A Practical Approach to the
or Moisture-associated Skin
Damage, due to Perspiration:
Expert Consensus on Best Practice
Consensus panel
R. Gary Sibbald MD
Professor, Medicine and Public Health
University of Toronto
Toronto, ON
Judith Kelley RN, BSN, CWON
Henry Ford Hospital – Main Campus
Detroit, MI
Karen Lou Kennedy-Evans RN, FNP, APRN-BC
KL Kennedy LLC
Tucson, AZ
Chantal Labrecque RN, BSN, MSN
CliniConseil Inc.
Montreal, QC
Nicola Waters RN, MSc, PhD(c)
Assistant Professor, Nursing
Mount Royal University
The development of this consensus document has been supported by Coloplast. Editorial support was provided by Joanna Gorski of Prescriptum Health Care Communications Inc. This supplement is published by Wound Care Canada and is available a All rights reserved. Contents may not be reproduced without written permission of the Canadian Association of Wound Care. 2013.
Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
Complications of Intertrigo .11 Moisture-associated skin damage Secondary skin infection .11 and intertrigo . 4 Organisms in intertrigo .11 Consensus Statements . 5 Specific types of infection .11 Methodology: Literature Search . 6 Dermatophytosis .12 Risk Factors for Intertrigo . 6 Bacterial infections: Pyodermas .12 Perspiration . 7 Inframammary intertrigo: Predisposing Deeper infection .13 Assessment of Intertrigo .13 Pathophysiology of Intertrigo: Moisture Barrier of the Skin . 8 Physical examination .14 Management of Intertrigo .14 Management principles .15 Location-specific Intertrigo: Clinical Features . 9 Inframammary and pannus intertrigo . 9 Groin and perianal intertrigo . 9 Toeweb and fingerweb intertrigo . 9 Hyperhidrosis .17 Common Differential Diagnoses of Intertrigo . 9 Intertrigo and moisture-wicking textile with silver .17 Seborrheic dermatitis of the flexural areas .10 Contact dermatitis of the flexural areas .10 Incontinence-associated dermatitis .10 Atopic dermatitis of the flexural areas .10 Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
A Practical Approach to the
or Moisture-associated Skin Damage, due to
Perspiration: Expert Consensus on Best Practice

Consensus panel
R. Gary Sibbald MD
Moisture-associated skin damage and intertrigo
Professor, Medicine and Public Health Moisture is an important risk factor contributing to the University of TorontoToronto, ON development of chronic wounds.1 Excessive moisture on Judith Kelley RN, BSN, CWON
the skin for a prolonged period of time may result in a Henry Ford Hospital – Main Campus spectrum of reversible and preventable skin damage that ranges from erythema to maceration (increased stratum Karen Lou Kennedy-Evans
corneum moisture content) and erosion (loss of surface RN, FNP, APRN-BCKL Kennedy LLC epidermis with an epidermal base). Erythema is the initial observable change in moisture-associated skin damage Chantal Labrecque RN, BSN,
(MASD). Prolonged exposure to moisture may result in CliniConseil Inc.
Montreal, QC more pronounced inflammation or erosion, which may Nicola Waters RN, MSc, PhD(c)
include both epidermal and dermal loss (dermal or deeper Assistant Professor, NursingMount Royal University base in ulcers), creating a partial-thickness wound and a risk of secondary infection. MASD is distinct from damage due to pressure, vascular insufficiency, neuropathy, or other factors, but the development of a wound may be associated with several risk factors. Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
b. Counsel patients to wear Consensus Statements
open-toed shoes and 1. Moisture-associated skin
7. Diagnosis of intertrigo:
loose-fitting, lightweight damage: Moisture is a risk
The diagnosis of intertrigo clothing of natural fab- factor for the development is based on the history and rics or athletic clothing of chronic wounds that characteristic physical find- that wicks moisture away is distinct from other risk ings supplemented with from the skin .
factors, including pressure, laboratory testing to rule c. Advise patients to wear arterial insufficiency, venous out secondary infection. proper supportive gar- stasis, and neuropathy.
8. Evidence for intertrigo
ments, such as brassieres, 2. Definition of intertrigo:
treatment: No well-de-
to reduce skin-on-skin con- Intertrigo, or intertriginous signed clinical trials are dermatitis, may be defined available to support ther- d. Consider using a mois- as inflammation resulting apies commonly used to ture-wicking textile from moisture trapped in treat or prevent intertrigo. with silver within large skin folds subjected to fric- 9. Principles of management
skin folds to translocate of intertrigo: Prevention
excessive moisture. 3. Disease classification of
and treatment of intertrigo 11. Treatment of intertrigo:
intertrigo: A disease code
should maximize the intrin- The following approaches for intertrigo could improve sic moisture barrier function may help treat intertrigo: of the skin by focusing on diagnosis of the condi- a. Follow recommended at least one of the following tion and support research preventive strategies to keep skin folds dry and a. Minimize skin-on-skin 4. Epidemiology of inter-
prevent or treat second- contact and friction.
trigo: The true incidence
ary infection.
b. Remove irritants from the and prevalence of intertrigo b. Consider using a mois- skin, and protect the skin is currently unknown.
ture-wicking textile with from additional exposure 5. Risk factors for intertrigo:
silver between affected to irritants.
The major documented risk c. Wick moisture away from factors for intertrigo include c. Continue treatment until affected and at-risk skin.
hyperhidrosis; obesity, intertriginous dermatitis d. Control or divert the especially with pendulous moisture source. has been controlled. breasts; deep skin folds; e. Prevent secondary infec- d. Treat secondary infection immobility and diabetes with appropriate system- mellitus; all risk factors are 10. Prevention of intertrigo:
ic and topical agents.
aggravated by hot and The following strategies e. Revisit the diagnosis humid conditions. may help prevent intertrigo in cases that do not 6. Complications of inter-
from developing or recur- respond to usual therapy.
trigo: Secondary bacterial
f. Initiate a prevention pro- infection is a common com- a. Cleanse skin folds gently, gram that can include plication of intertrigo that dry gently but thorough- weight loss, a skin-fold must be treated effectively ly (pat, do not rub), and hygiene program, and to prevent deep and sur- educate patients about early detection and treat- rounding invasive infection.
proper skin-fold hygiene.
ment of recurrences.
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Wound Care Canada – Supplement
There is no uniform nomencla- ture or assigned code in the Intertrigo may be found in skin damage
International Classification of patients in acute care, rehabili- Diseases-10 for intertriginous tation, extended-care facilities, Moisture is a risk factor for dermatitis.4 Intertrigo is usual- hospices and in home care.6 the development of chronic European studies have found the wounds that is distinct from ly listed under "miscellaneous" prevalence of intertrigo to be other risk factors, including or "other" dermatologic codes, 17% in a group of nursing home pressure, arterial insufficiency, especially once the condition patients and 20% in home care venous stasis and neuropathy.
is secondarily infected.5 This patients.7 Overall, little evidence hampers both the diagnosis of quantifies the incidence and MASD can be defined as "inflam- the condition and systematic prevalence of intertrigo. mation and erosion of the skin research into intertrigo. caused by prolonged exposure to various sources of moisture, CoNSENSuS STATEMENT #4:
including urine or stool, perspir- Epidemiology of
ation, wound exudate, mucus, Disease classification
or saliva."2 This type of skin damage includes intertriginous The true incidence and preva- (skin-fold) dermatitis, incontin- A disease code for intertrigo lence of intertrigo is currently ence-associated dermatitis, could improve diagnosis of periwound moisture-associated the condition and support dermatitis, and peristomal mois- research efforts.
Risk Factors for
ture-associated dermatitis.2 Intertrigo
This consensus document No formal risk assessment tool focuses on intertriginous derma- Literature Search
exists for intertriginous derma- titis, which is due to perspiration A MEDLINE search was per- trapped in skin folds plus the Risk factors for intertrigo effect of friction. Intertriginous formed using the key word are numerous, with the most dermatitis has been defined as "an "intertrigo." The only limits important including hyperhid- inflammatory dermatosis [derma- placed on the search were rosis, obesity and diabetes mel- titis] involving the body folds, English language and human litus.8 Immunocompromise and notably those of the sub-mam- studies. The search returned increased skin surface bacterial mary [under the breasts] and 375 citations. Abstracts were burden may also be risk factors, genitocrural regions,"3 and as "an reviewed and 47 articles were as may poor hygiene, malnutri- inflammatory dermatosis [derma- obtained for complete review. tion, tight and closed shoes, titis] of opposing skin surfaces The articles included 15 case and large, prominent skin folds. caused by moisture."4 reports, 7 cases series, 1 survey, In fact, any patients with skin 11 studies, 10 review or overview folds have a risk of intertriginous CoNSENSuS STATEMENT #2:
dermatitis. A hot and humid cli- articles, 2 consensus documents, mate promotes the development Definition of intertrigo and 1 symposium summary.
of intertrigo, although this has Intertrigo, or intertriginous Additional references were iden- not been studied in detail.
dermatitis, may be defined as tified from the reference lists of inflammation resulting from reviewed articles. Overall, little Skin folds
moisture trapped in skin folds evidence is available on the Skin folds that may develop subjected to friction. topic of intertrigo. intertrigo include those in the Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
neck; in the axilla; under the tus was diagnosed in 87 patients, breasts, especially if they are Sweat is composed of water con- and of these, 33 patients had pendulous; in the lateral flank taining urea, glucose, and elec- intertrigo. Boza et al. compared area; between the buttocks trolytes, including sodium and the prevalence of skin condi- (gluteal cleft, intergluteal cleft); chloride.2 On most parts of the tions in 76 obese patients with in the groin; in the creases body, perspiration is not linked those seen in 73 normal-weight of the knees or elbows; and to MASD, as sweat usually evap-orates readily. However, chronic controls.13 Among the skin prob- between the fingers and toes. perspiration that accumulates in lems with a statistically signifi- Intertriginous dermatitis may a skin fold, especially in an obese cant relationship with obesity be seen in lean individuals and individual with deep skin folds, was intertrigo, which was found in the neck region of infants. may result in MASD. in 45% of the obese group. In a Patients with lymphedema may discussion of the dermatological develop skin folds in the affect- complications of obesity, Garcia- ed limb. Patients who are bedrid- Brown et al. performed a self-re- den or incontinent are prone to Hidalgo found a linear relation port survey to identify skin prob- intertrigo, especially in the groin lems in 100 patients with obesity between intertrigo and the and perianal region, and they and to determine whether they degree of obesity.14 may have co-existing incontin- sought professional help.10 At ence-associated dermatitis.9 least one skin problem was Inframammary intertrigo:
Obese patients also develop identified in 75% of patients, Predisposing factors
multiple additional skin folds, especially itchiness and dry skin, McMahon et al. performed and 63% reported more than including lateral folds above the a point prevalence study of one problem. The most prevalent waist, folds across the back just inframammary (below the locations for problems were the below the scapulae (sometimes groin, limbs, beneath the breasts, breasts) skin problems found called angel wings), abdominal and the abdomen. The major among inpatients in a district folds, pannus, and folds in the perceived causes were perspir- health authority in England.15 legs and arms. "Angel wings" ation and friction. Although The survey included 131 wards develop both in overweight 25% of survey respondents had with 1,116 female patients. individuals, even with a body sought no help, 59% had seen Among these individuals, 5.8% mass index (BMI) less than 30 a physician and 16% had con- had active inframammary lesions kg/m2, and in the elderly who sulted other health-care profes- and 5.4% had a lesion that had have lost height. In patients with sionals.
healed during their hospital stay, a BMI above 40 kg/m2, skin also Several authors have evaluated for a total of 11.2% of female folds over at the waist laterally skin conditions associated with patients. The prevalence was and then centrally as weight obesity. Mathur et al. described intertrigo as a skin problem highest in wards with elderly increases. Lateral flank folds are in adolescents with obesity.11 prone to trauma and to devel- patients and those with patients Al-Mutairi performed a study of oping chronic low-grade infec- with acute mental illness. 437 overweight or obese adults tion. Pannus (abdominal fold) is Patients with active or healed to identify the spectrum of skin graded from 1 to 5, with a grade lesions had a higher than aver- diseases in the obese popu- 1 pannus apron reaching the lation.12 Among the diseases age body weight, and patients hairline and mons pubis but not identified in this population, with active lesions had signifi- the genitals, and a grade 5 pan- intertrigo was present in 97 indi- cantly higher body weight than nus apron reaching to the knees. viduals, or 22%. Diabetes melli- those with healed lesions. Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
movement out of the body and with those of normal controls. Risk factors for
preventing excessive environ- The authors found a significantly mental water absorption.2 The increased skin pH in three areas moisture barrier consists of in persons with diabetes; the The major documented risk hygroscopic (water-attracting) factors for intertrigo include inguinal and axillary regions molecules and lipids within the hyperhidrosis; obesity, espe- stratum corneum. The hygro- (p <.0001) and the inframam- cially with pendulous breasts; scopic molecules are humec- mary area (p <.01) of female par- deep skin folds; immobility tants (molecules that bind water ticipants. Increased skin surface and diabetes mellitus; all risk in the stratum corneum) that pH also predisposes the skin to factors are exacerbated by hot maintain 20% water content invasion by bacteria, yeasts and and humid conditions. within the stratum corneum and other microorganisms. As would comprise natural moisturizing Pathophysiology of
be predicted with increased pH factor. The lipids act as emol- and diabetes, six persons in this Intertrigo: Moisture
lients, enhancing the effect of natural moisturizing factor. study had intertriginous can- Barrier of the Skin
The pH of healthy skin is didal infections. The pH of the Although much remains to be between 5.5 and 5.9.2 Skin alka- skin varies in different locations. elucidated about the patho-physiology of intertrigo, or inter-triginous dermatitis, exposure to moisture alone is insufficient "Although much remains to be elucidated to produce skin damage.2 Both about the pathophysiology of intertrigo, or moisture and friction in skin intertriginous dermatitis, exposure to moisture folds are required. These two alone is insufficient to produce skin damage. Both promoting factors may result in erosions and secondary infec- moisture and friction in skin folds are required." tion, if potentially pathogenic microorganisms are present.8 Although erosion is a common linity, or increased skin pH, nega- manifestation of intertrigo, the tively affects the skin's moisture The efficiency of the moisture mechanisms leading to erosion barrier, along with other factors barrier slowly declines with age, are not fully elucidated,2 but a that disturb the barrier function, until the stratum corneum water combination of moisture and such as increasing age, obesity, content drops to less than 10% friction is most likely. in the elderly.17 This leads to dry The clinical course of inter- skin, or winter itch, comprom- trigo2 usually starts with ery- Increased pH
ising the normal barrier func- thema and inflammation, with Increased stratum corneum pH tion; in this situation, the skin the occurrence of erosions in prevents lipids from assuming has a very fine reticulate scale the presence of moisture due their normal structure,2 interfer- (crackled eczema, or eczema to macerated keratin and wet ing with the skin's barrier func- edema. Some or all of these fea- tion. A study by Yosipovitch et al. tures may present concurrently of skin pH and moisture includ- or individually. ed 50 patients with type 2 dia- Moisture barrier function is The skin's moisture barrier betes and 40 healthy controls.16 also impaired in obesity, with functions to maintain bodily The study compared the pH of increased sweating after over- homeostasis by slowing water persons with type 2 diabetes heating among obese compared Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
with lean individuals.18 Obese limus, may actually improve systemic antibiotics or immuno- individuals are less efficient than moisture barrier function. lean comparators in regulating In males, tinea infection is body temperature by sweating. more common in the groin This inefficiency increases the region. There is often an active duration of sweating and the Intertrigo: Clinical
red border to the eruption, exposure of the skin to moisture. Features
where the hair follicles may be Sweating is most pronounced involved in advance of the bor- in skin folds, where moisture is Inframammary and pannus
der. A fine surface scale is often prevented from evaporating. associated with the proximal intertrigo
Obese individuals also have margin of the eruption on the more alkaline skin pH than lean Intertrigo in the inframammary inner thighs. Central clearing area is often due to large or towards the inguinal crease is A study by Nino et al. of 65 pendulous breasts; abdominal often associated with sparing of overweight children and 30 nor- crease intertrigo occurs with mal-weight controls included abdominal pannus formation. In a clinical evaluation and calcu- both situations a hot and moist Toeweb and fingerweb
lation of transepidermal water environment predisposes to intertrigo
loss.19 The study discovered a intertrigo. The most common Intertrigo of the toewebs often significantly higher transepi- symptom is itch, but symp- starts in the webspace between dermal water loss in obese toms can vary from nothing to the fourth and fifth toe and than in normal weight children, burning or stinging with severe spreads proximally. Erythema suggesting that obese children irritant contact dermatitis. The and scale are often replaced by sweat more because of over- presence of satellite papules or maceration of the webspace heating, due to the thick layers pustules with a bright red col- keratin as the eruption spreads of subcutaneous fat and the our or confluent inframammary proximally. The moisture-asso- lower skin surface area relative erythema is often indicative of a ciated damage is often compli- to body mass.
secondary candidal infection. cated by tinea infection. Fingerweb intertrigo is most Groin and perianal intertrigo common in individuals with
In atopy, the genetic predis- Intertrigo due to irritant con- substantial water exposure, position to develop allergic tact dermatitis from sweat and including cooks, bartenders and reactions may be related to health-care workers. Moisture friction is common in the groin mutations in one of the proteins accumulating in the middle fin- region. In females, older or obese involved in natural moisturiz- ger webspaces along with fric- individuals and persons with ing factor; this may result in tion leads to intertrigo that can compromised moisture barrier diabetes, intertrigo of this region become secondarily infected, function, increasing skin sus- is often complicated by candidal most commonly with Candida. ceptibility to irritants, including intertrigo with the characteris- excessive moisture.20 Atopic tic bright red appearance and individuals in many studies have satellite (small lesions near the Common Differential
demonstrated a decreased skin main one) papules and pustules Diagnoses of Intertrigo
barrier function that is further that are usually, but not always Common differential diagnoses compromised by the common present. Candidal infection of of intertrigo include inflamma- use of topical steroids; topical the groin is also more common tory conditions, such as psoria- immune response modifiers, in individuals with vaginal yeast sis, atopic dermatitis and, less such as tacrolimus and pimecro- infections and in those receiving commonly, lichen planus. Atopic Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
individuals may also develop greasy scale. As infants become pruritus ani in 6%, psoriasis in dermatitis in the flexural areas older, it gradually improves. This 3%, contact eczema in 26%, and due to a combination of fac- condition is rare in older chil- no diagnosis (presumed contact tors.4, 21 Contact dermatitis is dren or adults except in associ- eczema) in 20%. Some patients more commonly irritant than ation with immunosuppression had more than one diagnosis. allergic and may be confused or immunodeficiency. with intertrigo. Incontinence- associated dermatitis in skin Contact dermatitis of the
folds exposed to urine or feces flexural regions
Incontinence of feces or urine can also be confused with inter- Eighty per cent of contact can result in incontinence-asso- trigo. Infections due to fungi, dermatitis is due to irritants ciated dermatitis.4 This derma- yeasts and bacteria, such as and 20% is allergic in nature. titis may occur in the perineum, erythrasma, can exist with and Irritant contact dermatitis is labial folds, groin, buttocks, without intertrigo, which is often diffuse, whereas many scrotum and perianal and inter- characterized by increased local contact allergies produce bright gluteal cleft. This condition is perspiration and moisture. Some red erythema with discrete mar- also commonly associated with rare flexural disorders are sum- gins. Irritant contact dermatitis candidal infection. In the pres- marized in Table 1.
is common, due to irritants in ence of pain and local tender- soaps, detergents, fabric softener ness, secondary cellulitis should Psoriasis
residue in clothes, deodorants, be suspected. Staphylococcal Psoriasis can occur in many antiperspirants and antimicrob- or streptococcal infection may forms, including plaque, pustular, ial preparations. need to be treated with systemic erythrodermic and intertriginous Common contact allergens in antimicrobial therapy. Perianal psoriasis. The intertriginous form the flexural areas include per- cellulitis is more common than of psoriasis is symmetrically fumes; preservatives such as cellulitis of the anterior groin distributed and bright red in col- formaldehyde and formaldehyde area. All anterior groin eruptions our with a sharp margin.21 It is releasers, including quater- may extend around the peri- distinguished from other forms nium-15; topical antimicrobials, neum into the perianal area and of psoriasis by the absence of a such as neomycin, bacitracin, onto the buttocks. Perianal erup- silvery scale even in untreated polymyxin and others; and tions are more common with cases. Intertriginous psoriasis occasionally topical steroids. hemorrhoids or loose, watery is most common in the groin, The allergic reaction can be under the breasts, in the axillae reproduced by the repeat open and in the perianal area, but application test. Products can Atopic dermatitis of the
it can occur in other locations. be screened by applying them flexural areas
There is usually an absence of twice a day for two or three Atopic individuals often have satellite papules or pustules. days to a coin-shaped circle on a decreased ability to sweat, Involvement of other areas may normal forearm skin. Allergic altered immunity and suscept- help to establish the diagnosis. reactions to irritants or sensitiz- ibility to eczema in the body ing agents can be confirmed by folds. Atopic flexural eczema Seborrheic dermatitis of the
is most common in the ante- flexural areas
Kranke et al. performed a pro- cubital and popliteal fossae, Seborrhea of the flexural areas spective study of 126 patients starting once individuals can is common in otherwise healthy, with a presumptive diagnosis of walk with an upright posture, young infants. Seborrhea pre- anal eczema.22 The clinical diag- and is less common as they sents as yellow-pink erythema, nosis was intertrigo/candidiasis reach adulthood.21 Itch often sometimes with a peripheral in 43%, atopic dermatitis in 6%, leads to scratching and rubbing 10 Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
the involved areas, which can Table 1. Rare Forms of Flexural Disorders
produce increased skin surface Disease Process
markings (lichen simplex chron- Violaceous papules or plaques that leave behind post-inflammatory pigmentation Fox Fordyce disease Rare disorder with extremely itchy peri- Complications of
follicular papules in the axilla, groin and around the nipples Hailey-Hailey disease Intertriginous fragile blisters that are often Secondary skin infection can (Benign familial worse in the hot months or when secondar- occur in the presence of inter- trigo or may occur independ-ently of any evidence of MASD. Unusual drug reactions Chemotherapy drug reactions Toxic epidermal necrolysis: most common with anticonvulsants, antibiotics, and non- Secondary skin infection
steroidal anti-inflammatory drugs Overhydration of the stratum corneum, due to an inability to evaporate or translocate mois- Table 2. Organisms Cultured from 15 Sites from 9 Patients with Intertrigo
ture from a skin fold, can disrupt the moisture barrier, allowing irritants to pass into the skin and Staphylococcus species coagulase negative produce dermatitis.5 Saturated Proteus mirabilis skin is also more susceptible to friction damage, resulting in fur- ther inflammation, which then allows the penetration of organ- Candida albicans isms to cause secondary bacter- Vancomycin-resistant Enterococcus faecium ial or fungal infection, the most Escherichia coli common complication of inter- Streptococcus viridans group trigo. The warm, damp environ- Group D Enterococcus ment in skin folds with associ-ated skin damage provides an Acinetobacter baumanni/haemolyticus ideal environment for organisms to proliferate. Infections due to intertrigo from nine hospitalized Candida albicans and dermato- Limitations of this study include patients (Table 2).23 phytes, such as Tricophyton the small size, the single site, and In this sample, there was no rubrum, are common, and many the lack of a control group. relation between the type or bacterial species can also be quantity of microorganism cul- Specific types of infection
seen, including staphylococci, tured and the severity of ery- streptococci, Gram-negative Although Kugelman21 and others thema. At four sites with satellite species, and antibiotic-resistant classify pyodermas, candidiasis, lesions, the satellites did not all dermatophytosis and erythrasma contain the same organism. In as differential diagnoses for oRGANISMS IN INTERTRIGo
addition, only two contained intertrigo, this document consid- Edwards et al. conducted a small Candida albicans, suggesting ers them to be secondary infec- single-hospital study to identify that antifungals should not be tions, or complications of inter- common microorganisms in prescribed based on the pres- trigo, when chronic exposure to intertrigo by culturing 15 sites of ence of satellite lesions alone. moisture in skin folds is present. Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
Because infections require a por- seen in adult males.21 Itchy, red, ism, but culture can take up to tal of entry and develop on skin scaling plaques on the upper a month. About 20% of fungal that has already been comprom- medial thighs characterize tinea infections are negative on a ised, it is more rational to con- cruris. Lesions tend to grow potassium hydroxide test and on sider them as secondary rather with a circular border, and cen- culture. With a high index of sus- than primary conditions.
tral clearing may be seen. The picion clinically, it is important macerated keratin compromises to obtain three negative cultures the cutaneous barrier and acts before considering another diag- Candidal infection is intensely as a portal of entry for second- nosis. Dermatophyte infection itchy, with plaques with sharp ary bacterial infection leading to generally responds well to topic- margins and frequent satellite lymphangitis and cellulitis.
al antifungal creams.9 lesions beyond the area of fric- Tinea of the interdigital spaces Gloor et al. performed a study tion. Whitish exudate may be of the toewebs is usually accom- present.21 As candidal organisms of the healthy skin of 27 patients panied by tinea pedis, charac- are frequently present, positive with tinea cruris and 27 healthy terized by a dry, white powdery culture alone is insufficient for a patients to assess biochemical scale. This scale accentuates diagnosis; the invasive mycelial and physiological parameters.24 the skin surface markings and phase of the organism must be The study found that significant- extends around the side of present on microscopic exam- ly more amino acids could be the feet in a distribution that ination of lesion scrapings. extracted from the skin surface would be covered by a mocca- Candidal intertrigo may often of patients with tinea cruris than sin (moccasin foot tinea pedis). respond to a topical antican- from the healthy controls. The The moccasin changes of tinea didal preparation.9 Resistant or authors hypothesized that the pedis need to be distinguished extensive cutaneous infections increase in amino acids may be from the dry skin that occurs as may require systemic antifungal related to excessive perspiration, a result of the autonomic com- agents, with difluconazole the and this finding may indicate a ponent of the neuropathy asso- most commonly used agent. factor predisposing to dermato- ciated with diabetes and other A study by Gloor et al. of the phyte infection. etiologies. The nails may also be biochemical and physiological involved with a distal streaking BACTERIAL INFECTIoNS: PyoDERMAS
parameters of areas of healthy and eventual whole nail plate Most pyodermas are caused by skin in 20 patients with candida involvement. Involvement often coagulase-positive staphylococci intertrigo found a significant starts asymmetrically and then and β-hemolytic streptococci, decrease in the amount of spreads to the other foot and, and systemic antibiotics are the squalene and an increase in wax in susceptible individuals, to usual therapy.21 Staphylococci and cholesterol esters in the skin the hands. A secondary bac-
may cause folliculitis (superficial surface lipids in these patients terial infection, often from
hair follicle infection) or furun- compared with 39 healthy con- the toewebs in a person with
culosis (deep hair follicle infec- trols.24 These alterations may diabetes, can be life or limb
tion) in the axilla or groin, which point to a predisposing factor must also be differentiated from for candidal infection. The diagnosis can be con- hidradenitis suppurativa, an firmed by examining fungal inflammatory condition of the Intertriginous infection with scrapings of the skin surface apocrine glands. Staphylococci dermatophytes (fungi that cause keratin for the presence of and streptococci may also cause skin disease), which may be septate hyphae in potassium cellulitis. Superficial, honey-col- caused by T. rubrum, T. menta- hydroxide preparations. A posi- oured intertriginous lesions may grophytes, or Epidermophyton tive culture on Sabouraud's agar be the presenting sign of impe- floccosum, is most frequently can identify the specific organ- 12 Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
be infected with bacteria or portals of entry of the infec- Streptococcal intertrigo is molds. Lin et al. reported on a tion as intergluteal intertrigo in caused by group A β-hemolytic case series of interdigital foot three patients, tinea pedis in one streptococci and presents as intertrigo with a poor response patient, a psoriatic plaque in one a fiery red or beefy-red, shiny, to antifungal therapy that patient and a carbuncle of the exudative lesion with well-de- included 32 episodes in 17 buttock in one patient. No portal fined borders without satellite patients.30 Clinically, the toewebs lesions and with a foul smell.25 of entry was found for the sev- were macerated. Most bacterial Microscopic examination and cultures (93%) grew a mixture of enth patient. culture provide the diagnosis. pathogens, with the most com- This complication of intertrigo mon being Pseudomonas aeru- CoNSENSuS STATEMENT #6:
most commonly occurs in ginosa, Enterococcus faecalis and infants, where it affects mainly Staphylococcus aureus. Complications of
the neck, but axillary, inguin- al and anal folds may also be Secondary bacterial infection involved.26-28 Infants have a Secondary infection of the skin is a common complication of predisposition to cervical infec- is a clinically relevant complica- intertrigo that must be treat- tion due to their relatively short tion of intertriginous dermatitis ed effectively to prevent deep necks, deep skin folds in chubby that can develop into deeper, infants and saliva from drooling, and surrounding invasive clinically important infections.2 which collects in the neck folds. Dupuy et al. performed a case-control study to assess risk factors for erysipelas of the leg, Assessment of
Erythrasma is caused by or cellulitis.31 The analysis includ- Corynebacterium minutissimum, ed 167 patients with erysipelas producing dull red scaling A full history and examination and 294 controls. Multivariate plaques with a sharp margin on of the entire body surface can analysis found an odds ratio (OR) the medial thighs, the axillae, help to differentiate intertrigo for lymphedema of 71.2 (95% toewebs and perianal area. The from conditions that may appear confidence interval [CI] 5.6 to diagnosis is made by finding 908) and an OR for site of entry coral-red fluorescence, which is of 23.8 (95% CI 10.7 to 52.5). The due to an excreted porphyrin, site of entry was defined as dis- under a Wood's light. Erythrasma ruption of the cutaneous barrier Clues to the diagnosis of inter- responds to topical imidazole and included leg ulcer, wound, trigo may often be found in antifungal agents (such as fissurated toe-web intertrigo, the patient's medical hist- clotrimazole and miconazole), pressure ulcer and leg dermato- erythromycin or clindamycin.9 ory.9 Patients with diabetes or sis. Other risk factors were leg Treatment with oral erythro- immunosuppression may have edema (OR 2.5, 95% CI 1.2 to mycin or clarithromycin may a greater incidence of intertrigo. 5.1), venous insufficiency (OR be necessary.29 In patients with In addition, patients who are 2.9, 95% CI 1.0 to 8.7) and over- interdigital erythrasma, a com- obese, bedridden or incontinent weight (OR 2, 95% CI 1.1 to 3.7). bination of oral and topical ther- are prone to intertrigo. It is also Studer-Sachsenberg et al. apy may be necessary. reported on seven cases of but- important to identify previous tock cellulitis at varying times therapies, such as topical or sys- Interdigital foot intertrigo after hip replacement surgery.32 temic corticosteroids, as they is commonly infected with In assessing these cases, the may affect the appearance of dermatophytes, but it can also authors identified the presumed Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
Physical examination
inflammatory signs, such as local infections or pseudohyphae in To assess a patient with pos- increased temperature, cellulitis, sible intertrigo, it is important exudate and smell, often alter to inspect the entire body, the appearance of the primary CoNSENSuS STATEMENT #7:
including all skin folds, right disease process.9 to their base. It may be useful Diagnosis of
to measure the depth of skin folds, as the deeper the fold, the The diagnosis of intertrigo is more likely is the development The diagnosis is often clear-cut based on the history and char- of intertrigo. Full body exam- and is generally based on the acteristic physical findings ination is best accomplished clinical presentation of charac- supplemented with laboratory with the patient lying flat. With teristic intertriginous dermatitis: testing to rule out secondary some obese patients, assistance mirror-image erythema, inflam- may be necessary to lift large mation or erosion within skin skin folds without exacerbating folds.8 The presence of other Management of
existing skin damage. Intertrigo types of lesions, such as pus- Intertrigo
appears as mirror-image ery- tules, deep papules, nodules or Evidence
Mistiaen et al. performed two
systematic literature reviews of
"Every effort must be made to restore a normal prevention and treatment of environment that will encourage the natural intertrigo in large skin folds of regenerative capacity of the skin."21 adults, published in 2004 and 2010.7,33 Only the more recent — TP. Kugelman review is discussed here. The review used a search of 13 data- thema, inflammation or erosion vesicles may offer a clue to the bases followed by reference within skin folds. Other signs diagnosis. If secondary infection tracking and forward citation and symptoms include itch, searches.7 Of 316 articles includ- is likely, it is appropriate to per- burning, pain and odour. Itch ed for full-text assessment, only form a culture and sensitivity. often requires sedating H anti- 68 studies met the inclusion Biopsy may be uninformative in histamines, such as diphenhyd- criteria, and only four of these uncomplicated intertrigo, but in ramine or hydroxyzine, which were randomized controlled atypical clinical presentations are taken at night and have a trials. Most of the studies lacked or lesions without a positive carryover effect the following scientific rigour for a variety of bacterial or fungal laboratory day. Pain with intertrigo may be serious methodological reasons. test that are nonresponsive to severe and sometimes requires No study addressed prevention treatment, biopsy may serve a pain medication. The burning of intertrigo. In the studies of associated with intertrigo may useful function. Examination treatment, secondarily infected approximate severe sunburn under a Wood's light may iden- intertrigo was generally the con- symptoms and may respond tify secondary infections, such dition treated, and a large var- to a combination of pain and as erythrasma (coral-red fluores- iety of therapies was evaluated, antihistamine medication. Pain cence) or pseudomonas (green primarily topical therapies, such may also indicate secondary fluorescence). Potassium hydrox- as antifungal and antibacterial infection. In this situation, super- ide examination may demon- creams. In addition, 15 studies imposed infection-associated strate hyphae in dermatophyte addressed reduction mammo- 14 Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
plasty. The review was also ham- ". . intertrigo deserves more serious attention from pered by differing descriptions the dermatology field on all aspects from defining to of intertrigo, diagnostic criteria and measurements of treatment diagnosing, pathophysiology, prevention, treatment success. Overall, no rigorous and evaluation."7 randomized controlled trial evi- — P. Mistiaen dence exists for the prevention or treatment of intertrigo of the large skin folds. ure to moisture was anticipated. rinseless cleanser is recom- Furthermore, measures to reduce mended. Irritated skin folds CoNSENSuS STATEMENT #8:
or eliminate skin-on-skin contact should be patted dry, rather and friction are important. than wiped or rubbed.4 Loose- Evidence for
fitting, lightweight clothing of intertrigo treatment
natural fabrics or athletic cloth- No well-designed clinical trials ing that wicks moisture away are available to support ther- Principles of
from the skin are good choices. apies commonly used to treat management of
Open-toed shoes may be bene- or prevent intertrigo. intertrigo
Prevention and treatment of
Notes on Skin
intertrigo should maximize Care for obese
A previous expert panel agreed the intrinsic moisture barrier that a preventive or treatment function of the skin by focus- approach for MASD should be Obese patients have a large ing on at least one of the fol- based on at least one of the fol- skin surface and more and deeper skin folds compared 1. Minimize skin-on-skin con- "1. an interventional skin care with lean individuals.34 tact and friction.
program that removes irri- Meticulous skin care is 2. Remove irritants from the tants from the skin, maximiz- necessary but difficult to skin and protect the skin es its intrinsic moisture bar- achieve in obese individ- from additional exposure to rier function, and protects the uals. Skin folds in obese skin from further exposure to individuals are often moist 3. Wick moisture away from and predisposed to devel- affected and at-risk skin.
2. use of devices or products oping intertrigo and to 4. Control or divert the mois- that wick moisture away from secondary infection. Due to affected or at-risk skin the potential itch or pain 5. Prevent secondary infection.
3. prevention of secondary associated with intertrigo, cutaneous infection it is helpful to use rinseless Prevention
4. control or diversion of the cleansers when cleansing No randomized controlled moisture source" skin folds in obese individ- trial, evidence-based literature uals. It is also important to The panel also agreed that a supports strategies to prevent dry skin folds by patting preventive or treatment regi- intertrigo, but common-sense rather than wiping to pre- men should be consistent and approaches are effective.8 It is vent causing more pain, include gentle cleansing, mois- important that skin folds be much as you would for a turization if indicated and appli- kept as clean and dry as pos- patient with sunburn—pat cation of a protective device or sible to minimize friction. Gentle gently, do not wipe. product when additional expos- cleansing with a pH-balanced, Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
Moisture-wicking Textile with Silver
This polyurethane-coated polyester textile is impregnated with a silver compound. The coating is
specifically designed to assist in the absorption and wicking away, or translocation, of moisture.
The moisture-wicking textile with silver translocates excess moisture from the skin fold to keep
skin dry, the silver-impregnated formulation provides effective antimicrobial action for five days,
and the soft knitted textile provides a friction-reducing surface that reduces the risk of skin tears.
The textile is effective for signs and symptoms of intertriginous dermatitis, such as maceration,
denudement, inflammation, pruritus, erythema and satellite lesions. Overall, the moisture-wick-
ing textile with silver treats intertriginous dermatitis by managing moisture, friction, bacteria and
odour. In addition to intertriginous dermatitis, other uses of the moisture-wicking textile with silver
in MASD include placement under
• blood pressure cuffs in intensive care unit patients
• immobilizers and medical devices
• compression bandages in patients with limb edema
ficial in preventing toe-web CoNSENSuS STATEMENT #10:
intertrigo.8 However, closed-toe Prevention of
A follow-up survey by McMahon shoes would be recommended et al. of nurses' knowledge about for patients with diabetes, and the management of inframam- The following strategies may a moisture-wicking textile with mary intertrigo found they had help to prevent intertrigo silver could be woven between a broad variety of recommen- from developing or recurring: the toes to help translocate dations, many of which were 1. Cleanse skin folds gently, moisture. (See Moisture-wicking contradictory. An example of a dry gently but thoroughly Textile with Silver, above.) Proper contradictory recommendation (pat, do not rub) and edu- supportive garments, such as included the use of talcum pow- cate patients about proper brassieres, can reduce appos- der (16.5%), and its avoidance skin fold hygiene.
(15.7%).3 Talcum (zinc oxide ition of skin surfaces. In addition, 2. Counsel patients to wear powder) can be useful, but this placing moisture-wicking textile open-toed shoes and product may be confused or with silver within large skin folds loose-fitting, lightweight substituted with corn starch, to translocate excessive mois- clothing of natural fabrics which can support the growth ture may be helpful.4 Ensuring or athletic clothing that of bacterial organisms. Another that 4 cm of the fabric hangs out wicks moisture away from the skin.
alternative is short-chain fatty of the fold allows translocation 3. Advise patients to wear acid powders, such as undecyclic of moisture. Patient education proper supportive gar- acid, which can decrease organ- should include the importance ments, such as brassieres, to ism growth and facilitate local of showering after exercise reduce skin-on-skin contact.
and carefully drying skin folds; 4. Consider using a mois- The consensus recommenda- awareness of the risk of inter- ture-wicking textile with trigo associated with sweating, silver within large skin folds • hygiene-related suggestions: such as in hot and humid weath- to translocate excessive washing thoroughly and dry- er, should be stressed. 16 Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
• clothing-related approaches: aluminum chloride hexahydrate, to determine the efficacy of the natural fibres and wearing a systemic β-blockers, or anti- moisture-wicking textile with sil- cholinergic drugs. ver instead of standard therapy • occlusive dressings and vari- Botulinum toxin A has been in patients with refractory inter- ous powders, especially short- evaluated in a multicentre trial trigo.36 Study participants were chain fatty acid powders in 145 patients with axillary 21 patients with intertriginous • protective barriers: zinc oxide hyperhidrosis.35 Botulinum toxin dermatitis from two long-term- or petrolatum, film-forming A blocks the release of acetyl- care centres. Mean patient age liquid acrylates and silicone- or choline, the sympathetic neuro- was 53.8 years and mean body dimethicone-based creams transmitter in the sweat glands, mass index was 54.75. The inter-trigo had been present for a The survey identified a lack of to stop excessive sweating. In varying number of weeks and in coherence in the management each patient, botulinum toxin most cases other products had of inframammary intertrigo. A 200 U was injected into one axilla and placebo into the other. been tried without a response. INEFFECTIVE THERAPIES
Two weeks later, botulinum Skin assessment was performed A previous expert panel iden- toxin A 100 U was injected into tified several therapies that the axilla that had previously itching/burning, maceration, were ineffective or harmful to received placebo. Patients were denudement, satellite lesions, prevent or treat intertriginous followed for 26 weeks, and the erythema and odour (Table 3). dermatitis.4 Powders, such as rate of sweat production meas- In this study, moisture-wicking cornstarch, have no proven ured. At two weeks, average textile with silver relieved the benefit and may encourage fun- sweat production had decreased patients' symptoms and signs gal growth, as cornstarch is a by 87.5%. At 26 weeks, sweat of intertrigo within a five-day substrate for growth of yeasts.9 production, which was similar period. The moisture-wicking Textiles, such as gauze, various in both axillae, was still 65.6% textile with silver is also cost-ef- fabrics or paper towels, placed lower than at baseline. Virtually fective, as it reduces nursing time between skin folds, are usually all (98%) patients reported they substantially. (See Cost-effective ineffective as they absorb mois- would recommend the therapy Treatment of Intertrigo, page 18.) ture but do not allow it to evap- orate, promoting skin damage.4 Intertrigo treatment relies on Home remedies, such as diluted INTERTRIGo AND MoISTuRE-WICKING

common-sense approaches vinegar and wet tea bags, have Various standard treatments because little evidence sup- never been evaluated in clinical Table 3. Signs and Symptoms in Study Patients
Sign or Symptom
Intertrigo due to hyperhidrosis, or increased perspiration, can be antifungals treated using several modalities. The first-line treatment is alum- inum chloride hexahydrate 20% Satellite lesions in anhydrous ethanol. Second- line therapies include oral and topical anticholinergics and botulinum toxin A. Intertrigo * One patient had maceration and odour due to urine prevention in this population is soiling of textile that was not removed immediately most commonly addressed with † Statistically significant decrease Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
Cost-effective Treatment of Intertrigo
A comparison of potential retail costs for each treatment and potential nursing time are listed below. In general this type of treatment may be offered in chronic care institutions, but it is unlike-ly that twice daily nursing visits would be authorized through home care. Table 4. Cost Comparison for Intertrigo Treatment
Clotrimazole antifungal cream, 30g, twice daily for 2 weeks, 7.5 applications per tube
Cost for 2 weeks' treatment with clotrimazole 28 applications over 14 days
Nystatin antifungal cream, 30g, twice daily for 2 weeks, 7.5 applications per tube
Cost for 2 weeks' treatment with nystatin 28 applications over 14 days
Moisture-wicking textile with silver, 10" x 12", applied every 5 days
Cost per roll (10" x 12')* Resolution in 5 days with the moisture-wicking textile with silver Resolution in 10 days with the moisture-wicking textile with silver 10 visits
* Retail cost; institutional cost lowerSource: Retail pharmacy costs ports various commonly used ture-wicking textile with silver ous dermatitis has resolved.1 It therapies. Most importantly, it has been shown to be effective is also important to recognize is necessary to establish or con- in treating intertrigo. Treatment that eroded intertrigo skin is not tinue a skin-care regimen that of secondary infection may completely healed until the nor- focuses on keeping the skin require topical and possibly mal skin thickness is re-estab- folds dry and prevents or treats oral therapy. Treatment should lished and the barrier function secondary infection.4 The mois- continue until the intertrigin- restored. The diagnosis should 18 Wound Care Canada – Supplement
Volume 11, Number 2 · Fall 2013
be revisited in cases of inter- A Case of Axillary Intertrigo
triginous dermatitis that do not A 60-year-old woman with a history of right-sided mastectomy respond to usual therapy.
presented with denuded and erythematous skin at the right axil- Weight loss is always an lary fold (Figure 1). The lesion was very painful, and a foul odour appropriate preventive and and drainage were present. The condition had been present for treatment strategy, but it is two weeks. Nystatin powder had been ineffective in improving the notoriously difficult to achieve. problem. At presentation, the lesion was cleaned gently and patted Although intertrigo is not an dry. A piece of moisture-wicking textile with silver was placed with- indication for reduction mam- in the axillary fold and secured at the shoulder, leaving adequate moplasty, a meta-analysis of textile exposed for translocation. The textile was replaced after five reduction mammoplasty out- days. At seven days, there was significantly less drainage and red- comes in 4,173 patients found ness and the denuded skin was almost healed (Figure 2). intertrigo decreased from 50.3% to 4.4% after surgery.37 CoNSENSuS STATEMENT #11:
Treatment of
The following approaches
may help treat intertrigo:
1. Follow recommended pre-
ventive strategies to keep Figures 1 and 2. Axillary intertrigo before and after seven days with
skin folds dry and prevent moisture-wicking textile with silver or treat secondary infection.
2. Consider using a mois- ture-wicking textile with silver between affected skin Intertrigo is a common condition associated with MASD. Intertrigo 3. Continue treatment until may be found in a variety of intertriginous dermatitis clinical settings, including acute, has been controlled. chronic, long-term and home 4. Treat secondary infection care. Overall, the limited informa- with appropriate systemic tion about intertrigo currently and topical agents.
available is a cause for concern. 5. Revisit the diagnosis in The incidence and prevalence of intertrigo are unknown, and cases that do not respond little evidence supports the use to usual therapy.
of commonly used therapies. The 6. Initiate a prevention pro- information in this consensus gram that can include document has been synthesized weight loss, a skin-fold for educational purposes for hygiene program and early clinicians and as a stimulus for detection and treatment of more research into this common Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement
8. Janniger CK, Schwartz RA, A Case of Inframammary Intertrigo
Szepietowski JC, Reich A. Intertrigo A 92-year-old female presenting for care of venous stasis ulcer- and common secondary skin infections. Am Fam Physician. ation complained of a persistent, painful rash underneath her breasts that had been unresponsive to treatment with a variety 9. Guitart J, Woodley GT. Intertrigo: of oral and topical therapies. Candida intertrigo was present with a practical approach. Compr Ther. erythematous papules, satellite lesions, denudement, weeping 1994;20(7):402–9. and a musty odour. Initial treatment was with an oral prescription 10. Brown J, Wimpenny P, Maughan H. antifungal for five days. When this was ineffective, a topical anti- Skin problems in people with obesity. Nursing Stand. 2004;18(35):38–42.
fungal powder was prescribed twice daily for two weeks. The rash 11. Mathur AN, Goebel L. Skin findings persisted and was then treated with an antifungal cream twice associated with obesity. Adolesc Med daily for two weeks State Art Rev. 2011;22(1):146–56.
At the next visit, the intertrigo was gently cleaned and pat- 12. Al-Mutairi N. Associated cutaneous ted dry. A piece of moisture-wicking textile with silver was then diseases in obese adult patients: placed beneath each breast, leaving 4 cm exposed for transloca- a prospective study from a skin tion and secured in place using a sports bra. Substantial improve- referral care center. Med Princ Pract. 2011;20(3):248–52.
ment was noted by 14 days with complete resolution by 21 days. 13. Boza JC, Trindade EN, Peruzzo J, Sachett L, Rech L, Cestari TF. Skin man-ifestations of obesity: a comparative study. J Eur Acad Dermatol Venereol. 2012;26(10):1220–3. 14. García Hidalgo L. Dermatological complications of obesity. Am J Clin Dermatol. 2002;3(7):497–506. 15. McMahon R. The prevalence of skin problems beneath the breasts of in-patients. Nurs Times. 1991;87(39):48–51. Figures 3 and 4. Inframammary intertrigo before and after mois-
16. Yosipovitch G, Tur E, Cohen O, Rusecki ture-wicking textile with silver Y. Skin surface pH in intertriginous areas in NIDDM patients: possible correlation to candidal intertrigo. Diabetes Care. 1993;16(4):560–3.
4. Black JM, Gray M, Bliss DZ, Kennedy- 17. Lekan-Rutledge D. Management of Evans KL, Logan S, Baharestani M, 1. Gray M, Bohacek L, Weir D, Zdanuk urinary incontinence: skin care, con- Colwell JC, Goldberg M, Ratcliff CR. J. Moisture vs pressure: making tainment devices, catheters, absorp- MASD part 2: incontinence-associated sense out of perineal wounds. J tive products. In: Doughty DB, ed. dermatitis and intertriginous derma- Wound Ostomy Continence Nurse. Urinary & fecal incontinence: current titis: a consensus. J Wound Ostomy management concepts. 3rd ed. St. Continence Nurs. 2011;38(4):359–70. Louis, MO: Mosby; 2006. p. 309–40. 2. Gray M, Black JM, Baharestani MM, 5. Voegeli D. Moisture-associated skin 18. Dougherty KA, Chow M, Kenney Bliss DZ, Colwell JC, Goldberg M, damage: an overview for communi- WL. Clinical environmental limits Kennedy-Evans KL, Logan S, Ratcliff ty nurses. Br J Community Nursing. for exercising heat-acclimated lean CR. Moisture-associated skin dam- and obese boys. Eur J Appl Physiol. age: overview and pathophysiology. 6. Muller N. Intertrigo in the obese J Wound Ostomy Continence Nurse. patient: finding the silver lin- 19. Nino M, Franzese A, Ruggiero Perrino ing. Ostomy Wound Manage. NR, Balato N. The effect of obesity on 3. McMahon R, Buckeldee J. Skin skin disease and epidermal permea- problems beneath the breasts of 7. Mistiaen P, van Halm-Walters M. bility barrier status in children. Pediatr in-patients: the knowledge, opinions Prevention and treatment of intertrigo Dermatol. 2012;29(5):567–70. and practice of nurses. J Adv Nurs. in large skin folds of adults: a system- 20. O'Regan GM, Sandilands A, McLean 1992t;17(10):1243–50. atic review. BMC Nurs. 2010;9:12. WH, Irvine AD. Filaggrin in atopic 20 Wound Care Canada – Supplement
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dermatitis. J Allergy Clin Immunol. vical folds in a five-month old infant. adults: a literature overview. Dermatol Pediatr Infect Dis J. 2012;31(8):872–3.
Nurs. 2004;16(1):43-46,49–57. 21. Kugelman TP. Intertrigo—diag- 27. Neri I, Savoia F, Giacomini F, Patrizi 34. Kennedy-Evans KL, Henn T, Levine N. nosis and treatment. Conn Med. A. Streptococcal intertrigo. Pediatr Skin and wound care for the bariatric Dermatol. 2007;24(5):577–8. patient. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic wound care: 22. Kränke B, Trummer M, Brabek E, 28. Honig PJ, Frieden IJ, Kim HJ, Yan AC. a clinical source book for healthcare Komericki P, Turek TD, Aberer W. Streptococcal intertrigo: an under- professionals. 4th ed. Malvern, PA: HMP Etiologic and causative factors in per- recognized condition in children. Communications; 2007. p. 695–699. ianal dermatitis: results of a prospec- 35. Heckmann M, Ceballos-Baumann AO, tive study in 126 patients. Wien Klin 29. Holdiness MR. Management of Plewig G, for the Hyperhidrosis Study Wochenschr. 2006;118(3-4):90–4. cutaneous erythrasma. Drugs. 2002;62(8):1131–41. Group. Botulinum toxin A for axillary 23. Edwards C, Cuddigan J, Black J. hyperhidrosis (excessive sweating).
Identification of organisms colonized 30. Lin JY, Shih YL, Ho HC. Foot bacterial New Engl J Med. 2001;344(7):488–93.
at site of intertriginous dermatitis intertrigo mimicking interdigital 36. Kennedy-Evans KL, Viggiano B, Henn in hospitalized patients. Toronto, tinea pedis. Chang Gung Med J. T, Smith D. Multisite feasibility study ON: World Union of Wound Healing 2011;34(1):44–9. using a new textile with silver for Societies: 2008. 31. Dupuy A, Benchikhi H, Roujeau J-C, management of skin conditions Bernard P, Vaillant L, Chosidow O, 24. Gloor M, Geilhof A, Ronneberger located in skin folds. Presented at: The Sassolas B, Guillaume JC, Grob JJ, G, Friederich HC. Biochemical and Clinical Symposium Advances in Skin Bastuji-Garin S. Risk factors for erysip- physiological parameters on the & Wound Care at the Wound Ostomy elas of the leg (cellulitis): case-control healthy skin surface of persons with and Continence Nurses Society 39th study. Br Med J. 1999;318(7198):1591– candidal intertrigo and of persons annual meeting; 2007 Jun 9–13; Salt with tinea cruris. Arch Dermatol Res. Lake City, Utah.
32. Studer-Sachsenberg EM, Ruffieux P, 37. Chadbourne EB, Zhang S, Gordon MJ, Saurat J-H. Cellulitis after hip surgery: Ro EY, Ross BD, Schnur PL, Schneider- 25. Wolf R, Oumeish OY, Parish LC. long-term follow-up of seven cases. Br Redden PR. Clinical outcomes in Intertriginous eruption. Clin Dermatol. J Dermatol. 1997;137(1):133–6.
reduction mammaplasty: a system- 2011;29(2):173–9. 33. Mistiaen P, Poot E, Hickox S, Jochems atic review and meta-analysis of 26. Silverman RA, Schwartz RH. C, Wagner C. Preventing and treating published studies. Mayo Clin Proc. Streptococcal intertrigo of the cer- intertrigo in the large skin folds of 2001;76(5):503–10. Volume 11, Number 2 · Fall 2013
Wound Care Canada – Supplement

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Turkey after the start of negotiations with the european union (part 1)

OÂRODEK STUDIÓW WSCHODNICH IM. MARKA KARPIA Raport OSW / CES Report RAPORT OSW Rafa∏ Sadowski, Wojciech Paczyƒski urkey after the start of negotiations T with the European Union – foreign relations and the domestic situation © Copyright by Centre for Eastern Studies Project co-ordinator Adam Balcer

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