A 5-month-old girl had an 8-week history of a persistent foul smelling intertriginous eruption involving the neck, axillae, groin, and flexural creases of the arms and legs. Lesions were unresponsive to topical and oral nystatin for presumed candidal intertrigo. Culture yielded heavy growth of a single organism (Group A beta-hemolytic Streptoccus). Group A beta-hemolytic streptococci (GABHS) produce a variety of skin infections, including cellulitis, ecthyma, erysipelas and perianal cellulitis in young children. Another streptococcal skin infection – GABHS intertrigo – represents an under-recognized cause of intertriginous eruptions in children.
Simple intertrigo results from the friction created by opposing skin surfaces and is exacerbated by moisture trapped in deep skin folds. Young infants are especially susceptible due to their relative chubbiness, short necks, and flexed posture, all of which lead to deep skin folds. Secondary infection by Candida albicans is not uncommon; however, other secondary pathogens, such as GABHS, should also be considered. Other bacteria reported to occur in mixed infections include Pseudomonas aeruginosa and Proteus vulgaris or P. mirabilis.
Certain clinical features may help to differentiate monilial intertrigo from GABHS intertrigo. Although present in both settings, satellite lesions favor Candida infection, whereas the presence of a distinct, foul smell on examination suggests GABHS intertrigo. GABHS skin infections may also induce psoriasiform skin lesions or may be associated with psoriasis, which present as scaly, erythematous islands that can resemble satellite lesions. Culture of the affected skin areas provides the most definitive tool to differentiate these two conditions. Some suggest the use of a rapid strep test to help with prompt diagnosis; however, the specificity and sensitivity of the technique for this anatomic site remains to be determined.
Simple intertrigo responds to measures that minimize moisture and reduce friction, such as barrier creams or absorptive powders such as cornstarch. Candidal intertrigo responds to anti-yeast preparations such as econazole, ketoconazole, or nystatin creams or ointments. A 10-day course of properly dosed penicillin successfully treats GABHS in most instances. For less-severe cases, a trial of topical mupirocin ointment can be utilized. Frequently, use of a low-potency topical steroid is helpful for decreasing inflammation and its associated symptoms.
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