease.
- Recurrent Candidal intertrigo without known risk factors — screen for diabetes mellitus and consider HIV testing.
- Perianal intertrigo with bleeding, induration, or ulceration — consider extramammary Paget's disease or perianal Crohn's disease. Biopsy may be required.
4 · What Do I Do Next?
- Identify the cause: irritant alone (no satellite lesions, no odor), Candida (satellite lesions, pruritus), bacterial (odor, discharge, coral-red fluorescence under Wood's lamp), or mixed.
- Address moisture control regardless of cause — this is the foundation of treatment and recurrence prevention.
- For Candida: topical antifungal (clotrimazole, miconazole, nystatin) applied to the affected area and allowed to dry before skin fold contact is restored.
- For bacterial/erythrasma: topical erythromycin or clindamycin. Wood's lamp examination to identify erythrasma.
- Screen for diabetes in patients with recurrent Candidal intertrigo without known risk factors.
Apply It · Patient Cases
CASE 1
A 72-year-old with obesity and urinary incontinence presents with erythema and maceration in the inguinal folds. No satellite lesions, no odor. Irritant intertrigo from moisture and friction. Barrier cream (zinc oxide), absorbent powder, and incontinence management are recommended. No antifungal is needed.
CASE 2
A 58-year-old with type 2 diabetes presents with pruritic erythema in the inframammary folds with satellite papules and pustules. KOH shows pseudohyphae. Candidal intertrigo is diagnosed. Topical clotrimazole twice daily is prescribed, along with moisture control measures. Glycemic control is reviewed.
NOW CHANGE ONE DETAIL
Same patient as Case 2, but the rash has a malodorous discharge and coral-red fluorescence under Wood's lamp. Mixed Candidal and bacterial (erythrasma) intertrigo is present. Topical clotrimazole plus topical erythromycin are prescribed, along with moisture control.
Bottom Line
Intertrigo is a location, not a diagnosis. Satellite lesions mean Candida. Coral-red fluorescence means erythrasma. Moisture control is the foundation of treatment regardless of cause.
EVIDENCE & REFERENCES
- Janniger CK, et al. Intertrigo and common secondary skin infections. Am Fam Physician. 2005;72(5):833–838. https://www.aafp.org/pubs/afp/issues/2005/0901/p833.html
- Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by IDSA. Clin Infect Dis. 2016;62(4):e1–50. doi:10.1093/cid/civ933
- Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Elsevier; 2016. https://www.elsevier.com/books/clinical-dermatology/habif/978-0-323-26607-5