A 52-year-old woman comes to the office due to a pruritic rash on the inguinal region and vulva. Over the last 2 weeks the patient's inguinal and vulvar skin has become increasingly irritated and pruritic, particularly after she wears tight clothing. Application of an over-the-counter moisturizing cream has not improved the symptoms. The patient was recently hospitalized for an asthma exacerbation and treated with inhaled bronchodilators and systemic corticosteroids. She underwent a cervical conization at age 36 for dysplasia; all subsequent Pap tests have been normal. The patient has been sexually active with a new partner for the past few months, but the pruritus has prevented intercourse. Her last menstrual period was 8 months ago. BMI is 32 kg/m². Vital signs are normal. Examination of the patient is seen in the exhibit. Which of the following is the most appropriate treatment for this patient?

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11ec25c8_d269_ab57_bc81_a52a80374a3a_MD0003_00 This patient's erythematous ("beefy red") plaques within the inguinal folds are consistent with intertrigo, a dermatitis that typically occurs within the inguinal, axillary, gluteal, and inframammary folds. Patients with intertrigo typically have erythematous plaques in a symmetric "kissing" or "mirror image" pattern across the skinfold and multiple satellite lesions near the primary infection. The most common cause of intertrigo is Candida albicans, a part of the normal flora of the urogenital and gastrointestinal tracts. Patients at risk for candida intertrigo include those with impaired immunity (eg, systemic corticosteroid use, diabetes mellitus), particularly when associated with increased skin moisture or friction (eg, obesity, tight-fitting clothing), which can cause skin maceration and trauma. Diagnosis is typically clinical but can be confirmed by visualization of hyphae or pseudohyphae on microscopic examination of skin scrapings from affected areas. Treatment is typically with topical azoles (eg, clotrimazole, ketoconazole), which help decrease the spread of infection and have some anti-inflammatory and antibacterial properties. (Choice B) Doxycycline is used for the treatment of hidradenitis suppurativa, which commonly occurs in intertriginous areas. Patients typically have tender inflammatory nodules, often with associated sinus tract formation and multiple open comedones. hidradenitis suppurativa (Choice C) Estrogen cream is indicated for the treatment of vulvovaginal atrophy (ie, genitourinary syndrome of menopause). Patients with vulvovaginal atrophy typically have thinned, hypopigmented skin with decreased moisture. (Choice D) Trichloroacetic acid is indicated in the management of condyloma acuminata (seen in a man in this exhibit), which are associated with persistent human papillomavirus infection. However, they typically appear as soft, verrucous growths in the anogenital region. exhibit (Choice E) Trimethoprim-sulfamethoxazole is a treatment option for cellulitis. In contrast to this patient, those with cellulitis typically have a unilateral, rather than bilateral, lesion. Educational objective: Intertrigo typically presents erythematous plaques with associated satellite lesions within intertriginous areas (eg, inguinal and axillary folds). A common cause is an overgrowth of Candida albicans, which often occurs during times of immunosuppression (eg, systemic corticosteroid use). Treatment includes topical azoles (eg, clotrimazole, ketoconazole). References: Fungal infections of the folds (intertriginous areas). (http://www.ncbi.nlm.nih.gov/pubmed/26051058) Intertrigo and secondary skin infections. (http://www.ncbi.nlm.nih.gov/pubmed/24695603)

A 52-Year-Old Woman Comes to the Office Due to a Pruritic