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Answer
The correct answer is intertrigo (choice “a”), an inflammatory condition seen only where skin touches skin—the so-called intertriginous areas such as axillae, groins, and in the case of babies, the rolls of their necks. Read on for further discussion.
Intertrigo is often mistaken for “yeast infection” (choice “b”). While yeast can colonize and worsen intertrigo, it is not the main cause of the problem.
Intertrigo is often difficult to treat, which leads many patients and providers to apply several different topical medications. It is therefore not unusual to see intertrigo worsened by way of an irritant or contact dermatitis (choice “c”) from one or more of these products. But again, this is not the basic nature of the problem.
Impetigo (choice “d”) is a superficial infection caused by a secondary staph and/or strep infection of skin disrupted by excoriated acne or eczema. Usually a localized process, it typically demonstrates a honey-colored surface on an eroded base, and looks entirely different from our patient’s rash.
Discussion
Warmth, friction, and moisture all conspire to result in maceration (disruption of barrier function); when chronic in nature, this manifests as an inflammatory rash in intertriginous areas. The classic example is seen in the inframammary area in obese women, with a worsening condition in warmer weather. But it can occur in any patient at any age, given the right conditions. The baby who drools into the cute chubby folds of its neck is a good example, for more than one reason.
For parents, the appearance of this rash is alarming to say the least. Everyone offers an opinion, from grandparents to pharmacists. Multiple creams not only fail to help, they often seem to make things worse. Primary care providers are dismayed to find that antiyeast creams don’t work, which often leads them to try a different antiyeast preparation—with the same result.
The explanation is simple: It is intertrigo, not an infection. Candida, being a ubiquitous contaminant of skin, is also an opportunistic organism that can play a role in intertrigo, but the latter is usually more about inflammation than it is infection. Even oral antiyeast medications such as fluconazole are of little help. In the unusual instance when Candida is a major player, multiple discrete erythematous papular erosions are seen as so-called “satellites” on the periphery of the process. Diabetes and/or immunosuppression are often involved in those instances.
Treatment
In this case, successful treatment entailed twice-daily application of a half-and-half mixture of hydrocortisone 2.5% cream and oxiconazole cream. Also recommended was the use of once-daily two-minute compresses of Burow’s solution (aluminum acetate powder, OTC, mixed with water according to package instructions), which dries the area.
Recurrences can be prevented with the application of a combination product containing miconazole cream and talcum-based powder at any sign of a flare; in the case of infants and children, care should be taken to avoid inhalation of the powder. (Miconazole, while ineffective as a treatment for intertrigo, is beneficial for prevention.) Starch-based powders are potentially counterproductive, since Candida actively feeds on starch.
When intertrigo occurs in the more classic inframammary location, a stronger steroid (such as triamcinolone 0.1% cream) is mixed with the oxiconazole. Additional strategies for dealing with perspiration include applying an actual antiperspirant to the area and/or cutting an old cotton t-shirt into strips that are then placed between the breasts and chest wall to cut down on chafing and provide absorption.