Pediatric Annals

Healthy Baby 

Tricky Triggers of Intertrigo

Stan L. Block, MD, FAAP

Abstract

As a full-time, practicing general pediatrician, most weeks I will encounter an infant or child who has some manifestation of a frictional-type of dermatitis known as intertrigo. It is triggered by two appositional skin surface areas rubbing against each other in conjunction with local heat and moisture. One of the critical questions practitioners must further answer is whether a secondary infection has occurred with any of the following: the typical common skin commensals; candidal species and other fungi; or with one of the other more worrisome pathogens, such as Staphylococcus aureus, Streptococcus pyogenes, or other streptococcal species.

Occasionally, infected intertrigo may cause malaise or fever, or even graduate into full-blown cellulitis or other invasive infection. Intertrigo is more common in warmer months and in infants, especially in obese infants because of their deep skin folds, chubbiness, drooling, and limited neck space. Other common sites that may develop intertrigo are inguinal, axillary, breast, and thigh areas, along with any other areas of flexion where two surfaces may create friction. According to the Principles and Practice of Pediatric Infectious Diseases, 4th edition “…the differential diagnosis includes seborrheic dermatitis, atopic dermatitis, irritant or allergic dermatitis, erythrasma, ‘inverse’ psoriasis, scabies and Langerhans cell histiocytosis.”1 Although most of us will rarely encounter erythrasma, it manifests as well-demarcated, reddish-brown plaques in areas typical for intertrigo. An additional evaluation with a Wood’s lamp will often reveal bright, coral red-colored fluorescence due to the porphyrins produced by the bacterium Corynebacterium minutissimum — if the skin has not been recently washed.

On a wintry day in January, during the peak of your current respiratory syncytial virus (RSV) season, a previously healthy, full term, 14-day-old white female developed a red, weepy, macerated, and irritated rash in her inguinal creases over a 48-hour period (Figure 1). She also had some inflammation of the labia majora. The mother says she started to worry about this “diaper rash” when the topical creams did not help it.

Figure 1.

A 14-day-old white female with a red, weepy, macerated, and irritated rash in her inguinal creases, with some inflammation of the labia majora. Note also that her umbilical cord was reddened with mild brownish discharge. What is your preferred management at this point?

All images courtesy of Stan L. Block, MD, FAAP.

The newborn has been afebrile, somewhat fussy, and not breast-feeding as well as usual. The mother denies any respiratory or gastrointestinal symptoms in the infant. The prenatal history was significant for a maternal asymptomatic positive culture for group B beta Streptococcus (GBBS) near delivery, for which the mother was treated with intravenous ampicillin just prior to delivery.

Your examination reveals an afebrile, otherwise normal infant who has an intertriginous, red, and slightly weepy diaper rash in the inguinal creases (Figure 1). You also note that the umbilical cord stump is mildly reddened and weepy.

Due to the baby’s age, her slight fussiness, and the deeper infected-looking appearance of the left inguinal crease, you decide to obtain a complete blood count, which shows a leukocytosis of 14,300 cells/mm3, which is at the upper limits of normal for an infant her age.2 Your past experience suggests that the most likely pathogen would be Candida. However, the more weepy nature of the intertrigo and the umbilical cord makes you consider the possibility of an early staphylococcal infection. Should you initiate treatment with an oral or topical anti-fungal, an anti-staphylococcal antibiotic, or maybe even parenteral antibiotics with hospitalization? You first obtain a skin culture. What is your preferred management at this point? Would you perform a blood culture or other septic workup in this afebrile infant?

As…


As a full-time, practicing general pediatrician, most weeks I will encounter an infant or child who has some manifestation of a frictional-type of dermatitis known as intertrigo. It is triggered by two appositional skin surface areas rubbing against each other in conjunction with local heat and moisture. One of the critical questions practitioners must further answer is whether a secondary infection has occurred with any of the following: the typical common skin commensals; candidal species and other fungi; or with one of the other more worrisome pathogens, such as Staphylococcus aureus, Streptococcus pyogenes, or other streptococcal species.

Occasionally, infected intertrigo may cause malaise or fever, or even graduate into full-blown cellulitis or other invasive infection. Intertrigo is more common in warmer months and in infants, especially in obese infants because of their deep skin folds, chubbiness, drooling, and limited neck space. Other common sites that may develop intertrigo are inguinal, axillary, breast, and thigh areas, along with any other areas of flexion where two surfaces may create friction. According to the Principles and Practice of Pediatric Infectious Diseases, 4th edition “…the differential diagnosis includes seborrheic dermatitis, atopic dermatitis, irritant or allergic dermatitis, erythrasma, ‘inverse’ psoriasis, scabies and Langerhans cell histiocytosis.”1 Although most of us will rarely encounter erythrasma, it manifests as well-demarcated, reddish-brown plaques in areas typical for intertrigo. An additional evaluation with a Wood’s lamp will often reveal bright, coral red-colored fluorescence due to the porphyrins produced by the bacterium Corynebacterium minutissimum — if the skin has not been recently washed.

Case 1

On a wintry day in January, during the peak of your current respiratory syncytial virus (RSV) season, a previously healthy, full term, 14-day-old white female developed a red, weepy, macerated, and irritated rash in her inguinal creases over a 48-hour period (Figure 1). She also had some inflammation of the labia majora. The mother says she started to worry about this “diaper rash” when the topical creams did not help it.

A 14-day-old white female with a red, weepy, macerated, and irritated rash in her inguinal creases, with some inflammation of the labia majora. Note also that her umbilical cord was reddened with mild brownish discharge. What is your preferred management at this point?All images courtesy of Stan L. Block, MD, FAAP.

Figure 1.

A 14-day-old white female with a red, weepy, macerated, and irritated rash in her inguinal creases, with some inflammation of the labia majora. Note also that her umbilical cord was reddened with mild brownish discharge. What is your preferred management at this point?

All images courtesy of Stan L. Block, MD, FAAP.

The newborn has been afebrile, somewhat fussy, and not breast-feeding as well as usual. The mother denies any respiratory or gastrointestinal symptoms in the infant. The prenatal history was significant for a maternal asymptomatic positive culture for group B beta Streptococcus (GBBS) near delivery, for which the mother was treated with intravenous ampicillin just prior to delivery.

Your examination reveals an afebrile, otherwise normal infant who has an intertriginous, red, and slightly weepy diaper rash in the inguinal creases (Figure 1). You also note that the umbilical cord stump is mildly reddened and weepy.

Due to the baby’s age, her slight fussiness, and the deeper infected-looking appearance of the left inguinal crease, you decide to obtain a complete blood count, which shows a leukocytosis of 14,300 cells/mm3, which is at the upper limits of normal for an infant her age.2 Your past experience suggests that the most likely pathogen would be Candida. However, the more weepy nature of the intertrigo and the umbilical cord makes you consider the possibility of an early staphylococcal infection. Should you initiate treatment with an oral or topical anti-fungal, an anti-staphylococcal antibiotic, or maybe even parenteral antibiotics with hospitalization? You first obtain a skin culture. What is your preferred management at this point? Would you perform a blood culture or other septic workup in this afebrile infant?

Case 2

As you are examining this previously healthy, mildly chubby, 4-month old white male during his well child visit, you try to palpate his neck for nodes and masses. At the same time, you are encountering difficulty obtaining a decent visual inspection of the neck area, which seems to have some form of rash starting. With firm traction, you pull the neck tissue downwards, which uncovers the erythematous weepy rash in between the neck folds (Figure 2A). Are those distinct “satellite lesions” or pustules on the neck region? You attempt to examine the lateral aspect of the neck and you notice the intertrigo lesion is more reddened and weepy than you first perceived (Figure 2B). You are also now able to observe the crusty impetiginous intertrigo lesions underneath the ear lobe.

(A) A previously healthy, mildly chubby, 4-month-old white male with erythematous weepy rash in between neck folds. Are those distinct “satellite lesions” or pustules? (B) A more thorough examination of the lateral neck area reveals red weepy and crusty lesions. The patient’s mother says that he has been feeding well, but he has been awakening nightly with crying and has been fussy during the day as well. What is your preferred course of management?

Figure 2.

(A) A previously healthy, mildly chubby, 4-month-old white male with erythematous weepy rash in between neck folds. Are those distinct “satellite lesions” or pustules? (B) A more thorough examination of the lateral neck area reveals red weepy and crusty lesions. The patient’s mother says that he has been feeding well, but he has been awakening nightly with crying and has been fussy during the day as well. What is your preferred course of management?

Case 3

On this office visit, an otherwise-healthy, 7-month-old white male presented with wheezing for 3 days. The baby was seen in the office 7 days earlier and diagnosed with a candidal intertrigo skin infection of the neck, for which he was treated with oral fluconazole and topical nystatin cream. The mother insists that you “just examine the infant with his shirt on, since he was just here a few days ago.” Fortunately, you always insist upon a complete examination with the shirt off. You can now visualize the full extent of this terrible intertriginous rash (Figure 3A). Are these truly “satellite lesions” or are they pustules underneath the neck? This boy is constantly drooling and has already soaked his shirt in only a few minutes.

(A) An otherwise healthy 7-month-old white male presented with wheezing for 3 days on this visit. The baby was also seen in the office 7 days earlier and diagnosed with a candidal skin infection that has already been treated with oral fluconazole and topical nystatin cream. Are these “satellite lesions” or pustules? (B) Because you always insist upon a complete examination of the diaper area in any sick or well infant visit, you discover a typical candidal diaper rash with somewhat purplish hue and satellite lesions.

Figure 3.

(A) An otherwise healthy 7-month-old white male presented with wheezing for 3 days on this visit. The baby was also seen in the office 7 days earlier and diagnosed with a candidal skin infection that has already been treated with oral fluconazole and topical nystatin cream. Are these “satellite lesions” or pustules? (B) Because you always insist upon a complete examination of the diaper area in any sick or well infant visit, you discover a typical candidal diaper rash with somewhat purplish hue and satellite lesions.

As is your customary approach for all younger children, you also diplomatically request to examine his diaper area, which reveals this typical candidal diaper rash with somewhat purplish hue and satellite lesions (Figure 3B). Most parents cannot fathom the number of visits and examinations of the genitalia region that have led you to important and dramatic diagnoses (see previous articles from this column on streptococcal dermatitis3 and sacral dimples4).

How do you wish to treat this young boy’s intertrigo? Should you initiate therapy with anti-bacterials, anti-fungals, or both?

Should you use topical or systemic? Are any ancillary measures worthwhile?

Case 4

This 4-year-old white boy presents with a red papular rash on the upper pole of his left ear lobe (Figure 4A). The mother says that the rash initially started behind his ear, where his typical locale of eczema has continual flare-ups. As you flip over the ear lobe, you can now see the red, crusty impetiginous lesions in the ear crease and on the posterior lobe (Figure 4B). You are also concerned that on the cephalad rim of the earlobe lesion, there appears to be a cluster of several small vesicles. Could this also be an early eczema herpeticum lesion? Will you need to not only treat for impetigo, but also for herpes simplex infection of this ear intertrigo?

(A) Earlobe of a 4-year-old white male with a history of eczema. His mother recently noticed that his upper, outer ear lobe region had developed this irritation rash. (B) A more thorough examination of the ear lobe area reveals red, crusty, impetiginous lesions in the ear crease and on the posterior lobe.

Figure 4.

(A) Earlobe of a 4-year-old white male with a history of eczema. His mother recently noticed that his upper, outer ear lobe region had developed this irritation rash. (B) A more thorough examination of the ear lobe area reveals red, crusty, impetiginous lesions in the ear crease and on the posterior lobe.

Discussion

Case 1

You know that the mother is an extremely reliable caregiver. In fact, you successfully managed her severe pneumococcal pneumonia and pleural empyema as an inpatient at your hospital when she was 8 years old. As you discuss her daughter’s care today, you offer her either outpatient or inpatient care for the next 24 hours until you are totally comfortable that the newborn has responded. You think that she could do well with initiation of therapy with oral clindamycin for 10 days to cover for methicillin-resistant Staphylococcus aureus (MRSA), as clindamycin tissue and serum concentrations are quite high. You would also plan to re-evaluate her in the office the next day.

You discuss the risks of admitting her to the hospital, including nosocomial infections such as RSV, norovirus, pertussis, and hospital-acquired MRSA; the problems and pain of intravenous access; and the high monetary cost. With outpatient oral therapy, she would miss most of those infectious exposures, but there is a slight risk that her skin infection could worsen. The mother opts for oral therapy as an outpatient, and you agree because the patient is stable and her overall condition looks good. You ask the mother to contact you immediately during the next 48 hours if any fever occurs or if the patient’s condition deteriorates at all. You further recommend for the rest of this week that the child be bathed with soap twice daily and be allowed to air dry for several minutes after the bath.

On follow-up the next day, you are relieved to see the tremendous resolution that her skin lesions have made within the first 24 hours (Figure 5A). You both agree to continue the oral therapy, and to recheck her again in another 48 hours when the culture results have returned. To your dismay, her culture grows GBBS on the return visit; yet, as seen in Figure 5B, the lesions have nearly totally dissipated. The newborn did well on the oral clindamycin regimen, but she later developed a candidal diaper infection while on the antibiotic. This fungal infection was responsive to clotrimazole applied topically.

(A) The patient was started empirically on oral clindamycin because of concerns about infection with Staphylococcus aureus. You can see the rapid clearing of the skin over the past 2 days. She actually had a group B beta Streptococcus (GBBS) infection of the skin. (B) After 3 days, her skin lesions had almost totally cleared. Her oral antibiotic was continued for a full 10-day course.

Figure 5.

(A) The patient was started empirically on oral clindamycin because of concerns about infection with Staphylococcus aureus. You can see the rapid clearing of the skin over the past 2 days. She actually had a group B beta Streptococcus (GBBS) infection of the skin. (B) After 3 days, her skin lesions had almost totally cleared. Her oral antibiotic was continued for a full 10-day course.

Case 2

You decide that those isolated maculopapules are not candidal satellite lesions, but rather pustules spreading from an impetigo intertrigo (Figure 2A). You know that impetigo is ordinarily caused by either S. aureus or S. pyogenes. While you await the results of the skin culture, you empirically initiate treatment with oral clindamycin, which is the only anti-staphylococcal antibiotic with coverage of both MRSA and S. pyogenes. You contact the mother by phone after 72 hours to inform her that his culture has grown MRSA. You further discover that the child has done extremely well, and you remind her to finish his full 10-day course of antibiotics.

Case 3

You still strongly suspect that this entire intertrigo infection has been exacerbated by a superinfection with Candida, especially when you consider the classic candidal-appearing diaper rash (Figure 3B). But why did the topical nystatin plus oral fluconazole not ameliorate the condition? Candida resistance is common for nystatin, but not for oral fluconazole. You surmise the failure may be related more to adherence issues or to local skin hygiene issues and the constant drooling.

On this visit you prescribe therapy with topical ketoconazole twice daily to both sites, prescribing a large tube size with volume enough to cover both areas. Community-acquired Candida resistance to ketoconazole is exceedingly rare. What about the use of gentian violet because he had failed more conventional therapies? As the Hurwitz Clinical Pediatric Dermatology textbook states: “Although gentian violet has been used for decades for the treatment of oral and diaper candidiasis, reports of bacterial infection and hemorrhagic cystitis, in addition to the staining associated with its use, suggest that gentian violet be avoided.”5

You also stress to the mother that he needs a bib change every few hours, or at least the continual use of a plastic backed bib to protect the area. You encourage her to clean the neck twice daily with bland soap, and to moisturize the region after the bath with a protective emollient such as Aquaphor (Beiersdorf AG; Hamburg, Germany). You also emphasize that the mother consider not letting him sleep on his back, which would additionally increase his time in neck apposition to the chest. On a follow-up visit 1 month later, the child’s intertrigo has improved notably. His mother states that he still has occasional flare ups of the neck intertrigo. She is just “praying for the day” when he stops drooling so much.

Case 4

You choose to treat his impetiginous intertrigo by selecting coverage for the more-common infection with MRSA, without as much concern for the less-common infection with S. pyogenes. His parent also reminds you that she has major difficulty getting the boy to take any liquid medicines, even with flavoring. Subsequently, you opt for treatment with trimethoprim-sulfamethoxazole suspension, which is much more palatable than oral clindamycin liquid.

With his underlying eczema, you also have significant concerns that the intertrigo lesion has a secondary herpes simplex infection in combination with MRSA, which could begin to spread to his other eczematoid lesions. Thus, you elect to initiate therapy with oral acyclovir to provide coverage for herpes simplex and to prevent the more worrisome generalized eczema herpeticum that you have seen before in other patients in your office (Figure 6).

Severe presentation of eczema herpeticum on the face of a 6-year-old white female. It was infected with both herpes simplex and methicillin-resistant Staphylococcus aureus. She required in-patient parenteral antimicrobials for both infections.

Figure 6.

Severe presentation of eczema herpeticum on the face of a 6-year-old white female. It was infected with both herpes simplex and methicillin-resistant Staphylococcus aureus. She required in-patient parenteral antimicrobials for both infections.

The child did very well with your combination antibacterial and antiviral therapy, with the lesions resolving over the next 3 days.

Conclusion

Intertrigo is a common skin problem in pediatrics, particularly in infants who are chubby or heavy droolers. Aside from the obvious hygienic care and friction-prevention care needed, deciphering which pathogen is exacerbating the problem can be quite tricky sometimes. The secondarily infecting pathogen can range from bacterial to fungal and even to viral, or any combination of these as well. As I am fond of saying about my pediatric patients, rarely are their diagnostic problems simple or straightforward.

References

  1. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric Infectious Diseases. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2012.
  2. Tschudy MM, Arcara KM. The Harriet Lane Handbook: A Manual for Pediatric House Officers. Maryland Heights, MO: Elsevier/Mosby; 2013.
  3. Block SL. Perianal dermatitis: much more than just a diaper rash. Pediatr Ann. 2013;42(1):12–14. doi:10.3928/00904481-20121221-05 [CrossRef]
  4. Block SL. The enigmatic sacro-coccygeal dimple: to ignore or explore?Pediatr Ann. 2014;43(3):95–100.
  5. Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2011.
Authors

Stan L. Block, MD, FAAP, is Professor of Clinical Pediatrics, University of Louisville, and University of Kentucky, Lexington, KY; President, Kentucky Pediatric and Adult Research Inc.; and General Pediatrician, Bardstown, KY. Address correspondence to Stan L. Block, MD, FAAP, via email: slblockmd@hotmail.com.

Disclosure: Dr. Block has no relevant financial relationships to disclose.


10.3928/00904481-20140417-04

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