Resistant "Candidal Intertrigo": Could Inverse Psoriasis Be the True Culprit?

Abstract

Inverse psoriasis is a disorder of intertriginous areas of the skin that can easily masquerade as candidal intertrigo. Candidal rashes are commonly encountered in primary care and typically respond promptly to therapy. When treatment fails, nonadherence to treatment and medication resistance often are suspected; however, the possibility of an incorrect diagnosis should also be entertained. This article presents the case of a patient with inverse psoriasis who was misdiagnosed with recurrent candidal intertrigo multiple times. The diagnosis and treatment of inverse psoriasis is reviewed, and other conditions that may be confused with Candida and inverse psoriasis, including bacterial intertrigo, tinea, and seborrheic dermatitis, are discussed. When confronted with a case of "resistant Candida," consideration of inverse psoriasis and other Candida mimics can allow physicians to diagnose and treat these conditions more effectively, avoiding the frustration experienced by our patient. A 68-year old woman with a history of poorly controlled type 2 diabetes mellitus presented as a new patient with exacerbation of chronic obstructive pulmonary disease (COPD) and a rash. The rash consisted of chronic, recurrent, erythematous patches in the inframammary and inguinal folds (Figure 1). The patches were mildly macerated. Scanty satellite lesions were observed near the inframammary but not the inguinal patches; scales were absent in these locations. There was scaling and tenderness in both auditory canals, with mild scaling of each pinna. Over the past week, the patient had applied multiple topical medications to the rash, including clotrimazole, moisturizer, and bacitracin/neomycin/polymyxin. She reported a 10-year history of similar rash affecting the axillae, groin, inframammary folds, retroauricular area, and gluteal cleft. The skin lesions had been diagnosed previously as candidiasis, but the patient was adamant that multiple trials with topical and oral antifungals did not help the rash. It is interesting that she noted that the skin lesions always improved when she was taking prednisone for the treatment of COPD exacerbations.The patient was prescribed prednisone for her COPD exacerbation and neomycin-polymyxin Bhydrocortisone otic solution for presumed otitis externa. Antifungal cream was offered but the patient was certain it would not help and insisted the prednisone would resolve the rash. She was instructed to discontinue all topical products for the rash and to return for follow-up. She presented 1 week later with a dramatic improvement in her rash. However, within 2 weeks of terminating oral prednisone, the erythematous patches recurred in the inframammary folds and gluteal cleft. The differential diagnosis included intertrigo, erythrasma, seborrheic dermatitis, inverse psoriasis, and resistant Candida secondary to poorly controlled diabetes. The affected areas were examined with a Wood's lamp and demonstrated no signs of fluorescence that would suggest erythrasma. A fungal culture was obtained, and clotrimazol...

Recurrent candidal intertrigo: challenges and solutions

“… Note: Data taken from several studies. 2 , 7 , 9 , 10 , 28 , 29 , 31 , 47 , 49 – 51 , 58 , 62 – 64 , 67 , 69 , 70 , 72 – 77 , 84 , 96 – 103 Abbreviations: HPV, human papillomavirus; EIB, Erosio interdigitalis blastomycetica …”

Psoriasis inversa en un paciente pediátrico

“…Lysell, en un estudio para caracterizar clínicamente la psoriasis en menores de 16 años, encontró la mayor proporción de casos de psoriasis inversa antes de la pubertad 14 . Este tipo de psoriasis es difícil de diagnosticar; siempre debe sospecharse ante un caso de dermatitis inflamatoria crónica, de tipo intertrigo candidiásico o tiña, que no mejore con el tratamiento antifúngico o cuando la prueba para hongos sea negativa 15,16 . La psoriasis inversa también es difícil de tratar y representa todo un reto debido a que no mejora con el tratamiento convencional 17 .…”

<p>Inverse Psoriasis: From Diagnosis to Current Treatment Options</p>

“…Superinfection by bacteria and fungi (especially Candida spp) is frequent in IP as the moist skin provides an ideal environment for growth of microorganisms. 11 On the other hand, colonization of flexural areas may also predispose to IP flares. 1…”

“…Erythrasma, which is caused by Corynebacterium minutissimum, appears as red-brownish patches with well-defined edges. Examination with Wood's light can help identify this form by showing a coral red fluorescence, 11 and a positive bacterial culture is diagnostic. Other bacteria may often complicate mechanical intertrigo including Staphylococcus aureus, Streptococcus, Pseudomonas aeruginosa, Proteus mirabilis and Proteus vulgaris.…”

“…The presence of yellowish, greasy scales can help differentiate seborrheic dermatitis from IP, although they may be absent. 11 The simultaneous involvement of typical areas (face, scalp) may address to the correct diagnosis.…”