Secondary Data Analysis of Intertrigo in Hospital and Geriatric Settings: A Comparison of Prevalence, Anatomical Locations, and Interventions

Intertrigo, an inflammatory condition also known as inflammatory dermatosis¹ or intertrigous dermatitis,² often occurs in skin folds on the body and is a form of moisture-associated skin damage.³ It is a disorder that is most frequently observed in the breast, inguinal, abdominal, and perianal skin folds. It is primarily caused by skin-on-skin friction and exacerbated by conditions associated with the moisture that collects in deep skin folds where air circulation is restricted.⁴

Intertrigo is characterized by reddening of the skin (erythema) on both sides of the skin fold, maceration, erosions, fissures (cracks), and wet skin and presents the risk of infection.^4-6 Skin damage can frequently become worse through the development of secondary cutaneous infections by bacteria, yeast, or fungi. The most common infections are caused by Candida bacteria.² Patients may complain of itching, burning, pain, and stinging in the skin folds.² In addition to their negative impact on the patient’s health, skin diseases place a financial burden on the health care system. For example, a cluster randomized trial in 56 Dutch nursing home wards reported mean per-patient costs for bed baths during a period of 6 weeks of €220 in the intervention group (washing without water) and €243 in the control group (traditional bed bath with water), respectively.⁷

In terms of risk factors, intertrigo commonly occurs in obese patients who have diabetes and who are exposed to heat and humidity.⁴ Other risk factors include urinary and fecal incontinence, hyperhidrosis, malnutrition, poor hygiene,⁴ and being dependent on a caregiver for activities of daily living regarding mobility, getting dressed and undressed, and personal hygiene.⁸ In a cross-sectional prevalence study of 223 German nursing home residents with an average age of 84 years, Gabriel et al found that the risk of developing intertrigo increased with age (odds ratio [OR], 1.052; 95% confidence interval [CI], 1.004-1.102) and female sex (OR, 1.290; 95% CI, 0.585-2.842).⁹

Prevention of intertrigo should ideally start with educating patients about intertrigo and how to care for their skin folds, especially for those patients at risk.¹⁰ Recommended nursing interventions in patients with intertrigo include keeping the skin clean and dry, applying topical medication as recommended, and reporting increasing redness, fever, or broken skin.⁶

Skin conditions and dermatological diseases (eg, dry skin, intertrigo, and fungal infections) in older patients are drawing increased attention from clinical practitioners and researchers. The estimated prevalence ranges from 3% to 20% in the main care settings such as nursing homes and hospitals.¹¹ In the Netherlands, the prevalence of intertrigo ranges from 2% in hospitals, to 7% in care homes, and 10% in home care settings.⁸ More than two-thirds of affected persons developed intertrigo after admission to an institution or after receiving home care.⁸ Rahman et al measured the prevalence of superficial fungal infections in hospitals in Bangladesh and found that 6.5% of outpatients who had visited the dermatology department in 2008 had candidal intertrigo.¹² In a systematic review, Mistiaen and van Halm-Walters concluded that no evidence exists on the prevention of intertrigo. In addition, they highlighted that more research on intertrigo is needed.¹¹

Intertrigo affects up to every fifth patient in the health care setting, leading to itching, burning, or pain.¹¹ In addition, intertrigo treatment (eg, skin care products) places a financial burden on the health care system. Although clinical practitioners and researchers are increasing their attention on skin conditions and dermatological diseases among older patients, more research on intertrigo, and specifically on prevalence rates and intervention approaches, is recommended. Therefore, the purpose of this study was to conduct a secondary data analysis to compare the treatment of intertrigo in terms of its prevalence, anatomical locations, and applied interventions in hospitals and geriatric institutions.

The Nursing Quality Measurement 2.0 is an annually conducted cross-sectional study that is the Austrian version of the International Prevalence Measurement of Care Problems (LPZ).¹³ It is conducted every year on a predefined date, creating a comprehensive database over the years. The data were collected on April 17, 2012; April 9, 2013; April 8, 2014; April 14, 2015; and April 12, 2016 and constitute the database for this secondary data analysis.

The LPZ consists of a general module including questions on the structural level about the quality of care offered in the entire institution and about the quality of care offered in specific wards.¹³ Additionally, there are a number of specific modules containing demographic data and nursing topics, such as pressure ulcer, malnutrition, and intertrigo.¹³ The current article concentrates on the intertrigo data from 2012 to 2016 only. Data collection for Nursing Quality Measurement was approved by the ethics committee of the Medical University of Graz (20-192 ex 08/09). Written informed consent was obtained from the participating persons or their legal representatives as a prerequisite for participation. The study was conducted in accordance with recognized ethical standards.

Settings and sampling methods. The authors planned and organized the annual study and invited all Austrian hospitals, nursing homes, and geriatric hospitals to participate by sending a leaflet and an e-mail during the study years 2012 to 2016. Nursing homes and geriatric hospitals were categorized under the heading of geriatric institutions for the purposes of this analysis. Nurses at each participating institution took part in a training session, in which the data collection method, questionnaire, and online data entry program were presented.

All patients hospitalized on the days of the measurement were invited to participate in Nursing Quality Measurement 2.0. Two nurses (one nurse from the patient’s ward and another nurse from another ward) assessed each patient per ward. In cases of disagreement, the assessment of the external nurse was accepted. Demographic data (sex and age), medical diagnoses according to the 10th revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems,¹⁴ and degree of care dependency^15,16 were collected. In this study, the degree of care dependency was defined as the degree to which the patient was dependent on nursing care for performing activities of daily living.¹⁵ The Care Dependency Scale (CDS) was used to measure the degree of care dependency. The CDS includes 15 items, including continence and mobility, that are evaluated on a 5-point Likert scale (from completely care dependent to completely care independent).^15,16 CDS scores range from 15 to 75 points,^15,16 with higher scores indicating a lower degree of care dependency (15–24 points = completely dependent; 25–44 points = to a great extent dependent; 45–59 points = partially dependent; 60–69 points = to a great extent independent; and 70–75 points = completely independent).¹⁷

The authors collected data on intertrigo regarding its (institution-acquired) prevalence, anatomical location (eg, the anal cleft or breast skin folds), and applied interventions. Interventions (yes/no) included the application of skin care products, zinc-containing oil, antifungal products, other kinds of treatment, and expert consultations. Other kinds of treatment encompassed all interventions that could not be categorized in one of the above-mentioned treatments.

Data analysis. Data analysis was performed by using SPSS 25.0 statistical software for Windows. Nominal and ordinal variables were displayed with descriptive statistics. The authors used the median for ordinal variables and the mean with standard deviation (SD) for metric variables. The nominal and ordinal data were analyzed by applying the chi-square test. To test the metric data for its normal distribution, Shapiro-Wilk and Kolmogorov-Smirnov tests were conducted, whereas nonparametric data were analyzed using the Mann-Whitney U-test. Statistical significance was considered if P values were < .05.

Sample characteristics. In total, 114 institutions with 349 wards participated in the subsequent measurements. The data sample includes 26,145 patients who were 65 years and older, and patients at either the hospitals or the geriatric institutions on the days of the measurements. In the hospitals, 69.9% (n = 21,711) of patients took part in the measurements as opposed to 84.5% (n = 4434) of patients in geriatric institutions. Table 1 shows the participant characteristics by type of institution.

The majority of patients (54.7%) were female. The mean age of patients in the hospital (70 years) and of patients in the geriatric setting (84 years) differed significantly. Hospital patients were less likely to be care dependent (CDS sum score = 66) than patients in the geriatric institutions (CDS sum score = 44). The most prevalent medical diagnosis in both groups was cardiovascular disease.

Figure 1 shows the median of the 15 CDS items for patients in the hospitals and geriatric institutions. The median of each care dependency item for hospital patients (n = 15,110) was 5, which means they were completely independent. This result contrasted with that of the patients in geriatric institutions who were partially care dependent for the majority of the items (9). Patients in geriatric institutions were to a great extent care dependent (median of 2) for the items of incontinence, getting dressed and undressed, and hygiene. Patients in geriatric institutions, however, were almost care independent (median of 4) for the items of contact with others, communication, and body temperature.

(Nosocomial) prevalence of intertrigo. For the results on intertrigo, the authors used data only from participants who completed all questions on intertrigo (n = 18,895). Overall, 2.4% (n = 359) of the participating hospital patients (n = 15,152) had intertrigo, while 3.3% (n = 122) of the patients in the geriatric institutions (n = 3743) had intertrigo. This difference was statistically significant (P = .00). A significant difference regarding the time of intertrigo development was also observed between the 2 settings. In 77.9% of 122 patients with intertrigo in geriatric institutions, intertrigo developed after admission. This differed from the hospital patients, in whom 93 (25.9%) experienced intertrigo development after admission.

Anatomical location of intertrigo wounds. In the hospital setting, 359 patients were diagnosed with intertrigo. The anatomical location of the intertrigo was unknown for 6 of these 359 patients. The remaining 353 hospital patients had 466 intertrigo wounds. In the geriatric setting, 122 patients had intertrigo. The anatomical location of the intertrigo was unknown for 3 patients in the geriatric institutions. The remaining 119 patients in the geriatric institutions had 151 intertrigo wounds (Table 2). In hospital patients, there were 158 (33.9%) intertrigo wounds in the inguinal folds and 146 (31.3%) wounds in breast skin folds. In geriatric institutions, 46 (30.5%) intertrigo wounds were in the inguinal folds and 55 (36.4%) in breast skin folds. The abdomen was another frequently affected anatomical location for patients in both settings.

Interventions for the treatment of intertrigo. In general, hospital patients received fewer interventions for treating intertrigo than did patients in geriatric institutions (Figure 2). Skin care products were used to treat intertrigo in almost half of the hospital patients (45.4%), whereas intertrigo was treated with a skin care product in nearly one-third of patients in the geriatric institutions (32.8%). These results were statistically significant (P = .015).

The second most commonly used intervention in geriatric institutions was the application of antifungal products (n = 122; 27%). In hospitals, the use of antifungal products was the third most commonly used intervention for treating intertrigo (n = 359; 16.4%). The differences between hospitals and geriatric institutions regarding the use of skin care and antifungal products were statistically significant (P = .010).

Expert consultation was conducted in 6.1% of hospital patients who had intertrigo. In geriatric institutions, 9.8% patients with intertrigo received an expert consultation. No statistically significant difference was observed between institutions regarding expert consultation.

No statistically significant difference was observed between institutions regarding the use of zinc-containing oil or other kinds of treatment.

No patient in a geriatric institution and only 3 (0.8%) patients in hospitals who had intertrigo were untreated.

Intertrigo has been investigated rarely in different health care settings, including hospitals and geriatric institutions, as shown by the low number of studies identified in the literature about the prevalence of or nursing care in intertrigo. Therefore, the aim of this study was to compare the prevalence and anatomical location of intertrigo as well as the applied interventions for its treatment in hospitals and geriatric settings.

The authors found that 2.4% of the hospital patients (n = 15,152) and 3.3% of the patients in geriatric institutions (n = 3743) had intertrigo. The most frequently used intervention for the treatment of intertrigo in both settings was the use of skin care products. Experts were rarely involved as an intervention in either hospitals or geriatric institutions.

Regarding the prevalence rates of intertrigo, the results of this study (2.4% in the hospital setting) are similar to the prevalence estimates of 2% in the Netherlands⁸ from 4 cross-sectional prevalence studies in the years 2013 to 2016 with more than 40,000 patients as well as 3% reported in a systematic review.¹¹ This result indicates that intertrigo seems to be a rare occurrence in the hospital setting.

Nevertheless, the prevalence of 3.3% in this study is lower compared with prevalence rates from other studies using LPZ data. In one cross-sectional study with 1497 nursing home residents, the estimated prevalence was 5.7%.¹⁸ In another cross-sectional study, the prevalence rate was 9%¹⁹ among 4227 nursing home residents. One explanation could be that the current study included nursing homes and geriatric hospitals under the heading of geriatric institutions, whereas the aforementioned LPZ studies included only data from nursing homes. It also seems that in the geriatric hospital setting, intertrigo appears to be a rare occurrence.

In this study, hospital patients were to a great extent care independent. This is in line with other studies. As an example, 2 cross-sectional studies on hospitalized patients 65 years and older with more than 1700 and 11,000 participants, respectively, reported mean CDS scores of 63 and 64, indicating them to be independent to a great extent.^20,21 Another study also reported a mean CDS score of 63 (to a great extent independent) in 1412 hospitalized patients 70 years or older.²² The patients in geriatric institutions included in this study were to a great extent care dependent. This is similar to another study, according to which the 577 nursing home residents were partially care dependent.²³ Additionally, another study, using the Barthel-Index, reported a mean Barthel score of 45 points in 223 nursing home residents,⁹ which is comparable to the results of this study.

A systematic review reported many therapeutic interventions for intertrigo, with the majority consisting of pharmaceutical products (antimycotics, antibiotics, antiseptics, corticosteroids, or combinations of these),¹¹ but little information on the use of nursing interventions is available. The current study reported on nursing interventions, such as the application of zinc-containing oil, skin care products, antifungal products, and expert consultation, with skin care products being used more often in hospitals than in geriatric institutions for the treatment of intertrigo. Skin care products were recommended in a literature review to treat uncomplicated intertrigo while keeping the skin folds dry, clean and cool.²⁴ In a discussion of skin care products, Surber and Kottner stated that applying skin care products can reduce skin damage and relieve pain.²⁵

Antifungal products for treating intertrigo were used more frequently in geriatric institutions than in hospitals. The differences in the use of skin care products and antifungal products in the hospitals and geriatric institutions might be explained by the assumption that intertrigo was more severe in patients in the geriatric institutions than in hospital patients. As a result, nurses in the geriatric institutions might be encouraged to treat intertrigo or prevent an infection. Nurses in the hospital setting might be encouraged to prevent or support healing of intertrigo without infection. Nevertheless, in hospitals and geriatric institutions, expert consultation was seldom used. The authors believe that further improvement is highly warranted in collaborating with experts when preventing or managing intertrigo, as interdisciplinarity and interprofessionality is warranted in moisture-associated skin damage such as intertrigo.³

A selection bias on the institutional and patient levels may have existed. Participation was voluntary, so it is possible that only institutions’ representatives with the greatest interest in the topic of intertrigo decided to participate. This limitation might influence the generalizability of the study results. On the patient level, all patients who agreed to participate in the study had to provide their written informed consent. It is possible that patients in good health showed a higher tendency to participate, whereas patients in very poor health might have refused to participate. This may have led to an underestimate for the prevalence of intertrigo in the latter group.

This study compared the prevalence and anatomical locations of intertrigo as well as applied interventions in hospitals and geriatric institutions. This secondary data analysis used data from 4 consecutive cross-sectional studies with more than 15,000 hospital patients and 3743 patients from geriatric institutions. Of the hospital patients, 2.4% had intertrigo compared with 3.4% of the patients in geriatric institutions. The most frequently affected locations were the inguinal folds and breast skin folds. Skin care products were used most often for the treatment of the intertrigo, whereas expert consultation was seldom used. Independent of the setting, the authors expect that the number of patients with intertrigo will be increasing. Therefore, implementing standardized skin assessments for moisture-associated skin damage to identify intertrigo as early as possible is highly recommended. Moreover, as the consultation of experts was seldom used in both settings, advances in the interdisciplinary and interprofessional management of moisture-associated skin damages are needed.

The authors thank Dr C. Lohrmann, RRN, FEANS, for initiating the nursing care quality measurement.

Ms Osmancevic, Ms Eglseer, Ms Bauer, and Ms Hoedl are nursing researchers, Institute of Nursing Science, Medical University of Graz, Graz, Austria.

Address all correspondence to: Selvedina Osmancevic, MSc, BSc, Institute of Nursing Science, Medical University of Graz, Universitätplatz 4/3, 8010 Graz, Austria; email: selvedina.osmancevic@medunigraz.at.

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