Case Presentation:
A 45-year-old obese female presents to the clinic with a complaint of itchy, red rash under her breasts for the past two weeks. She reports increased discomfort and a burning sensation in the affected area, especially after sweating. She denies fever, chills, or systemic symptoms. Her medical history includes type 2 diabetes mellitus and hypertension.
Physical Examination
On examination, the patient is found to have erythematous, macerated plaques with satellite pustules in the inframammary folds. There is a distinct malodor. No signs of systemic infection are observed.
Initial Investigations
A KOH (potassium hydroxide) preparation is performed on skin scrapings from the affected area, revealing budding yeast cells and pseudohyphae. These findings confirm the diagnosis of candidal intertrigo.
What is Candidal Intertrigo?
Candidal intertrigo is a superficial fungal infection caused by Candida species, typically Candida albicans. It occurs in skin folds where moisture, warmth, and friction provide an ideal environment for yeast overgrowth. Common sites include the axillae, groin, inframammary folds, and intergluteal cleft.
Causes of Candidal Intertrigo
Candidal intertrigo is caused by the overgrowth of Candida species in warm, moist areas of the skin. Several factors can disrupt the normal skin barrier and promote fungal proliferation, including:
- Excessive sweating: Creates a moist environment.
- Friction: Damages the skin barrier.
- Obesity: Increases skin folds and moisture retention.
- Poor hygiene: Accumulation of sweat and debris.
- Occlusive clothing: Traps moisture and heat.
Risk Factors
Certain conditions and behaviors increase the likelihood of developing candidal intertrigo, including:
- Diabetes mellitus: High blood sugar levels promote fungal growth.
- Immunosuppression: Conditions like HIV/AIDS or medications such as corticosteroids.
- Antibiotic use: Disrupts normal bacterial flora, allowing Candida to proliferate.
- High humidity: Living in a hot, humid climate.
- Incontinence: Prolonged exposure to moisture from urine or feces.
Signs and Symptoms
Candidal intertrigo presents with several characteristic symptoms, including:
- Erythema: Red, inflamed skin in the affected folds.
- Maceration: Softening and breaking down of skin due to moisture.
- Satellite pustules: Small, red pustules around the main rash.
- Pruritus: Intense itching.
- Burning sensation: Particularly after sweating.
- Malodor: Unpleasant smell from the affected area.
Diagnosis of Candidal Intertrigo
Clinical Evaluation
The diagnosis of candidal intertrigo is primarily clinical, based on the characteristic appearance of the rash and its location in skin folds.
Laboratory Tests
- KOH Preparation: Scraping of the affected skin is examined under a microscope after applying KOH, which reveals budding yeast cells and pseudohyphae.
- Fungal Culture: Sometimes performed to confirm the species of Candida.
Treatment of Candidal Intertrigo
Topical Treatments
- Antifungal creams or ointments: Such as clotrimazole, miconazole, or nystatin, applied to the affected area twice daily until the rash resolves.
- Barrier creams: Zinc oxide or petroleum jelly to protect the skin and reduce friction.
- Drying agents: Powders like talcum or antifungal powders to keep the area dry.
Systemic Treatments
- Oral antifungals: Such as fluconazole or itraconazole, may be necessary for extensive or refractory cases.
Lifestyle and Home Remedies
- Hygiene: Regular cleansing and thorough drying of skin folds.
- Weight management: Reducing obesity to decrease skin folds.
- Loose clothing: Wearing breathable, loose-fitting clothes to reduce moisture retention.
- Avoiding irritants: Such as perfumed soaps and lotions.
Complications
If left untreated, candidal intertrigo can lead to several complications, including:
- Secondary bacterial infection: Bacteria can invade macerated skin, leading to cellulitis or abscess formation.
- Chronicity: Recurrent or chronic intertrigo due to persistent predisposing factors.
- Skin breakdown: Leading to painful fissures and ulcers.
Conclusion
Candidal intertrigo is a common fungal infection affecting skin folds, primarily caused by Candida albicans. Early diagnosis and treatment are crucial to prevent complications and alleviate symptoms. Managing underlying risk factors, such as obesity and diabetes, and maintaining good hygiene are essential steps in preventing recurrence.
