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Neck-Fold Intertrigo in Babies: Think of Strep

Looks can be deceiving.

Chubby babies often have deep, moist body folds. Red, macerated, crescentic patches are frequently seen in the valleys of these folds. Pediatricians and dermatologists are trained to think of candida intertrigo in such instances, as candida readily colonizes moist areas, particularly in the diaper region. Candida intertrigo usually responds promptly to topical antifungal agents coupled with drying strategies.

These authors describe three infants, a 3-month-old girl and two 5-month-old boys, with intertrigo that did not respond to topical antifungal medications. Cultures of intertrigo samples grew group A ß-hemolytic streptococci (GABHS). Each of the patients had a 4- to 8-week history of a sharply demarcated, bright red, macerated patch deep in the neck folds that failed to respond to topical nystatin, econazole, or 1% hydrocortisone cream. Additional body folds were affected in two infants. All three infants responded well to treatment, which included topical mupirocin, oral penicillin or cephalexin, and topical 1% hydrocortisone cream.

The appearance of candidal intertrigo and GABHS intertrigo are similar. GABHS infections tend to have a foul odor and rarely involve satellite lesions, whereas candidal infections usually lack an odor and have satellitosis as a hallmark symptom. Other differential diagnoses that should be considered include inverse psoriasis, seborrheic dermatitis, atopic dermatitis, mixed bacterial intertrigo, and Langerhans cell histiocytosis.

GABHS infections can be complicated by rheumatic fever and acute glomerulonephritis. However, rheumatic fever has not been associated with cutaneous GABHS infections. Early treatment of acute rheumatic fever has not been shown to prevent streptococcal glomerulonephritis.

Comment: Bacterial and fungal cultures should be done for intertrigo in babies, especially that occurring in the neck folds. These authors administered systemic as well as topical antibiotics, but with close follow-up, topical mupirocin alone may be sufficient to clear these superficial infections. In Canada and Europe, topical fusidic acid is available and should be considered.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology February 4, 2004

Citation(s):

Honig PJ et al. Streptococcal intertrigo: An underrecognized condition in children. Pediatrics 2003 Dec; 112:1427-9.

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