Download www.PTools.ir

13 Superficial Fungal Infections
527
Intertrigo
Diaper Candidiasis
Intertrigo is an inflammatory condition of skin folds of
the axillae, breasts, abdomen, groin, or buttocks (see p.
496). Obese people are at greatest risk. Itching, burning,
and stinging are the most common symptoms. Apposing
skin folds retain moisture and become warm, macerated,
and inflamed. Candida is the most common secondary infection but bacteria, fungi, or viruses may be a factor.
Erosions are possible. Sweat, feces, urine, and vaginal discharge may aggravate intertrigo. The course can be recurrent and chronic.
An artificial intertriginous area is created under a wet diaper, predisposing the area to a yeast infection with the
characteristic red base and satellite pustules as described
earlier (Figure 13-66). Diaper dermatitis is often treated
with steroid combination creams and lotions that contain
antibiotics. Although these medications may contain the
anti-yeast agent clotrimazole, its concentration may not
be sufficient to control the yeast infection. The cortisone
component may alter the clinical presentation and prolong the disease. A nodular, granulomatous form of candidiasis in the diaper area, appearing as dull, red, irregularly shaped nodules, sometimes on a red base, has been
described and may represent an unusual reaction to Candida organisms or to a Candida organism infection modified by steroids. Although dermatophyte infections are
unusual in the diaper area, they do occur. Every effort
should be made to identify the organism and treat the
infection appropriately.
Treatment. A 1- or 2-week course of group VI to VII
topical steroids (desonide, hydrocortisone) may be all
that is necessary. Long-term continuous use of topical
steroids in skin fold areas may result in the formation of
atrophy and striae; 0.1% tacrolimus may be used as an
antiinflammatory agent instead of topical steroids for initial treatment or for cases requiring long-term intermittent treatment. Some patients respond to just 1% hydrocortisone cream or lotion. This is safe for intermittent
long-term treatment and has a low potential for causing
striae or atrophy. Add topical anti-yeast medications such
as econazole cream if Candida infection is suspected. Alternate these creams with topical steroids. To separate
and expose skin effectively in order to promote dryness,
administer while the patient is in the supine position.
Cool water compresses applied for 1/2 hour two or three
times a day for just a few days are rapidly effective in controlling moisture and suppressing inflammation.
Castellani’s paint (carbolfuchsin paint) is very effective
but not readily available at all pharmacies.
“Greer’s goo” is prepared by the pharmacist. It is composed of nystatin powder 4 million units, hydrocortisone
powder 1.2 gm, and zinc oxide paste 4 oz and is applied
one or twice a day as another treatment. Thick barrier
creams such as Desitin may prevent recurrences. Powders
may be used after resolution to promote dryness. Oral
fluconazole is usually not as effective in localized cutaneous Candida secondary infections as topical anti-yeast
creams.
Treatment. Dryness should be maintained by changing
the diaper frequently or not using a diaper for short periods. Antifungal creams should be applied twice a day until
the eruption is clear, in approximately 10 days. Some erythema from irritation may be present after 10 days; this
can be treated by alternately applying 1% hydrocortisone
cream followed in a few hours by creams active against
yeasts (see the Formulary). Apply each agent twice a day.
Baby powders may help prevent recurrence by absorbing
moisture. Mupirocin ointment 2% (Bactroban) applied
three or four times daily is effective for severe Candida
and bacterial diaper dermatitis.
Differential Diagnosis. Any recalcitrant diaper dermatitis must be further investigated to uncover underlying
disease. Inflammation in the diaper area can be caused by
psoriasis, seborrheic dermatitis, Langerhans cell histiocytosis (Letterer-Siwe disease), acrodermatitis enteropathica (zinc deficiency), biotin deficiency, Kawasaki disease,
and HIV infection.
FIGURE 13-66 Diaper candidiasis, an advanced case. The
skin folds are deeply erythematous. The urethral meatus
is infected and numerous satellite pustules are on the
lower abdominal area.
www.PTools.ir