Snapshot A 70-year-old man presents from his nursing home for an armpit rash. He reports itchiness and some irritation with movement. His medical history includes obesity, diabetes, hypertension, hyperlipidemia, and rheumatoid arthritis. He is currently taking immunosuppressive drugs for his rheumatoid arthritis. Physical exam reveals a 5-cm erythematous plaque with peripheral scales. There are multiple satellite lesions. A skin scraping KOH preparation reveals septated hyphae. He is given topical therapy for his rash. Introduction Clinical definition inflammatory condition of the intertriginous areas (two skin surfaces in close proximity) often caused by superficial infection of Candida spp. Associated conditions persistent candidal infections may indicate immunodeficiency diabetes HIV Epidemiology Demographics children and adults infants candidal diaper dermatitis Location intertriginous regions Risk factors warm and moist environment of skin folds obesity constricting clothing hyperhidrosis incontinence diabetes Etiology Pathogenesis T-cell mediated immunity is used against candidal infections Candida spp. are part of the skin’s normal flora in low numbers can cause infection when the bacterial flora is altered host defenses are impaired trauma, occlusion, or abrasions can disrupt skin integrity Candida spp. unicellular and dimorphic fungus with budding yeast often have septate hyphae and pseudohyphae most common Candida albicans Presentation Symptoms pruritus painful if there is significant maceration easily irritated Physical exam erythematous and macerated plaques “beefy red” erosions with peripheral scaling erythematous satellite papules and pustules classic for candidal cutaneous infections locations inguinal folds axilla intergluteal folds inframammary folds Studies KOH preparation skin scrapings at active edge of lesion mixed with KOH presence of septated hyphae and spores indicates fungal infection Trypan blue stain for rapid diagnosis Fungal culture skin scrapings at edge of lesion indications if there is any doubt about diagnosis Making the diagnosis this is a clinical diagnosis satellite lesions are classic and support the diagnosis of candidal intertrigo Differential Tinea cruris Atopic dermatitis Erythrasma Treatment Conservative weight loss indication prevention of future recurrence Medical topical antifungal therapy indications first-line treatment localized disease drugs nystatin clotrimazole ketoconazole topical corticosteroids indications adjunctive therapy for symptomatic relief should be used with antifungal topical therapies drugs 2% hydrocortisone oral antifungal therapy indications severe and refractory disease widespread disease drugs fluconazole itraconazole Complications Secondary bacterial infection