Intertriginous psoriasis L40.84

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

flexural psoriasis; Intertriginous psoriasis; Inverted psoriasis

Definition
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This is a chronic variant of psoriasis (see also psoriasis vulgaris) which mainly affects the large skin fold zones(inverse psoriasis).

Intertriginous psoriasis can "accompany" classical psoriasis vulgaris. In this form, however, the intertriginous zones are usually free.

However, intertriginous psoriasis can also affect only the intertriginous in isolation (and this is actually the definition of the term "intertriginous psoriasis"). As the clinical picture differs considerably from the classic distributed psoriasis vulgaris, intertriginous psoriasis (which occurs in isolation) represents a special diagnostic challenge.

Localization
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Axilla, inguinal region, scrotum or vulva; perianal region.

Clinical features
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There are sharply defined, frequently itchy, usually macerated, red, fully filled 5.0 - 10.0 cm large or larger, spots or very flat sometimes weeping plaques; no prominent edge accentuation (DD Tinea intertriginosa); no satellite foci (as in intertriginous candidiasis), no central healing pattern.

The typical psoriatic scaling is always absent.

Often itching is the main symptom. This applies particularly to genital and perianal psoriasis vulgaris. In these cases, the itching can be excruciating, especially at higher outside temperatures.

In cases of severe itching, superimposed scratching effects, also extensive maceration and sweetishly unpleasant local foetus due to secondary microbial colonisation are impressive.

Differential diagnosis
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For axillary and inguinal infestation

Frequently:

  • Tinea corporis: At the time of first diagnosis, this shows one or more inflammatory reddened, slightly scaly plaques with edges and a centrifugal expansion tendency and central healing. There is almost always a marked itching. Mycological proof!
  • Candidosis, intertriginous: Sharply defined, peripherally scaly erythema and plaques. Frequently pustule fringe or splashes of papulovesicular to pustular satellites in the surroundings. Mycological evidence!
  • Intertrigo: Mostly obese patients; clinical signs: High red, usually sharply defined (satellite foci indicate intertriginous candidiasis or contact allergic eczema), extensive, itchy or painful erosions, spots or erosive plaques and often rhagades. An unpleasant sweetish fetus indicates a bacterial superinfection.

Rarely:

  • Pemphigus chronicus benignus familiaris: Long-standing finding; more frequent in the intertriginous regions; familial accumulation. Itchy, reddened, roundish, oval or circulatory plaques covered by greasy scale crusts, usually sharply defined with typical transverse fissures (typical sign). Often secondary infections (e.g. with candida). Nikolski phenomenon is positive.

With perianal infestation:

Often:

  • Anal eczema (see also differential diagnosis of anal eczema)
  • Candidosis
  • M. Crohn
  • Atopic Anal Eczema
  • Lichen simplex chronicus Vidal
  • lichen sclerosus et atrophicus
  • lichen planus

Rare:

  • Pemphigus chronicus benignus familiaris
  • Dyskeratosis follicularis (M. Darier).
  • Bowen's disease
  • Paget's disease, extramammary

Complication(s)
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It is not uncommon for bacterial or mycotic (Candida species) superposition of the intertriginous plaques to occur.

Therapy
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Therapeutically difficult, different therapeutic strategies according to the acuteity.

External therapy
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  • Mild form: In case of few, smaller, painless intertriginous plaques, only nurturing external agents. The use of simple zinc ointment R296 has proven to be effective. Cleaning of the affected intertriginous areas with peanut or castor oil. In case of mycotic overlay 1% Clotrimazole in Zinc Ointment R058 is recommended.
  • Alternatively, an ointment containing calcipotriol(e.g. Daivonex, Psorcutan) can be applied (note the irritant potential of the ointments!). Calcipotriol and tazarotene are usually too irritating when used intertriginously. As an experiment, Tacalcitol (Curatoderm) can be used once a day.
  • Alternatively the use of the calcineurin inhibitors Tacrolimus (off-label use) and Pimecrolimus (off-label use) should be considered. The clinical results are remarkably good. Cave! High therapy costs! Because of the unknown long-term effects of calcineurin inhibitors and the carcinogenicity of Pimecrolimus which has been proved in animal experiments, the indication for the therapy with calcineurin inhibitors has to be set very strictly!
  • Large-area, little irritated form: non-aggressive local therapy. Initial application of a zinc ointment. Astringent sitting baths with synthetic tannic acid (e.g. Tannolact solution, Tannosynt liquid). Cleaning of the areas with pure olive, castor or peanut oil. Application of a bandage (preferably gauze compresses, TG tubular bandage or cotton underpants). If no satisfactory treatment success can be achieved, the use of a soft dithranol zinc paste is recommended: application overnight; start with a 0.05% soft dithranol zinc paste R078, if necessary increase the concentration after 1 week (e.g. to 0.1% dithranol).
  • Large, irritated, possibly weeping form: exclusion of superimposed mycoses by smear and culture! In case of suspicion short-term combination preparation glucorticoid/azole antimycotic (e.g. Vobaderm cream). After the acute phase has subsided, the glucocorticoid externum is removed; alternate treatment with a pure base, and finally, nursing therapy.

Remember!

Higher potent glucocorticoids should be avoided in long-term application in the genito anal area! Occlusive effect due to the special topography with high risk of steroid atrophy! After the acute situation has subsided, the use of a soft dithranol-zinc paste is recommended (application especially overnight). The danger of soiling the laundry must be pointed out. Start with a 0.05% soft dithranol zinc paste R078. If necessary increase the concentration after 1 week, e.g. to 0.1% dithranol R078, R070. In addition to therapy, regular astringent sitz baths (e.g. with tannolact) or bran baths (e.g. potter's bran bath) are well suited.

Notice! Patience of therapist and patient is important when dealing with this disease! Basically it can be said that therapy with dithranol can only be carried out with patients who show a high level of compliance!

Internal therapy
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If these measures are not sufficient, an antipsoriatic systemic therapy with fumarates can be used for highly irritated, extensive and therapy-resistant intertriginous psoriasis (therapy modalities see below Psoriasis vulgaris).

Literature
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  1. Avila Alvarez A et al (2009) Flexural psoriasis induced by infliximab and adalimumab in a patient with Crohn's disease. To Pediatr (Barc) 70:278-281

  2. Freeman AK et al (2003) Tacrolimus ointment for the treatment of psoriasis on the face and intertriginous areas. J Am Acad Dermatol 48: 564-568
  3. Nuño-González A et al (2012) Flexural or inverse psoriasis in a patient with hidradenitis suppurativa receiving treatment with infliximab. Actas Dermosifiliogr 103:936-937

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020