Professor Somita Keita Department of Dermatology, University of Bamako CNAM Ex Institut Marchoux PO Box 251, Bamako, Mali E-mail: email@example.com
Dermatitis of the folds (intertrigo) is a frequent reason for attending consultations, particularly in Africa, where the hot and humid climate constitute an aggravating factor. It is a complex pathology with multiple and intricate etiologies. The aim of this study was to describe epidemiological and etiological aspects of dermatitis of the folds in black-skinned subjects in Bamako (Mali). We conducted a transversal descriptive survey of cases of localized dermatitis of the folds of the skin in dermatology clinics in Bamako. In total, 141 cases of intertrigo were identified: 96 female subjects (68%) and 45 male subjects. The average age of patients was 30 ± 18 years (2–80 years). The majority of patients were seen between March and June; 52% of patients had already received treatment before the consultation. The lesions affected skin folds of the groin area and/or area between the buttocks in 95 patients (57.4%), and folds of the armpits and area under the breasts were affected in 46 cases (42.6%). Eczema, erythrasma, and fungal disease were the most frequently observed pathologies. Of interest to this study is the topographical approach that a dermatologist must adopt when diagnosing certain forms of dermatitis. In populations with specific cultural practices, apart from a thorough knowledge of these specific factors, treatment of these conditions requires certain harmful attitudes and behaviors to be abandoned.
Dermatitis of the folds (intertrigo; from the Latin inter meaning between, terere: to rub), is the name for an erythematous inflammation of skin folds.1 It is frequently the reason for dermatology consultations, because of the pruritus or burning sensation or even, sometimes, the pain that it causes. It can affect all skin folds:2 large folds (armpits, groin, area under the breasts, between the buttocks, and abdomen), and smaller folds (between the fingers and toes, retro-auricular region, and neck). However, folds of the groin, armpits, and skin under the breasts are the most commonly affected areas. Clinically, the bottom of the fold is erythematous, damp, sometimes cracked, and oozing, on the other hand, it may be lichenoid and desquamative. From an etiopathogenic perspective, intertrigo is a complex pathology with multiple and intricate etiologies.3 The responsible factors may be local (heat, perspiration, poor hygiene, obesity, use of perfumes and topical cosmetics) or general (allergy, diabetes, drugs, immunosuppression). In tropical regions, the heat and humidity encourage maceration and exacerbate bodily odors, in particular in the folds. These conditions prompt certain populations to adopt cultural practices that are sometimes harmful, to improve their comfort. The lack of studies on dermatitis of the folds in the literature is striking, particularly in Africa. The aim of this study is to describe the epidemiological and etiological aspects of dermatitis of the folds in black-skinned subjects in Bamako (Mali).
Materials and methods
We carried out a transversal survey of instances of dermatitis in skin folds during our consultations at the Department of Dermatology, National Centre for the Support of the Fight Against Disease (previously Institut Marchoux), Bamako, Mali. The study took place from February 1 to September 30, 2010. The study included “all patients, irrespective of their sex, who attended consultations for dermatitis of the folds”; nursing mothers, cases of erythrodermia, and non-consenting parents and patients were systematically excluded. All the patients were examined by a dermatologist. A diagnostic laboratory work-up was carried out as required: blood sugar, HIV serology, and/or skin biopsy. The circumstances of occurrences of the condition and maintenance factors of intertrigo were described. The patients were treated according to an etiological approach associated with the advice given. The data were collected and analyzed using the Epi Info software program, version 6.04.fr.
In total, of the 7327 consultations during the study period, we grouped together 141 cases of intertrigo, corresponding to a frequency of 2%. Ninety-six subjects were female (68%) and 45 were male, representing a sex ratio of 2:1 in favor of women. The patients’ ages varied from 2 to 80 years, and the average age was 30 ± 18 years. The majority of patients attended consultations between March and June (Fig. 1). Approximately 52% of patients had already received treatment before their consultation.
The condition had been developing for more than 6 weeks in 85 (60%) patients. The lesions were accompanied by pruritus in 102 cases (85.7%).
From a clinical perspective, the lesions affected the skin folds of the groin area and/or the area between the buttocks in 95 patients (57.4%), and the folds of the armpits and area under the breasts were affected in 46 cases (42.6%) (Table 1). Some patients were affected in two different places: the underarm and groin areas in two cases, and area under the breasts and groin in four cases.
Table 1. Location of intertrigo in 141 patients
Groin and/or area between the buttocks
Underarms and/or area under the breasts
From an etiological perspective, 141 patients belonged to four groups of pathologies: inflammatory dermatitis, infectious dermatitis, friction dermatitis, and general dermatitis (Table 2) (Fig. 2–7). Eczema, erythrasma, and fungal disease were the most frequently observed pathologies. In the eczema cases, the local following local risk factors were identified: using perfume (16), wearing synthetic underpants and panties (nine) and bras (seven), fumigation with incense (four), and wearing tight rings (one). General risk factors were found in 45 patients (32%), of whom 31 were obese, eight had an allergy, four were diabetic, and two were HIV positive.
Table 2. Etiologies in the cases of observed intertrigo
There was no link between the type of pathology and sex of the patient.
From a cultural perspective, in Africa, in particular in Mali, the skin folds are of great importance in everyday life. They contribute to body odor and constitute a weak point in the cutis, due to thinness of the skin and frequent lack of aeration. In addition, we often have a tendency, albeit unconscious, to associate a particular odor with each individual. The predominance of females in our study is a testament to the importance of this perception of skin folds in women. This explains why certain people go to such lengths to improve the comfort of this sensitive part of the body, using perfumes and deodorizing products. In our study, eczema was the most frequent etiology. It was essentially linked to burning incense, using perfumes, and application of cosmetic products. Rubbing the skin with pumice stones or the use of sponges with plant fibers was also noted. This is a cultural practice, deeply rooted in our populations, in particular women, who believe that “the more we rub our skin, the cleaner it is, and therefore the better it will smell.”
It is important to stress that of all of the supposed triggers referred to above, heat was the principal driving force. This explains why the majority of our patients attended consultations between March and June, which are the hottest months of the year in Mali. From a physiopathological perspective, permanent or intermittent contact between two skin surfaces that rub against each other leads to a local increase in temperature, stimulating the secretion of sweat and sebum, and thereby modifying the physicochemical (pH, humidity) and microbiological parameters of skin folds.3
In general, there have been very few studies into dermatitis of the folds. Of interest to this study is the topographical approach that a dermatologist must adopt to diagnose certain forms of dermatitis; in particular, in populations such as ours that have specific cultural practices.
In Mali, dermatitis of the folds is a condition that affects young adult women. It is frequently the motive for a consultation with a dermatologist, especially during periods of intense heat. The etiologies are dominated by eczema and dermatophytosis. A thorough knowledge of the specific cultural factors of the individual and the abandonment of harmful attitudes and behavior could prevent the onset of the vast majority of these cases of dermatitis of the folds.