A 45-year-old man comes to the office for evaluation of a rash on his abdomen. The rash started 3 weeks ago and has slowly worsened since. There is no pruritus. The patient has a history of diabetes treated with metformin. He has no history of tobacco or alcohol use.
Vital signs are within normal limits. BMI is 32 kg/m². Skin examination findings are shown in the image below. There is no warmth or tenderness around the skin lesions. The remainder of his physical examination is normal.

Which of the following is the best next step in management of this patient?

Question

A 45-year-old man comes to the office for evaluation of a rash on his abdomen. The rash started 3 weeks ago and has slowly worsened since. There is no pruritus. The patient has a history of diabetes treated with metformin. He has no history of tobacco or alcohol use.
Vital signs are within normal limits. BMI is 32 kg/m². Skin examination findings are shown in the image below. There is no warmth or tenderness around the skin lesions. The remainder of his physical examination is normal.

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9792_0722_853d_fb6869fd3156_MD0002_00 This patient's presentation is consistent with intertrigo, defined as an infectious or noninfectious skin inflammation in the intertriginous areas (eg, inguinal, perineal, genital, intergluteal, axillary, or inframammary). Risk factors for intertrigo include conditions that increase skin friction (eg, obesity), increase moisture (eg, tight clothing, hyperhidrosis), or promote fungal overgrowth (eg, diabetes, immunosuppression). Candidal intertrigo is the most common etiology as fungi grow well in the warm, moist environment of the skinfolds. Patients typically develop erythematous plaques and erosions, sometimes with satellite papules and pustules. The lesions can also be pruritic or painful if there is significant skin breakdown. Diagnosis is made clinically but can be confirmed with potassium hydroxide (KOH) examination. Topical antifungals (eg, miconazole, nystatin, terbinafine) are preferred for initial treatment of intertrigo. After antifungal treatment, skin-drying agents and addressing the underlying predisposing conditions can reduce the risk of recurrence. (Choice A) Oral cephalexin can treat cellulitis, which usually presents with a more acute onset of erythema, edema, and warmth. The duration of this patient's rash and absence of warmth make this less likely. cellulitis (Choice B) Oral antifungals (eg, fluconazole, itraconazole) are typically reserved for treatment of severe intertrigo (eg, multiple areas involved, significant skin breakdown, pustules) or for patients who fail initial topical antifungal therapy. (Choice C) Topical hydrocortisone ointment is a low-potency glucocorticoid that can be used as adjunctive therapy for patients with intertrigo who have significant pruritus, pain, and burning. However, this patient does not have these symptoms. (Choice E) Topical tacrolimus can treat inverse (intertriginous) psoriasis, which can sometimes mimic intertrigo. Patients usually develop smooth patches or plaques in skinfolds instead of on the extensor surfaces. However, this patient's skin findings are more consistent with candidal intertrigo. inverse (intertriginous) psoriasis Educational objective: Intertrigo is most commonly due to Candida infection and presents as erythematous plaques and erosions in skinfolds of intertriginous regions. Topical antifungals (eg, miconazole, nystatin, terbinafine) are the preferred initial therapy. __________ References: Intertrigo and secondary skin infections. (http://www.ncbi.nlm.nih.gov/pubmed/24695603)

A 45-Year-Old Man Comes to the Office for Evaluation of a Rash