Under the Umbrella of MASD – Intertriginous Dermatitis (ITD)

Review of the literature by Valerie Dowley, Independent Tissue Viability Specialist, September 2023

Quick Refresh, what is MASD and why all the fuss?

Moisture Associated Skin Damage (MASD) is an umbrella term for skin inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, sweat, faeces, wound exudate, saliva, or mucus (LeBlanc, 2019). There are 4 main types of MASD which are.

• Intertriginous Dermatitis (ITD) – where moisture gets trapped within folds of skin causing inflammation.
• Peristomal MASD – inflammation and erosion, caused by moisture, around and extending outwards from the stoma/skin junction.
• Peri-wound MASD – skin maceration and erosion from wound exudate.
• Incontinence Associated Dermatitis (IAD) – chemical irritation caused by prolonged contact between the skin and urine and/or faeces. (Fletcher, J. 2020. Yates, A. 2020)

For the purposes of this clinical blog, I am going to discuss Intertriginous Dermatitis (ITD) in more detail. 

Intertriginous Dermatitis, or Intertrigo, is a common condition, which falls under the umbrella of MASD. However, the condition has had less of a spotlight in terms of MASD research (Voegeli, 2020) in comparison to the three other forms of MASD (Cotterell et al, 2020).

It is a common inflammatory condition that happens when there is skin-on-skin friction because of moisture, mainly sweat, being trapped between skin folds. This causes the skin surfaces to ‘stick’ together, increasing friction, leading to skin inflammation and increased risk of infection or fungal colonisation. It can be described as a form of contact dermatitis in areas of skin folds such as axillary, genitocrural (groin folds and upper thighs), and abdominal folds but can happen in any area of the body where two skin surfaces are in close contact with each other such as interdigital spaces. Due to lack of effective air flow, there is no evaporation of the sweat, and the epidermal layer of skin, mainly the stratum corneum, becomes waterlogged and macerated (Voegeli, 2020. Romanelli et al, 2023. Cottrell et al, 2020). 

What are the predisposing factors?

• Young children with neck creases due to flexed posture and dribbling.
• Obesity (skin folds are more pronounced, skin barrier function impaired, and difficulty in keeping these areas clean and dry). There is a direct relationship between degree of obesity and the incidences of Intertrigo.
• Hyperhidrosis (over production of sweat in axilla and groin area, that is not always related to heat or exercise).
• Diabetes (skin pH has been found to be higher particularly in skin folds).
• Poor hygiene.
• Immuno-compromised (HIV infection, chemotherapy, or high dose oral steroid treatment).
• Wearing tight, restrictive clothing such as closed toe or tight-fitting shoes.

What are the clinical presentations?

Like any other form of MASD, Intertrigo can present clinically in a range from mild erythema (redness), to extensive skin breakdown. It often appears as mirror-image (i.e. each side of the skin folds are similarly affected) and patients may complain of itching, stinging or a burning sensation. As this warm, moist, and airless environment is an ideal breeding ground for micro-organisms, Intertrigo can progress to more severe inflammation, with maceration, erosion, and secondary infection. Secondary fungal infection, with Candida albicans, is very common and can be identified by the sharp margins and satellite pustular lesions. 

When Intertrigo is present in the groin region it can be difficult to differentiate it from Incontinence Associated Dermatitis (IAD) as the same skin folds can be exposed to urine and faeces (Young, 2017). 

How to manage Intertrigo

Early detection of skin damage and identification of the causative factors are essential for care planning, as well as to avoid further deterioration and poor clinical outcomes.

• Taking a focused patient history and physical examination can help with diagnosis. Consider location, duration, aggravating factors, physical symptoms including smell will help to focus on what the causative factors may be. It is important to rule out any other dermatological condition that can affect skin folds (Romanelli et al, 2023).

• Cleaning the skin – ideally cleansers should be pH balanced, avoiding harsh soaps which create a more alkaline environment. Foam, no rinse cleansers can help when the area is particularly difficult to access or painful to clean (Beldon 2012). Emollient can be used as a cleanser and some cleansing lotions containing chlorhexidine may help to keep levels of skin bacteria low (Dermol 600 or 500 or Eczmol 2%). 

• Drying thoroughly – care should be taken to ensure that all skin folds are dried thoroughly and gently to prevent further friction and damage to the skin integrity. Pat dry rather than rubbing and using cotton rich cloths/ towels not washed with fabric conditioner (which can make the fibres hard and rough). If there is any suspected fungal infection present, then all towels/ cloths should be washed after each use to prevent cross contamination. Sometimes having multiple face cloths for drying is more clinically effective and easier to launder.

• Skin barrier products – can help to minimise skin-on-skin contact and friction. NICE 2014 recommend skin barrier products are considered for any patient assessed to be at risk from any form of MASD or have dry or inflamed skin. Any applied barrier product should be allowed to dry completely to prevent any more skin-on-skin adhesion (Cottrell et al, 2020). Consideration needs to be given to whether a patient can apply these skin barriers independently and effectively themselves, or if they will require some assistance with application. The use of absorbent or medicated powders, such as talc, are not recommended as they tend to clog on the skin and may require overzealous cleansing to remove (Romanelli et al, 2023).

• Topical treatment for fungal infection may need to be considered and can be used in conjunction with topical barrier products. These generally need to be used twice daily for 2-3 weeks and until the fungal symptoms have been cleared for 7 days. Fungal treatment can be applied to the affected area, allowing it to dry in before applying the barrier product on top.

• Clothing – patients should be encouraged to wear loose fitting, cotton, or natural fibre clothing, which is absorbent. Alternatively, there is a range of athletic clothing designed to wick away perspiration from the skin which may help. Avoid any synthetic fabrics. There are some moisture-wicking textiles available specifically designed for skin fold management so consult your Tissue Viability Service for more information on these (InterDry by Coloplast).

• Patient and carer education – ensuring patients have a good understanding of the causes and how to manage excessive moisture. Hints and tips such as using a hair dryer on low heat to dry skin folds after bathing, advice on clothing, blotting moist areas during the day if sweaty or seeking early intervention if they have symptoms of pain, itching or increased odour.

• Addressing predisposing factors where possible (weight loss, good diabetic control, incontinence, or wound exudate management). 

In conclusion, Intertrigo presents several clinical challenges, and management will require clinicians to have a greater understanding of what it is, the causes, signs and symptoms and how to manage these to help prevent and effectively manage this condition. This starts with a patient-centred, holistic, and problem-solving approach, alongside adopting a structured skin care regime to cleanse and protect the skin which should be reflected in the care plans available to all staff. The importance of clear, interprofessional communication, clear care guidelines and seeking further advice if interventions are key to achieving a positive outcome.

More blogs on MASD:

Under the Umbrella of  MASD – Peri-wound and Peri-stomal Moisture-Associated Dermatitis

Under the umbrella of MASD – Incontinence Associated Dermatitis (IAD)

References

• Beldon P (2008) Moisture lesions: the effect of urine and faeces on the skin. Wound Essentials 3: 82-7
• Cottrell, L., Boutflower, R., Copson, D. (2020). Managing intertriginous dermatitis (intertrigo) with a Total Barrier Protection strategy. Wounds UK, Vol 16 (4). Available at https://wounds-uk.com/journal-articles/managing-intertriginous-dermatitis-intertrigo-total-barrier-protectiontm-strategy/
• Dissemond, j. et al, (2021). Moisture-associated skin damage (MASD): A best practice recommendation from Wund-D.A.CH. JDDG. 19(6). Pg 815-825
• Fletcher, J. (2020) Pressure ulcer education 6: incontinence assessment and care. Nursing Times. Vol 116: 3, 42-44
• National Institute for Health and Clinical Excellence (2014) Pressure Ulcers: Prevention and Management. NICE Guidelines (CG179). Available at: https://www.nice.org.uk/guidance/cg179 (accessed 20.09.2019)
• Romanelli, M., et al (2023). The diagnosis, management, and prevention of intertrigo in adults: a review. Journal of Wound Care. Vol 32 (7). Pg 411-420. Available at https://www.magonlinelibrary.com/doi/full/10.12968/jowc.2023.32.7.411
• Voegeli, D. (2020). Intertrigo: causes, prevention and management. British Journal of Nursing. Vol 19 (12). Available at https://www.britishjournalofnursing.com/content/intertrigo/intertrigo-causes-prevention-and-management/
• Yates, A. (2020). Incontinence-associated dermatitis 1: risk factors for skin damage. Nursing Times [online] Vol 116: 3. Pg 46–50.
• Young T (2017) Back to basics: understanding moisture associated skin damage. Wounds UK 13(4)