Streptococcal intertrigo

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Streptococcal intertrigo
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Severe skin inflammation at armpit (warm, moist fold of skin) Axillary intertrigo.png
Severe skin inflammation at armpit (warm, moist fold of skin)

Streptococcal intertrigo is a skin condition that is secondary to a streptococcal bacterial infection. It is often seen in infants and young children and can be characterized by a fiery-red color of the skin, foul odor with an absence of satellite lesions, [1] and skin softening (due to moisture) in the neck, armpits or folds of the groin. [2] : 262  Newborn children and infants commonly develop intertrigo because of physical features such as deep skin folds, short neck, and flexed posture. [3] Prompt diagnosis by a medical professional and treatment with topical and/or oral antibiotics can effectively relieve symptoms. [4]

Contents

Etiology

The main causes of intertrigo are mechanical factors, such as heat and maceration of the skin, and secondary infections, which mostly happens due to moisture build-up in the skin folds, making those areas ideal feeding places for secondary bacterial and fungal infections. [5] A lot of cases of this disease are seen in individuals with diabetes mellitus since they have higher pH levels in their skin folds because of their condition. [6] Given these reasons mentioned above, there have been higher cases of intertrigo in individuals with obesity, diabetes mellitus, immunodeficiency secondary to virus infection, large skin folds, are bedridden, or wear diapers that trap moisture (i.e. babies or older adults using incontinence supplies). [7] [8]

Signs and symptoms

Streptococcal intertrigo commonly presents with a beefy-red, smooth, shiny lesion that has well-defined borders. There are no satellite lesions surrounding the area, and a distinct foul smell is common. The infection may be accompanied by general malaise and a low-grade fever. The folds of the neck are most commonly affected, but other areas with skin folds are also susceptible, including the armpits, groin, and anus. [9]

Complications

Progression of intertrigo is dependent on the strain of streptococcus responsible for the symptoms. Streptococcal intertrigo can lead to complications if not appropriately diagnosed and treated in a timely manner. It has been reported that bacteremia, or a bacterial infection of the circulating blood, can occur which may require intravenous antibiotic therapy. Streptococcus pyogenes is also known to cause other serious diseases such as meningitis, necrotizing fasciitis, toxic shock syndrome, and osteomyelitis. [10] Skin infections caused by Group A Beta-hemolytic streptococci (GABHS) can also be associated with acute glomerulonephritis, furthering the need for prompt diagnosis and treatment. [11]

Cause

Intertrigo is a skin condition often associated with rashes in deep skin folds with increased friction and moisture exposure. There are various causes that can lead to intertrigo including fungal and viral, although the agent would depend on the nature of the infection whether it be candidal or bacterial. In the case of bacterial infections, the main etiological agents are either group A beta hemolytic streptococci or Staphylococcus aureus. [12] Group A streptococci (GAS) are ubiquitous microorganisms found in the surrounding environment and in the normal skin microbiota. [13] Although there are different severities of infections Group A streptococci can affect individuals, broken skin and wounds allow easier access for colonization by the bacteria. The streptococci family has its own factors that aid in its promotion of infection and severity. Group A streptococci have surface molecules of lipoteichoic acid and protein F which aid in the adhesion to host cells. Once adhered, it releases streptolysin and hyaluronidase to further degrade host tissues, enabling a deeper colonization. In addition to attachment and dissemination factors, Group A streptococci are also encapsulated and have other varying protein factors that defend it from host immunity. [14]

Mechanism

The most common symptom associated with streptococcal associated intertrigo is erysipelas, an infection of the upper or superficial layers of the skin. [15] This infection is mostly associated with group A beta-hemolytic streptococcal bacteria (GABHS) since they are normally found in the skin flora. This group of bacteria typically invades and affects the lymphatic vessels, often leading to a localized inflammation. The infection can be recognized by tongue-like or irregular extensions of the rash, accompanied by systemic symptoms such as fever, chills, or a general feeling of discomfort. [16] Once in the lymphatic system of the host, GABHS can easily disseminate systemically to produce effects.

Risk Factors

Streptococcal intertrigo occurs when bacteria penetrates the skin. Having an increased amount of skin folds can increase the risk of skin abrasion and erosion, leading to inflammation. Therefore, individuals with obesity, infants, and other factors that increase one's own skin-to-skin contact have an increased risk of intertrigo. Immunocompromised individuals are also at a greater risk for intertrigo since they are more susceptible to infection from any foreign pathogen. Environmental factors also play a role in increasing the risk of this condition. Living in a humid region increases sweat and the accumulation of moisture, contributing to the aggravation of the skin. [7] Similarly, poor hygiene can exacerbate friction as this brings dirt and other particles to build up, increasing the potential and severity of an inflammatory response. Infants' tendency to drool onto their skin folds also puts them at greater risk for infection and intertrigo. [17]

Diagnosis

Streptococcal intertrigo is diagnosed by a medical professional after performing a detailed physical examination and taking an overnight culture of the affected areas. A second sample is tested with a rapid antigen detection test for Group A streptococcus. [18] Upon physical examination, streptococcal intertrigo commonly presents with a marked area of redness of the skin, a distinct, foul smell, and a lack of satellite lesions. The presence of satellite lesions, or lesions smaller and further away from the main affected region, may point to a differential diagnosis of candidal intertrigo, which is a more common cause of these characteristics. Streptococcal intertrigo is frequently underdiagnosed and should be considered as a causative agent when standard therapy for candidal intertrigo fails. [1]

Other differential diagnoses which may present similarly include seborrheic dermatitis, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, mixed bacterial intertrigo, scabies, erythrasma, and inverse psoriasis. [1]

Prevention

Given the main etiology of streptococcal intertrigo is the warm and moist skin surface, in order to prevent future infection and repeat incident of this kind, it is best to keep the affected area and other skin folds clean and dry of moisture. [8] [19] It is also helpful to expose such areas to air and limit skin-on-skin friction as much as possible. [19] In order to decrease friction as a predisposing factor, weight loss for individuals with obesity or reduction mammoplasty for large breasts is encouraged and recommended. [20] To decrease the chance of worsening symptoms, a drying agent, such as baby powder, can be applied. [8] [4] Application of other barrier agents, such as zinc oxide or petrolatum, aids in the reduction of skin deterioration and alleviates itching and pain. [4]

Treatment

The most common treatment options of intertrigo complicated with secondary bacterial infection such as group A beta-hemolytic streptococcus are topical mupirocin (bactroban), erythromycin, low potency topical steroids like hydrocortisone 1% cream, and oral antibiotics (such as oral penicillin, cephalexin, ceftriaxon, cefazolin, and clindamycin). [8] [4] These broad-spectrum antibiotics are ideal in targeting bacterial agents due to the large number of microbiota on the human skin. Additionally, the low potency steroids aid in the reduction of the reaction, reducing discomfort to the patient. [8] [4] Drying agents, such as aluminum sulfate and talcum powder, may be used alongside other treatments to help the healing process to go faster. [1] [4] [21] Although, if these agents are to be used, it is better to space them few hours apart. [22] [4] A hair drier could also be utilized on the affected area as intertrigo responds well to the removal of moisture. [18] Age is an important factor to consider when dosing since intertrigo is prevalent amongst young children. Proper identification of etiology is required in order to treat optimally. [5] [21]

Case studies

3-month old infant

A 3-month old infant presented with streptococcal intertrigo after experiencing a rash in their groin area for 3 days. A bright, distinct red coloration was evident in the infant's skin folds, which were also moist and wrinkly. A bacterial sample was collected and tested on with antibiotics. The infant was initially treated with oral flucloxacillin which proved to be effective in clearing the bacteria. From the culture, the bacteria was classified as a group A beta-hemolytic streptococci. [12]

5-month old male

A 5-month old infant with a history of eczema presented with a dark red rash on their ear, neck and lower limbs. They were initially diagnosed with intertrigo due excessive drooling and were prescribed a course of antifungal topical powder. The infant returned to the pediatrician a week later because the rash had gotten worse and their eczema was greatly exacerbated. A skin culture was done as it was suspected that the rash was due to a bacterial infection instead. Streptococcus pyogenes was the predominant growth found in the culture. The patient was prescribed a cephalexin suspension and a dexamethasone suspension, which resolved the inflammation after 3 weeks. [18]

2-year old female

A 2-year old female presented with a well-demarcated red, smooth plaque, foul smell, and no satellite lesions on the left armpit and neck for 2 weeks. They were initially treated for candidal intertrigo without improvement in their condition. The affected areas were swabbed, and the culture grew group A beta-hemolytic Streptococcus pyogenes that was sensitive to penicillin. They were then diagnosed with streptococcal intertrigo and prescribed amoxicillin plus clavulanic acid antibiotics for 7 days along with topical application of fusidic acid. The intertrigo completely resolved with this regimen. [9]

Epidemiology

Cases of intertrigo originating from streptococcal bacteria are uncommon and underreported. Because intertrigo can come from many different sources, it is difficult to reliably track its etiology. [17]

See also

Related Research Articles

<i>Streptococcus</i> Genus of bacteria

Streptococcus is a genus of gram-positive coccus or spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales, in the phylum Bacillota. Cell division in streptococci occurs along a single axis, so as they grow, they tend to form pairs or chains that may appear bent or twisted. This differs from staphylococci, which divide along multiple axes, thereby generating irregular, grape-like clusters of cells. Most streptococci are oxidase-negative and catalase-negative, and many are facultative anaerobes.

<span class="mw-page-title-main">Erysipelas</span> Human disease from a bacterial infection of the skin

Erysipelas is a relatively common bacterial infection of the superficial layer of the skin, extending to the superficial lymphatic vessels within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin. It is a form of cellulitis and is potentially serious.

<span class="mw-page-title-main">Group A streptococcal infection</span> Medical condition

Group A streptococcal infections are a number of infections with Streptococcus pyogenes, a group A streptococcus (GAS). S. pyogenes is a species of beta-hemolytic Gram-positive bacteria that is responsible for a wide range of infections that are mostly common and fairly mild. If the bacteria enter the bloodstream an infection can become severe and life-threatening, and is called an invasive GAS (iGAS).

<i>Streptococcus pyogenes</i> Species of bacterium

Streptococcus pyogenes is a species of Gram-positive, aerotolerant bacteria in the genus Streptococcus. These bacteria are extracellular, and made up of non-motile and non-sporing cocci that tend to link in chains. They are clinically important for humans, as they are an infrequent, but usually pathogenic, part of the skin microbiota that can cause Group A streptococcal infection. S. pyogenes is the predominant species harboring the Lancefield group A antigen, and is often called group A Streptococcus (GAS). However, both Streptococcus dysgalactiae and the Streptococcus anginosus group can possess group A antigen as well. Group A streptococci, when grown on blood agar, typically produce small (2–3 mm) zones of beta-hemolysis, a complete destruction of red blood cells. The name group A (beta-hemolytic) Streptococcus (GABHS) is thus also used.

<span class="mw-page-title-main">Scarlet fever</span> Infectious disease caused by Streptococcus pyogenes

Scarlet fever, also known as scarlatina, is an infectious disease caused by Streptococcus pyogenes, a Group A streptococcus (GAS). The infection is a type of Group A streptococcal infection. It most commonly affects children between five and 15 years of age. The signs and symptoms include a sore throat, fever, headache, swollen lymph nodes, and a characteristic rash. The face is flushed and the rash is red and blanching. It typically feels like sandpaper and the tongue may be red and bumpy. The rash occurs as a result of capillary damage by exotoxins produced by S.pyogenes. On darker-pigmented skin the rash may be hard to discern.

<span class="mw-page-title-main">Streptococcal pharyngitis</span> Medical condition

Streptococcal pharyngitis, also known as streptococcal sore throat(strep throat), is pharyngitis (an infection of the pharynx, the back of the throat) caused by Streptococcus pyogenes, a gram-positive, group A streptococcus. Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever. Symptoms typically begin one to three days after exposure and last seven to ten days.

<span class="mw-page-title-main">Impetigo</span> Human disease (bacterial infection)

Impetigo is a bacterial infection that involves the superficial skin. The most common presentation is yellowish crusts on the face, arms, or legs. Less commonly there may be large blisters which affect the groin or armpits. The lesions may be painful or itchy. Fever is uncommon.

<span class="mw-page-title-main">Irritant diaper dermatitis</span> Medical condition

Irritant diaper dermatitis is a generic term applied to skin rash in the diaper area that are caused by various skin disorders and/or irritants.

<span class="mw-page-title-main">Intertrigo</span> Medical condition

Intertrigo refers to a type of inflammatory rash (dermatitis) of the superficial skin that occurs within a person's body folds. These areas are more susceptible to irritation and subsequent infection due to factors that promote skin breakdown such as moisture, friction, and exposure to bodily secretions and excreta such as sweat, urine, or feces. Areas of the body which are more likely to be affected by intertrigo include the inframammary fold, intergluteal cleft, armpits, and spaces between the fingers or toes. Skin affected by intertrigo is more prone to infection than intact skin.

<span class="mw-page-title-main">Cefaclor</span> Chemical compound

Cefaclor, sold under the trade name Ceclor among others, is a second-generation cephalosporin antibiotic used to treat certain bacterial infections such as pneumonia and infections of the ear, lung, skin, throat, and urinary tract. It is also available from other manufacturers as a generic.

<span class="mw-page-title-main">Lymphangitis</span> Medical condition

Lymphangitis is an inflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel. The most common cause of lymphangitis in humans is Streptococcus pyogenes, hemolytic streptococci, and in some cases, mononucleosis, cytomegalovirus, tuberculosis, syphilis, and the fungus Sporothrix schenckii. Lymphangitis is sometimes mistakenly called "blood poisoning". In reality, "blood poisoning" is synonymous with sepsis.

<span class="mw-page-title-main">Clobetasone</span> Chemical compound

Clobetasone (INN) is a corticosteroid used in dermatology, for treating such skin inflammation as seen in eczema, psoriasis and other forms of dermatitis, and ophthalmology. Topical clobetasone butyrate has shown minimal suppression of the hypothalamic–pituitary–adrenal axis.

<i>Arcanobacterium haemolyticum</i> Species of bacterium

Arcanobacterium haemolyticum is a species of bacteria classified as a gram-positive bacillus. It is catalase-negative, facultative anaerobic, beta-hemolytic, and not motile. It has been known to cause head and neck infections, pharyngitis, and sinusitis.

Streptolysins are two hemolytic exotoxins from Streptococcus. Types include streptolysin O, which is oxygen-labile, and streptolysin S, which is oxygen-stable.

<span class="mw-page-title-main">Guttate psoriasis</span> Medical condition

Guttate psoriasis is a type of psoriasis that presents as small lesions over the upper trunk and proximal extremities; it is found frequently in young adults.

<i>Streptococcus dysgalactiae</i> Species of bacterium

Streptococcus dysgalactiae is a gram positive, beta-haemolytic, coccal bacterium belonging to the family Streptococcaceae. It is capable of infecting both humans and animals, but is most frequently encountered as a commensal of the alimentary tract, genital tract, or less commonly, as a part of the skin flora. The clinical manifestations in human disease range from superficial skin-infections and tonsillitis, to severe necrotising fasciitis and bacteraemia. The incidence of invasive disease has been reported to be rising. Several different animal species are susceptible to infection by S. dysgalactiae, but bovine mastitis and infectious arthritis in lambs have been most frequently reported.

<i>Streptococcus iniae</i> Species of bacterium

Streptococcus iniae is a species of Gram-positive, sphere-shaped bacterium belonging to the genus Streptococcus. Since its isolation from an Amazon freshwater dolphin in the 1970s, S. iniae has emerged as a leading fish pathogen in aquaculture operations worldwide, resulting in over US$100M in annual losses. Since its discovery, S. iniae infections have been reported in at least 27 species of cultured or wild fish from around the world. Freshwater and saltwater fish including tilapia, red drum, hybrid striped bass, and rainbow trout are among those susceptible to infection by S. iniae. Infections in fish manifest as meningoencephalitis, skin lesions, and septicemia.

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues.

Bacteriophage T12 is a bacteriophage that infects Streptococcus pyogenes bacteria. It is a proposed species of the family Siphoviridae in the order Caudovirales also known as tailed viruses. It converts a harmless strain of bacteria into a virulent strain. It carries the speA gene which codes for erythrogenic toxin A. speA is also known as streptococcal pyogenic exotoxin A, scarlet fever toxin A, or even scarlatinal toxin. Note that the name of the gene "speA" is italicized; the name of the toxin "speA" is not italicized. Erythrogenic toxin A converts a harmless, non-virulent strain of Streptococcus pyogenes to a virulent strain through lysogeny, a life cycle which is characterized by the ability of the genome to become a part of the host cell and be stably maintained there for generations. Phages with a lysogenic life cycle are also called temperate phages. Bacteriophage T12, proposed member of family Siphoviridae including related speA-carrying bacteriophages, is also a prototypic phage for all the speA-carrying phages of Streptococcus pyogenes, meaning that its genome is the prototype for the genomes of all such phages of S. pyogenes. It is the main suspect as the cause of scarlet fever, an infectious disease that affects small children.

<span class="mw-page-title-main">Lancefield grouping</span>

Lancefield grouping is a system of classification that classifies catalase-negative Gram-positive cocci based on the carbohydrate composition of bacterial antigens found on their cell walls. The system, created by Rebecca Lancefield, was historically used to organize the various members of the family Streptococcaceae, which includes the genera Lactococcus and Streptococcus, but now is largely superfluous due to explosive growth in the number of streptococcal species identified since the 1970s. However, it has retained some clinical usefulness even after the taxonomic changes, and as of 2018, Lancefield designations are still often used to communicate medical microbiological test results.

References

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  12. 1 2 Castilho S, Ferreira S, Fortunato F, Santos S (March 2018). "Intertrigo of streptococcal aetiology: a different kind of diaper dermatitis". BMJ Case Reports. 2018: bcr. doi:10.1136/bcr-2018-224179. PMC   5878283 . PMID   29559490.
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