EXPERIENCE AND REASON |
Streptococcal Intertrigo: An Underrecognized Condition in Children
* Department of Pediatrics and Dermatology, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Departments of Pediatrics and Dermatology, University of California-San Francisco, San Francisco, California
Department of Dermatology, University of Virginia Hospitals, Richmond, Virginia
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ABSTRACT |
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 TOP ABSTRACT CASE REPORTSDISCUSSIONREFERENCES |
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Group A ß-hemolytic streptococci have been implicated in a variety of common childhood cutaneous infections. Infants and young children may be particularly susceptible to a form of streptococcal intertrigo that has heretofore been underrecognized in this population. Manifesting as intense, fiery-red erythema and maceration in the intertriginous folds of the neck, axillae, or inguinal spaces, the condition is characterized by a distinctive foul odor and an absence of satellite lesions. Specific clinical features help differentiate this condition from its clinical mimics. Topical and oral antibiotic therapy with or without concomitant low-potency topical steroid application is generally curative.
Key Words: streptococcal intertrigo • skin infection • children • infants
Abbreviations: GABHS, group A ß-hemolytic streptococci
Group A ß-hemolytic streptococci (GABHS) produce several widely known skin infections, including impetigo, cellulitis, ecthyma, and erysipelas. Perianal streptococcal disease, a more recent addition to the family of streptococcal infections, was first described in 1966.1 As a result of several reports during the late 1980s2,3 and the 1990s,4–7 this entity is now readily recognized by pediatric practitioners. Another streptococcal skin infection, GABHS intertrigo,8,9 has received scant attention and represents an underrecognized cause of intertriginous eruptions that responds to prompt diagnosis and treatment. The typical presentation and clinical course of 3 patients with GABHS intertrigo are described in this report.
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CASE REPORTS |
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TOPABSTRACTCASE REPORTSDISCUSSIONREFERENCES |
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Case 1
A 3-month-old girl presented with a 5-week history of an intertriginous eruption. Therapy for suspected candidal intertrigo with topical econazole and 1% hydrocortisone cream provided little response. The child was otherwise well. No other family members were affected.
Physical examination revealed a well-appearing, well-developed infant with confluent areas of fiery-red, moist, somewhat denuded skin with macerated, irregular, scaling borders that was foul smelling and involved 2 areas: the creases of the neck (Fig 1) and the right inguinal region. Satellite lesions were absent.
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Cultures of both areas were obtained by swabbing the involved skin, plating the sample on 5% sheep blood agar, and incubating at temperatures between 35°C and 37°C. This yielded a heavy growth of a single organism, GABHS, which was sensitive to penicillin. Treatment with penicillin V-K suspension, 125 mg orally 3 times daily, and topical mupirocin ointment resulted in improvement of the erythema and maceration after 10 days. Persistent erythema of the involved areas was then cleared with 1 additional week of topically applied 1% hydrocortisone cream.
Case 2
A 5-month-old boy presented with a 4-week history of a persistent nuchal eruption unresponsive to topical nystatin and 1% hydrocortisone cream for presumed candidal intertrigo. No other family members were affected.
Physical examination revealed a well-appearing infant with a moist, glistening, foul-smelling, erythematous eruption involving the entire neck fold. Satellite lesions were absent. No other intertriginous areas were involved.
Bacterial culture of the neck folds were obtained and processed in a manner similar to case 1. This culture yielded a pure growth of GABHS sensitive to penicillin. After 1 week of a 10-day course of therapy with penicillin suspension, 125 mg 3 times daily, and topical mupirocin ointment, the moist areas resolved but the erythema persisted. Topical hydrocortisone 1% cream was then prescribed. After 1 month of topical therapy, only slight residual pink erythema remained and the patient was discharged to his primary physician.
Case 3
A 5-month-old girl presented with an 8-week history of a persistent intertriginous eruption that was presumptively diagnosed as candidal intertrigo but that was unresponsive to 3 weeks of treatment with both topical and oral nystatin. Other than a congenital onset of unilateral exophthalmos, the child was well. Family history was unremarkable for skin conditions, atopic or otherwise.
On examination, sharply demarcated, beefy-red plaques were evident on the neck, antecubital, popliteal, axillary (Fig 2), and inguinal folds. Scattered satellite papules were also present.
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Initial differential diagnoses included GABHS intertrigo, atopic dermatitis, inverse psoriasis, and Langerhans’ cell histiocytosis (Table 1). Bacterial cultures were performed, and the child was started on empiric topical mupirocin ointment 3 times daily. Cultures from the left antecubital space grew moderate amounts of GABHS sensitive to penicillin as well as penicillin-resistant Staphylococcus aureus (sensitive to erythromycin and cephalosporin) and Proteus mirabilis (sensitive to cephalosporin). Treatment with penicillin, 125 mg 3 times daily, had been started on the basis of initial culture results, but with sensitivities available, cephalexin, 62.5 mg 4 times daily, and topical 1% hydrocortisone cream were substituted for penicillin. The eruption improved with the aforementioned treatment.
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DISCUSSION |
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TOPABSTRACTCASE REPORTSDISCUSSIONREFERENCES |
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Although reports of localized outbreaks of rheumatic fever,10,11 perianal streptococcal disease,1–7 and invasive streptococcal disease such as toxic shock syndrome12,13 are commonplace, little attention has been paid to GABHS intertrigo. As a result, delays in diagnosis, multiple office visits, and great anxiety for both parent and physician occur.
Intertrigo is a process created by friction of opposing skin surfaces exacerbated by moisture trapped in deep skin folds. Young infants are especially susceptible because of their short necks, relative chubbiness, and flexed posture, all of which produce deep skin folds. Other factors, such as drooling, may also make intertriginous areas in infants vulnerable to irritation and frictional forces. In addition, secondary infection with Candida albicans is common, as in diaper dermatitis.14 However, other secondary invaders such as GABHS must also be considered. S aureus may be present alone or in combination with GABHS,15 as was the situation in case 3. Isolation of both organisms now occurs less frequently than in the past.16 Other bacteria reported to occur in mixed infections include Pseudomonas aeruginosa and Proteus vulgaris17 or P mirabilis (case 3).
When evaluating a patient with persistent intertriginous inflammation, pediatric practitioners often reflexively assume a diagnosis of candidal intertrigo. A sharply demarcated, erythematous, weeping eruption in intertriginous areas that is presumed characteristic of candidal intertrigo may actually represent GABHS intertrigo. Certain clinical features can help to differentiate monilial intertrigo from GABHS intertrigo. Although present in both settings, the appearance of satellite lesions surrounding the main eruption favors Candida infection, whereas the presence of a distinct, foul smell on examination suggests GABHS intertrigo. GABHS skin infections may also induce psoriasiform18–20 (thick, red, macerated, or scaly plaque-type) skin lesions or be associated with psoriasis. In these instances, the guttate lesions of psoriasis, which present as scaly, erythematous islands, may resemble satellite lesions. Patients with GABHS intertrigo may be fussy or have low-grade fevers. Finally, culture of the affected areas and the response to treatment can most clearly distinguish these 2 diagnoses (Table 2).
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Resolution should occur with proper treatment. Persistence of the eruption indicates that alternative diagnoses should be considered. Simple intertrigo will respond to measures that minimize moisture and reduce friction (eg, thorough drying of the skin folds, barrier creams, and absorptive powders such as cornstarch). Candidal intertrigo will respond to anti-yeast preparations such as econazole, ketoconazole, or nystatin creams or ointments; anti-inflammatory agents, such as topical hydrocortisone 1% cream, may also be helpful in this instance. Bacterial cultures and sensitivities should be obtained if these interventions fail. A properly dosed 10-day course of penicillin successfully eliminates GABHS in most instances (cases 1 and 2). Recurrences may occur and require re-treatment. Case 3 illustrates that multiple organisms may be involved. Anti-inflammatory creams are helpful in more effectively clearing the erythema associated with GABHS intertrigo as a result of underlying atopic or seborrheic dermatitis. If these treatment approaches prove ineffective, then a skin biopsy should be considered to rule out the less common causes of intertrigo as listed in Table 1.
GABHS infections may lead to complications such as rheumatic fever and acute glomerulonephritis in certain clinical situations. However, rheumatic fever has not been associated with cutaneous GABHS infections. Likewise, early treatment for acute rheumatic fever has not been shown to prevent streptococcal glomerulonephritis.21
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ACKNOWLEDGMENTS |
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We gratefully acknowledge the assistance of William Witmer in the preparation of the clinical images.
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FOOTNOTES |
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Received for publication Jan 27, 2003; Accepted May 5, 2003.
Reprint requests to (A.C.Y.) Pediatric Dermatology, Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail: yana{at}email.chop.edu
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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