Intertrigo is an inflammatory dermatosis of the skin folds of the body, for which a large variety of topical medications may be recommended. A systematic literature review was performed to find scientific evidence for preventing and treating intertrigo within the nursing domain. Seven electronic databases were searched with a simple broad-scope search strategy. The aim was to identify all publications that concerned intertrigo itself and other conditions that were related to intertriginous regions. This search produced 451 references. A final set of 24 studies was retained and analyzed on content and methodologic quality. Most studies concerned treatments with antifungals or disinfectants in heterogeneous research samples, with only small subsamples of people with intertrigo. Six studies were randomized controlled trials. In general, the methodologic quality of the studies was poor. The analyzed studies provided no scientific evidence for any type of nursing prevention or treatment strategy. There is a great need for well-designed clinical studies on intertrigo.
Intertrigo is an inflammatory dermatosis involving body folds (Arndt & Bowers, 2002). Intertrigo is found principally in the inframammary, axillary, and inguinal folds, but it may also affect other areas as folds of the eyelids, neck creases, antecubital fossae, and umbilical perineal and interdigital areas (Arndt & Bowers, 2002). Although the exact pathogenesis of intertrigo is unknown (Burkhart, Mulholland, & Burnham, 1981), it is generally believed (McMahon, 1994) to be primarily caused by skin-on-skin friction: opposing skin surfaces rub against each other, causing erosions that become inflamed (Itin, 1989; Selden, 2001). The condition is considered to be aggravated by heat, moisture, maceration, and lack of air circulation (Itin, 1989; Selden, 2001). As a result of skin constantly rubbing on skin, heat and moisture lead to maceration and inflammation, and often to secondary bacterial or fungal infection (Arndt & Bowers, 2002; Burkhart et al., 1981). Intertrigo is characterized initially by mild erythema; red plaques oppose each other on each side of the skin fold, almost in a mirror image. This may then progress to more intense inflammation with erosions, oozing, exudation, and crusting (Arndt & Bowers, 2002). Patients may complain of itching, burning, and pain in the affected areas (Itin, 1989).
The exact prevalence of intertrigo is unknown, because many dermatologic diseases can affect the skin folds, which makes the diagnosis of intertrigo difficult (Guitart & Woodley, 1994; Itin, 1989), also due to unclear definitions and overlap in medical taxonomies between intertrigo, dermatomycoses, and bacterial skin infections. However, McMahon (1991) found submammary intertrigo (defined as a submammary skin problem of any description) to be prevalent in 5.8% of all female inpatients. It is generally believed that intertrigo is more common in patients with poor hygiene, obese patients, and patients with diabetes (Arndt & Bowers, 2002; Selden, 2001).
Nurses are considered to be the most appropriate health care professionals to prevent, detect, and treat intertrigo (McMahon & Buckeldee, 1992). The prevention and treatment of intertrigo is often one of the first subjects that is addressed in many nursing training programmes (van Beelen, 2001).
The medical and nursing literature contains several articles with advice for preventing and treating intertrigo. It is most remarkable, however, that the majority of the recommendations lack an empirical basis. A MESH-search (August 2002) with “intertrigo” in Pubmed, limited to “randomized controlled trial” produced only two references (Cullen, 1977; Hedley, Tooley, & Williams, 1990). This makes it difficult to choose the best evidence-based approach for preventing and treating intertrigo.
In general there is agreement in the literature that the best prevention for intertrigo is to minimize causal factors such as skin- on-skin friction, heat and moisture in and around skin folds, and by keeping the high-risk areas clean and dry. Most authors also agree that treatment of intertrigo should focus primarily on reducing causal factors and secondarily on restoring a normal skin environment and treatment of the possible bacterial or fungal infections in intertriginous areas. Surgical treatment of intertrigo, such as reduction mammaplasty (Brown & Young, 1993; Chadbourne et al., 2001), may also be indicated.
Although there is agreement on the general principles, a wide variety of methods and products is recommended to achieve treatment goals, but in most cases no research evidence is available to support the recommendations. Not exhaustive, but exemplary, some of these advised applications include: English cotton (van Beelen, 2001), wet tea bags (Selden, 2001), talcum powder with aspirin (Marghescu, 1970), Castellani’s paint (Bohm, 1996), Domeboro soaks (Aly, Forney, & Bayles, 2001), hydrocolloid dressings (McMahon, 1994), Burow’s solution (Fragola & Watson, 1981), diluted vinegar (Davis, 1980), hamamelis (this is a tree, “witch hazelnut,” from which a lotion is prepared) (Schindera, 1999), bedrest (the authors of this article do not explain why they advise bedrest for intertrigo nor give the theoretical or scientific grounds why bedrest would work; as stated earlier, this is common for most of the cited interventions) (Moulin, Gaboriaux, & Joseph, 1983), disrobing (Arndt & Bowers, 2002) (the authors advise to have the patient disrobe for at least 30 minutes twice a day and expose the involved folds to hair dryer, fan, or an electric bulb to promote drying). Furthermore they advise wearing light, nonconstricting, and absorbent clothing, while avoiding wool, nylon, and synthetic fibers. Biotextiles (cotton or polyester gauze in which antiseptic molecules, such as zeolite or triclosane, are fixed) are recomended (Benigni, Cazaubon, & Djian, 2000).
This finding is similar to that of McMahon and Buckeldee (1992) who interviewed 115 ward nurses on their knowledge and current practice of intertrigo. The nurses suggested 12 different creams and a variety of other substances such as rose oil, yoghurt, etc. They also found that nurses have contradictory opinions with regard to both cause and determining factors as well as diagnostic and treatment procedures: for instance, 16.5% of the respondents in this study favored the use of talcum powder, while 15.7% stated this should be avoided; with regard to diagnostic investigations 39% of the nurses would not initiate any test at all, while others would take microbiologic swaps or perform some kind of fungal investigation (McMahon & Buckeldee, 1992).
There is also disagreement about whether a product is good, or should be avoided; for example, applying absorbing powders is encouraged by some (Guitart & Woodley, 1994; Kugelman, 1969; Marghescu, 1970; Selden, 2001) and discouraged by others (van Beelen, 2001). Sometimes an antiseptic such as clioquinol is advocated (Arndt & Bowers, 2002; Wanic, 1967) but others (Gloor, 1988) advise against it. Different views are also reported in the literature with regard to which topical antibacterial and antifungal products should be used, and whether or not they should be combined with steroids.
In order to create evidence-based nursing guidelines and/or to support existing nursing guidelines with evidence from research, a systematic review was made of the literature on the efficacy of prophylaxis and treatment of intertrigo from the nursing perspective. The aim of this review was to systematically collect and assess the evidence in relation to the prevention and treatment of intertrigo in an adult population within the nursing domain.
Method
Study configuration. The study was limited to adult patients with intertrigo of the large skin folds (submammary, axillary, inguinal, perianal, abdominal), because this is the condition that is mainly encountered by nurses and health care workers, and because a systematic review of treatment for intertrigo between the toes has already been performed (Crawford et al., 2001). The working definition of intertrigo for this review is infected or noninfected inflammation of the large skin folds, as described by the authors or referred to as “intertrigo.”
Intervention. Only manuscripts concerning methods and products that are within the nursing domain were reviewed. The nursing domain is defined as interventions that can be carried out without doctor’s order (for example, topical applications and drugs that are available without medical prescription). The Dutch official list of prescription drugs (www.cbg-meb.nl) was used to decide whether a product fell within the definition of the nursing domain. If a certain product was not found on this list (for example, due to non- availability in the Netherlands), the article in which it was mentioned was included. (If a product was not on the list, it could not be determined if it was a medical or nonmedical product. In that case the product was given “the benefit of doubt,” because it is possible that this product is freely available in other countries (for instance Vioform is not on the Dutch list, but is freely available in Bulgaria). It did not matter who applied a product to the intertrigo areas (doctor, patient, nurse, \or another caregiver).
Since it was clear from a preliminary search that there were not many randomized controlled trials on the subject, it was decided to include all manuscripts that reported results of empirical research, no matter what design they used, or whether or not there was any kind of control group.
There was no predefined specific outcome. Outcomes such as prevalence of intertrigo, skin condition, skin infection, symptom scores, microbiological tests, use of antibiotics and topical agents, and costs of treatments could be included.
Inclusion criteria were (a) empirical research based on one of the following study designs (randomized controlled clinical trial, controlled clinical trial, other designs as patient series and pre- post studies), (b) intertrigo in adult patients, (c) intertrigo in large skin folds, (d) preventive and therapeutic interventions, of which at least one (main or control intervention) is within the nursing domain, and (e) outcomes such as intertrigo prevalence, skin condition, skin infection, use of antibiotics and topical agents, costs of treatment.
Exclusion criteria included (a) articles not reporting results of empirical research, (b) articles concerning research in animals, (c) intertrigo in body extremities (for example, interdigital of hands or feet), (d) intertrigo in children (for example, diaper rash), (e) surgical treatments, and (f) medically prescribed pharmacological agents.
Search Strategy. Relevant studies were identified by searching electronic databases (PUBMED, CINAHL, EMBASE, Cochrane Controlled Trials Register, Science Citation Index, PICARTA, and INVERT).
Databases were searched with a simple broad-scoped strategy (intertrigo [MESH] OR intertrig* [textword]) limited by NOT animal). This strategy was used in all databases with only minor adaptations for each specific database (for example, in the Dutch databases PICARTA and INVERT, the search strategy was completed with the Dutch term “smetten”). With this search strategy it was expected to identify all articles concerning intertrigo itself and all articles concerning diseases and conditions in the intertriginous regions. Before the final search was performed, other search strategies were tried (for example, (“dermatomycoses”[MeSH Terms] OR dermatomycoses [Text Word])) AND (“skin” [MeSH Terms] OR skin [Text Word]) AND fold [All Fields]), but these either gave less references or added no further references to the final search strategy.
Additional searching was done by checking reference lists from obtained articles and by forward searching in the Science Citation Index for articles that cited some of the relevant articles that had already been obtained previously. Since it was clear from preliminary searches that there was no great volume of literature available, and to ensure finding as much evidence as possible, no limits were applied with regard to languages, or date and type of publication. The time frame for the search covered the complete databases from their start until June 2002.
Figure 1.
Criteria for Methodologic Quality of Randomized Control Trials
Inclusion procedure. An initial check on inclusion and exclusion criteria was made by two reviewers independently on the basis of the title and, if available, the abstract of the manuscript. In case of disagreement, the reviewers discussed their findings until consensus was achieved.
If both reviewers decided to include a reference, or they both had doubts, or they could not achieve consensus about a disagreement, the full text of the reference was ordered via the international library loan systems. Articles that were not obtained within 4 months after ordering were considered to be unobtainable and excluded from further processing.
The included articles initially were then all checked again against the inclusion and exclusion criteria, this time on the basis of the full text, and by the same two reviewers independently. Articles that met all the criteria, according to both reviewers, were selected for further content and methodologic analysis. In the case of disagreement, both reviewers tried to find consensus and if this was not reached a third reviewer made the final decision to include or exclude the study.
Data extraction. By means of a self-made data extraction sheet, the following details were extracted from the included articles:
* Reference characteristics (title, journal, author, publication date, country of origin).
* Study characteristics (number of patients, study design, intervention and co-interventions).
* Patient characteristics (gender, age, main medical diagnoses, onset and duration of intertrigo).
Figure 2.
Criteria for Methodologic Quality of ‘Other Designs’
Figure 3.
Search Results
* Outcome measures (type, method, time and frequency of assessment).
Methodologic quality of the final set of manuscripts was also assessed. The variety of study designs included in this systematic review necessitated the use of different quality assessment tools. Methodologic quality of the randomized controlled trials was rated according to a list developed by van Tulder, Assendelft, Koes, and Bouter (1997). This list has been recommended and adapted by the Cochrane Back Group as the instrument to assess methodologic quality (Bombardier et al., 2002).
The list consists of 11 criteria for internal validity, six descriptive criteria and two statistical criteria (see Figure 1). All criteria were scored as yes, no, or unclear. Equal weight was applied to all items. Scores could range from 0 to 19, by counting the yes answers as 1 and the others as 0. So, the higher the score, the higher the methodologic quality of the manuscript. Studies were considered to be of sufficient quality if at least six criteria for internal validity, three descriptive, and one statistical criteria were scored positively.
The methodological quality of studies based on other designs than randomized controlled trials was rated with an adapted version of the van Tulder list, as developed and used by Steultjens et al. (2002). This list of criteria consists of seven criteria for internal validity, four descriptive criteria, and two statistical criteria (see Figure 2). All criteria were scored as yes, no, or unclear. Equal weight was applied to all items. Scores could range from 0 to 13, by counting the yes answers as 1 and the others as 0. So, the higher the score, the higher the methodologic quality of the manuscript. Studies were considered to be of sufficient quality if at least four criteria for internal validity, two descriptive, and one statistical criteria were scored positively.
The cut-off scores for final quality assessment were derived from Steultjens et al. (2002). The methodologic quality of the included trials was independently assessed by two reviewers. Disagreements were resolved by discussion; if no consensus was achieved, a third reviewer made the final decision.
Results
Search results. Figure 3 presents a flow diagram of the results of the search strategy. All searches were carried out in June 2002. The electronic database searches produced a total of 451 references across all databases; 303 references were found in PUBMED, 258 in EMBASE, 106 in SCI, 34 in PICARTA, 15 in Cochrane, 3 in CINAHL, and 1 in INVERT. Although there was a considerable overlap between databases, all but one database added exclusive manuscripts (159, 116, 6, 5, 2, and 2, respectively, exclusive in PUBMED, EMBASE, PICARTA, SCI, Cochrane, and CINAHL).
The title was accompanied by an abstract in 60% of the cases. Of the 451 references, 102 (22.6%) were initially included for further study of the full text; 5 references could not be obtained within 4 months, and 17 articles, which fulfilled all the criteria for inclusion, were processed for further methodologic analysis. Additional searches resulted in ordering 12 full-text articles of which 7 met inclusion criteria. The final set consisted of 24 (see Table 1, p. 50). Details about the excluded studies can be obtained from the authors.
General characteristics of the final set. There is very little recent research; 5 manuscripts were published in the last decade of the 20th century, and 12 of the 24 studies were performed at least 20 years ago. The manuscripts were published in 21 different journals, and 23 different first authors were listed. Studies were performed in 13 different countries; 6 studies originated from Germany.
With regard to study design, six randomized controlled trials were found, six controlled trials (three of which used the patients as their own controls) and 12 studies used other noncontrolled designs.
Methodologic quality score was “sufficient” in four studies (Cullen, 1977; Cullen, Rex, & Thorne, 1984; Galbiati & Scarabelli, 1998; Mertens, Morias, & Verhamme, 1976). An overview of the study designs and their methodologic quality scores is presented in Table 1.
Patients. Patients with intertrigo were mostly included in larger research samples covering a variety of medical diagnoses (see Table 2, p. 51), mainly under the umbrella of dermatomycoses. It was difficult to determine how many patients with intertrigo of the large skin folds were included in each study. In most studies, intertrigo was not or not clearly defined. The onset and duration of the condition varied considerably. Two studies (McMahon, 1994; Schindera, 1999) explicitly stated that their sample concerned noninfected intertrigo. From the details that were given in the manuscripts, the samples appeared to differ quite a lot with regard to inclusion and exclusion criteria (setting, co-morbidity, age, gender, duration of condition, etc.).
Sizes of the total study populations varied from 14 to 683 patients (median=41, mean=89.3, SD=156). However, the subsamples of patients with intertrigo of large skin folds varied from 1 to 46 (median=12.5, mean=15.4, SD=14.2). In six studies it was unclear how many patients with intert\rigo were included in the research population. Studies that used some method of control had sample sizes of patients with intertrigo varying from 9 to 42, and some of them were spread over two to five treatment groups.
Interventions and control/comparisons. As can be seen from Table 3, p. 52, no less than 25 (excluding placebo agents) different products and methods were reported in these 24 manuscripts. In 12 studies the intervention was studied without any form of control treatment, and three (Cullen, 1977; Cullen et al., 1984; Gip, 1966) of the other 12 studies in which two or more agents were compared used a placebo control treatment
Four products, econazole (Cullen et al., 1984; Hempel, 1975; Scherwitz, 1977; Schwarz, Much, Konzelmann, 1975; Siboulet, 1976; Wurster, 1993), miconazole (Cullen, 1977; Galiano, Ruggiero, Gregori, & Menozzi, 1990; Mertens et al., 1976; Torok et al., 1979), tolnaftate (Hackbarth& Markson, 1966; Meyer-Rohn, 1979), tioconazole (Somorin, 1985; Taube, Duhr, Koepke, & Haustein, 1995) were investigated in more than one study.
Between, and even within products, there is a great variety in strength of composition, combination with other products, application form, and frequency and duration of the treatment. Moreover, within one study the intervention could differ from patient to patient (for example, one patient applied the cream for 1 week and another for 3 weeks). It was also not always clear who applied the products to the skin, and none of the studies were explicit about whether the application was, in fact, performed in the right dose and frequency. All this makes comparisons between treatment groups within studies difficult, and comparisons across studies almost impossible.
Overall, the products that were studied can be labeled as antifungal agents or as disinfectants and, as such, are directed at treating the secondary infections of the intertriginous lesions. Only two studies (McMahon, 1994; Peltonen & Havu, 1981) focused solely on reducing the causal factors of the intertrigo, and none of the studies reported on the prevention of intertrigo.
Outcome measurements. Most studies used objective and subjective methods to measure the effectiveness of the treatments. The objective measures included microscopic examination and cultures of bacteria and fungi, and the subjective measures included the rating of symptom (itching, erythema, exudation, burning, etc.) presence and severity, by clinicians and/or patients, and the rating of cure (for example, amelio-rated, worsened, cured). None of the studies described the psychometric properties of their subjective outcome measurement instruments or made any reference to their validity. Moreover, the outcomes in the various studies were measured at different times and in different frequencies.
Findings. In most studies some favorable effects of the remedies were found or advocated for the total research population. As shown in Table 4 (p. 54), the effects for the subsample of patients with intertrigo of the large skin folds could be traced in 12 of the 24 studies.
Positive effects (clinically and microbiologically) were reported for econazole (Cullen et al., 1984; Hempel, 1975; Scherwitz, 1977; Schwarz et al., 1975; Siboulet, 1976). No effect was found for dibenzthieen (Gip, 1966) or for the typical nursing interventions studied by McMahon (1994). In the noncontrolled studies, positive effects were claimed by the authors for Melaleuca alternifolia (also named the “tea tree,” a plant growing in Australia from which an essential oil is made) (Belaiche, 1985) and Hamamelis virginiana (a tree, “witch hazelnut,” from which a lotion is prepared) (Schindera, 1999).
Table 1.
Study Designs and Methodological Quality Score
Table 2.
Study Populations and Sample Sizes
Table 3.
Interventions and Control Treatments
Table 4.
Effects in Intertrigo Subsamples
Discussion
The prevention and treatment of intertrigo of the large skin folds with remedies that lie within the nursing domain lack almost all forms of evidence. Research articles are very scarce, especially on the measures that are often recommended to reduce the believed causal factors of intertrigo. The scarce empirical evidence that was found in this review mainly concerned the effect of antifungal therapeutics.
Moreover, the research that was found on the subject suffers from several weaknesses, such as ill-defined research populations, lack of control groups, small samples sizes, many interventions in very heterogeneous populations, and weak research designs, etc.
Therefore this review can provide no basis, evidence, advice, or contra-advice for any particular nursing treatment. Perhaps the only thing that can be said is that some type of antifungal agent, such as econazole, may be of value if the intertrigo is infected by fungi. But only one study (Cullen et al., 1984) reporting such an effect was placebo controlled and was of sufficient methodologic quality; all other studies focusing on econazole had weaker designs and small sample sizes. It should also be noted that McMahon (1994) found that no submammary intertriginous lesion in his study was infected by a fungus, and that Hedley et al. (1990) found that only 7 of the 83 patients with intertrigo had a positive fungal culture.
This review obviously has several limitations. It is not possible to offer “a best treatment” advice since the review excluded all literature in which medical treatment was discussed as surgery, combinations of antifungals with corticosteroids, topical antibiotics, systemic treatment, etc. It is possible that reviews of those articles could result in well-evidenced treatments, but this is not very likely because, as mentioned earlier, a PUBMED search with “intertrigo” [MESH] AND “randomized controlled trial” [pt] revealed only two references: one in which Cullen (1977) investigated the efficacy of miconazole, and which is included in this review; and another study (Hedley et al., 1990) comparing hydrocortisone cream versus hydrocortisone plus miconazole cream, in which both products were found to be equally effective. Moreover, it can be assumed that those “medical” articles will focus on treatments for infected intertrigo and not on preventing intertrigo or reducing the causal factors, what doctors consider to be the nursing domain. A glance at some of these, for this review excluded “medical” studies, reveals many noncontrolled trials and small sample sizes exist (Grigoriu & Grigoriu, 1982; Hedley et al., 1990; Minelli & Ragher, 1989; Radovic-Kovacevic, Ratkovic, & Milenkovic, 1990; Reiffers, 1981; Venier, Carnevali, Alessandrini, & Urbani, 1982). Moreover, recent clinical medical guidelines state that very little evidence exist (de Kock et al., 1997; Rex et al., 2000).
Implications
This review has several implications. First, from a taxonomy point of view, it seems important to formulate a clear definition of intertrigo and how it can be distinguished from other skin diseases, and especially from the various forms of dermatomycosis. This was a problem that was encountered in the selection procedure of this review; most authors did not mention what they mean by intertrigo, and the instruments and methods to diagnose the condition were often not stated. Generally, most publications focused on intertrigo infected by fungi or they made no differentiation between infected intertrigo and the noninfected or “simple” intertrigo as mentioned by McMahon (1991).
Second, it is easy to propose a research agenda for intertrigo. Research is needed on the pathogenesis of intcrtrigo. What comes first, infection or maceration? What is necessary for the development of intertrigo: rubbing, occlusion, moisture, heat? Further, it would be worthwhile to conduct prevalence studies; it is a shame that no one knows how many patients suffer from intertrigo, while it is considered to be a common condition (van Beelen, 2001). And is it true that intertrigo is more prevalent in diabetic or obese patients, as many authors suggest? However, such a prevalence study should be based not only on a clear definition of intertrigo, but also on reliable and valid diagnostic instruments, which do not yet seem to exist.
There is also a great need for research on preventive measures: what is the effect of drying skin folds with a hair dryer, how often should the skin folds be washed, are soap or deodorants of value, can natural fabrics prevent intertrigo, etc? This applies to the many therapeutic interventions that are recommended in the literature. As long as everybody swears by his or her own method, but no research is carried out, patients are exposed to therapies that are probably ineffective or harmful, and unnecessary costs are incurred.
Third, no research basis was found for any of the current nursing approaches in the prevention or treatment of intertrigo. Nurses and other caregivers should see this as a challenge to discuss their current practices with each other and to initiate clinical studies on the subject.
With regard to the development of a clinical nursing guideline on intertrigo, there is no published evidence on which to base any recommendations. Therefore, the development of the guideline will have to rely on other methods for evidence grading, such as expert opinion, consensus meetings, and common sense. Useful information may also be derived from partly related guidelines, such as on pressure ulcers, neonatal skin care, skin care in general, and medical guidelines on the diagnosis and treatment of dermatomycoses and bacterial skin infections.
A final remark concerns the usefulness of performing a systematic review, such as the one described here. At the start of this project it was clear there was very little hard evidence on the subject, and therefore the inclusion criteria were extended to all kinds of research designs. This made it possible to identify more empirical studies, although it was som\etimes difficult to find the publications. However, the greater number of studies that were finally identified did not change the conclusion that was obvious at the start: there is very little evidence available on the subject. However, it may be of value to demonstrate there is a considerable amount of research that could be improved and to show that the nursing profession lacks a research basis for a basic nursing problem.
References
Aly, R., Forney, R, & Bayles, C. (2001). Treatments for common superficial fungal infections. Dermatology Nursing, 13(2), 91-94, 98- 101.
Arndt, K., & Bowers, K. (2002). Manual of dermatologic therapeutics (6th ed.). Philadelphia: Lippincolt Williams & Wilkins.
Belaiche, P. (1985). Traitement des infections cutanees par l’huile essentielle de melaleuca alternifolia [Treatment of skin infections with the essential oil of melaleuca alternifolia]. Phytotherapy, 15, 15-17.
Benigni, J.-P., Casaubon, M., & Djian, B. (2000). Les biotextiles antiseptiques: Leur interet dans la contention medicale [Antiseptic biotextiles and their role in medical support]. Angeiologie, 52, 43- 45.
Bohm, I. (1996). Candida-Intertrigo (ICD B37.2): Therapeutische trends und leitlinien [Candida-inlertrigo (ICD B37.2): Therapeutic trends and guidelines]. Der Deutsche Dermatologe, 44, 39.
Bombardier, C., Bouter, L., de Bie, R., Deyo, R., Guillemin, F., Shekelle, P. et al. (2002). Cochrane Back Group. Toronto: The Cochrane Library.
Brown, D.M., & Young, V.L. (1993). Reduction mammoplasty for macromastia. Aesthetic Plastic Surgery, 17, 211-223.
Burkhart, C.G., Mulholland, M.B., & Burnham, J.C. (1981). Scanning electron microscopic evidence of bacterial overgrowth in intertrigo. Journal of Cutaneous Pathology, 8, 273-276.
Chadbourne, E.B., Zhang, S., Gordon, M.J., Ro, E.Y., Ross, S.D., Schnur, P.L. et al. (2001). Clinical outcomes in reduction mammaplasty: A systematic review and meta-analysis of published studies. Mayo Clinic Proceedings, 76, 503-510.
Crawford, F., Hart, R., Bell-Syer, S., Torgerson, D., Young, P., & Russell, I. (2001). Athlete’s foot and fungally infected toenails. British Medical Journal, 322, 288-289.
Cullen, S.I. (1977). Cutaneous candidiasis: Treatment with miconazole nitrate. Cutis, 19, 126-129.
Cullen, S.I., Rex, I.H., & Thorne, E.G. (1984). A comparison of a new antifungal agent, 1 percent econazole nitrate (Spectazole(TM)) cream versus 1 percent clotrimazole cream in the treatment of intertriginous candidosis. Current Therapeutic Research, 35, 606- 609.
Davis, S.A. (1980). How I treat groin eruptions. Medical Times, 108, 54-59.
de Kock, C.A., Duyvendak, R.J., Jaspar, A., Krol, S.J., Hoeve van, J.A., Romeijnders, A.C., et al. (1997). NHG-standaard dermatomycosen [NHG-guideline dermatomycoses]. Huisarts en Wetenschap, 40, 541-552.
Fragola, L.A.J. & Watson, P.E. (1981). Common groin eruptions: Diagnosis and treatment. Postgraduate Medicine, 69, 159-159, 172.
Galbiati, G., & Scarabelli, G. (1998). Trattamento delle intertrigini con una soluzione antisettica a base di cloroxilenolo ed eosina: Atudio controllato in doppio ciecco verso soluzione die eosina [Treatment of interlrigo with a chloroxylenol and eosine antiseptic solution. A controlled double-blind study versus eosine solution]. Giornale Italiano di Dennatologia e Venereologia, 133, 299-303
Galiano, P., Ruggiero, G., Gregori, S., & Menozzi, M. (1990). Dermatiti superficiali micotiche trattate con una nuova crema al 2% di miconazolo in liposomi [Superficial mycotic dermatitis treated with a 2% miconazole cream in liposomes]. Dermatologia Oggi, 5, 60- 63.
Gip, E. (1966). Klinische prufung der Fungiplex-Salbe an einem geriatrischen material mit intertriginoser candidamykose [Clinical testing of Fungiplex ointment on a geriatric material with intertriginous Candida mycosis]. Dermatologische Wochenschrift, 152, 482-484.
Gloor, M. (1988). Windeldermatitis und ahnliche hauterkrankungen [Diaper rash and similar skin lesions]. Medizinische Monatsschrift fur Pharmazeuten, 11, 346-347.
Grigoriu, A., & Grigoriu, D. (1982). Superficial mycoses: Ketoconazole treatment. Mykosen, 25, 258-262.
Guitart, J., & Woodley, D.T. (1994). Intertrigo: A practical approach. Comprehensive Therapy, 20, 402-409.
Hackbarth, D.E., & Markson, E. S. (1966). A new fungicidal agent for intcrtriginous dermatomycosis. Current Therapeutic Research, 8, 175-178.
Hedley, K, Tooley, P., & Williams, H. (1990). Problems with clinical trials in general practice – a double-blind comparison of cream containing miconazole and hydrocortisone with hydrocortisone alone in the treatment of intertrigo. British Journal of Clinical Practice, 44, 131-135.
Hempel, M. (1975). Klinische erfahrungen in der lokalen behandlung von dermatomykosen mit econazol-hautmilch [Clinical experiences with the topical treatment of dermatomycoses with econazol-skinmilk]. Mykosen, 18, 213-219.
Itin, P. (1989). Intertrigo – ein therapeutischer problemkreis/ Intertrigo – a therapeutic problem circle. Therapeutische Umschau, 46, 98-101.
Kugelman, T.P. (1969). Intertrigo – diagnosis and treatment. Connecticut Medicine, 33, 29-36.
Marghescu, S. (1970). Die intcrlrigo, ihre Prophylaxe und behandlung [Intertrigo, its prevention and treatment]. Therapie der Gegenwart, 109, 813-814.
McMahon, R. (1991). The prevalence of skin problems beneath the breasts of in-patients. Nursing Times, 87, 48-51.
McMahon, R. (1994). An evaluation of topical nursing interventions in the treatment of submammary lesions. Journal of Wound Care, 3, 365-366.
McMahon, R., & Buckeidee, J. (1992). Skin problems beneath the breasts of inpatients: The knowledge, opinions and practice of nurses. Journal of Advanced Nursing, 17, 1243-1250.
Mcrtens, R., Morias, J., & Verhamme, G. (1976). A double blind study comparing Daktacort, miconazol, and hydrocortisone in inflammatory skin infections. Dermatologica, 153, 228-235.
Meyer-Rohn, J. (1979). Piadar (Ladar): Ein neues antimykoticum mit dem wirkstoff siccanin [Piadar (Ladar): New antimycotic drug containing the antifungal agent siccanin]. Mykosen, 22, 255-258.
Minelli, L., & Ragher, L. (1989). Avaliacao da eficacia terapeutica da associacao de nistatina com oxido de zinco e plastibase em dermatites intertriginosas [Evaluation of therapeutic efficacy of the association of Nystatin with zinc oxide and plastibase in intertriginous dermatitides]. Revista Brasileira de Medicina, 46, 14-18.
Moulin, G., Gaboriaux, M.C., & Joseph, J.Y. (1983). Pathologie du pli interfcssier [Pathology of the perianal region]. Concours Medical, 105, 353-367.
Peltonen, L., & Havu, V.K. (1981). Debrisan paste in the treatment of exudative intertriginous dermatoses and leg ulcers. Clinical Trials Journal, 18, 353-362.
Radovic-Kovacevic, V., Ratkovic, R., & Milenkovic, A. (1990). Obytin u lecenju povrsnih mkoza koze [Obylin (1% cyclopyroxolamine) in the treatment of superficial skin mycoses]. Medianski Pregled, 43, 329-331.
Reiffers, J. (1981). Essai d’une nouvelle creme antifongique et antibacterienne a base de triclosan (CGP 433-Logamel). [Clinical report of triclosan, a new topical with antifungicidal and antimicrobial activity (CGP 433-Logamel)]. Schweizerische Rundschau fur Medizin Praxis, 70, 1050-1053.
Rex, J, Walsh, T., Sobel, J, Filler, S, Pappas, P., Dismukes, W., et al. (2000). Practice guidelines for the treatment of candidiasis. Clinical Infectious Diseases, 30, 662-678.
Scherwitz, C. (1977). Klinische prufung von econazol haut-milch und creme bei hautmykosen [Clinical study with econazol skin-milk and cream in dermatomycoses]. Zeitschrift far Hautkrankheiten, 52, 117-125.
Schindera, I. (1999). Intertrigo-therapie heute: Behandlungsergebnisse mit hamamelis virgimana [Current intertrigo therapy: Treatment results with Hamamelis virginiana]. Forschende Komplementarmedizin, 6, 31-32.
Schwarz, K., Much, T., & Konzelmann, M. (1975). Poliklinische prufung von econazol bei 594 fallen von hautmykosen. [Study of econazol in 594 outpatients with dermatomycoses]. Deutsche Medizinische Wochenschrift, 100, 1497-1500.
Selden, S. (2001). Intertrigo. eMedicine Journal, 2.
Siboulet, A. (1976). L’econazol spraypoudre en dermato- venereologie [Econazole spray-powder in dermovenereology]. Schweizerische Rundschau fur Medizin Praxis, 65, 977-981.
Somorin, A.O. (1985). Clinical evaluation of tioconazole in dermatophyte infections. Current Therapeutic Research, 37, 1058- 1061.
Steultjens, M., Dekkcr, J., Bouter, L., Van de Nes, J., Cardol, M., & Van den Ende, C. (2002). Occupational therapy for multiple sclerosis (Protocol for a Cochrane Review). Toronto: The Cochranc Library.
Taube, K-M., Duhr, M., Koepke, M., & Haustein, U.-F. (1995). Behandlung von pilzinfektionen der haut mit tioconazol [Treatment of fungal infections of the skin with tioconazole]. Zeitschrift fur Dermatologie, 181, 125- 128.
Torok, L, Varkonyi, V, Podanyi, B., Soos, G., Denes, M., & Kiraly, K. (1979). Vergleichende Untersuchungen mit mycosolon, miconazol, und depersolon-salbe im doppelblindversuch [Comparative studies of Mycosolon, miconazole and depersolone ointments in a double-blind test]. Dermatoloeische Monatsschrift, 165, 788-794.
van Beelen, A. (2001). Prevenue en behandeling van intertrigo: Ont-smelten [Prevention and treatment of intertrigo]. Verpleegkunde Nieuws, 75, 18-21.
van Tulder, M.W., Assendelft, WJ., Koes, B.W., & Bouter, L.M. (1997). Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine, 22, 2323-2330.
Venier, A., Carnevali, P., Alessandrini, A., & Urbani, S. (1982). Valutazione clinica controllata di un preparato topico contenente fluocortolone biesterifiacto associato a clorchinaldolo [Controlled clinical trial of a topical formulation of fluocortolone (as privalate and caproate esters) plus chlorquinaldol]. Clinica Europea, 21, 932- 939.
Wanic, A. (1967). Behandlungsversuche einiger Hautkrankheiten mittels chinolin und chinaldinderivaten [Therapeutic tr\ials of various skin diseases using chinoline and chinaldinc derivatives]. Zeitschrift fur Haut- und Geschlechtskrankheilen, 42, 27-32.
Wurster, J. (1993). Die behandlung von intertriginosen dermatosen und windeldermatitis mit einer kombination von econazol und zinkoxid [Treatment of intertriginous dermatosis and diaper dermatitis with a combination of econazole and zinc oxide]. Ars Medici, 83, 792-795.
Patriek Mistiaen, MSN, RN, is a Nurse Researcher, Netherlands Institute of Health Services Research, Utrecht, The Netherlands.
Else Poot, MSN, RN, is a Nurse Researcher, Netherlands Institute of Health Services Research, Utrecht, The Netherlands.
Sophie Hickox, MS, RN, is a Project Advisor, Netherlands Expertise Center for Nursing and Care, Utrecht, The Netherlands.
Christ Jochems, RN, is a Clinical Nurse Specialist, Dermatology, Albert Schweizer Hospital, Dordrecht, The Netherlands.
Cordula Wagner, PhD, is a Senior Researcher, is a Nurse Researcher, Netherlands Institute of Health Services Research, Utrecht, The Netherlands.
Acknowledgment: The authors thank the NIVEL Library for their tremendous assistance in tracing and ordering the literature.
Copyright Anthony J. Jannetti, Inc. Feb 2004
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