Risk factors and diverse management approaches for intertrigo: Analysis of the “All of Us” research cohort

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Woodie, Megan M. Mukenge, Steven R. Feldman, Alan B. Fleischer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6866473/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Intertrigo is an inflammatory dermatosis of skin folds whose risk factors and real-world management are incompletely defined. We analyzed electronic health records for 370,639 adults in the National Institutes of Health All of Us Research Program controlled tier version 8 and identified 5,487 participants with at least one diagnostic code for intertrigo and a recorded body-mass index (BMI). Demographic, socioeconomic, and clinical covariates were compared with 365,152 controls using 𝛸 2 tests and multivariable logistic regression. Treatment patterns were assessed at the visit level; encounters containing concurrent codes for common chronic inflammatory dermatoses or cutaneous infections were excluded to identify prescriptions intended for non-infected intertrigo. Higher BMI, older age, female or other sex, White race, non-Hispanic or Latino ethnicity, diabetes mellitus, incontinence, hyperhidrosis and vitamin D deficiency were all risk factors for intertrigo. A total of 14,173 visits for intertrigo were analyzed to identify treatment utilization. Topical antifungals were prescribed in 36% of visits, chiefly imidazoles (25%), and the most common combination was an imidazole plus a medium-potency corticosteroid (7.2%). Oral or topical antibiotics appeared in 15% of visits, usually as adjunctive rather than sole therapies, and skin protectants were rarely prescribed. These findings expand the spectrum of risk factors to include hyperhidrosis and vitamin D deficiency and reveal heterogeneity in real-world treatment, identifying a potential need for evidence-based intertrigo management guidelines. antifungal agents corticosteroids topical antibiotics body mass index obesity diabetes mellitus incontinence hyperhidrosis vitamin D deficiency socioeconomic factors health care disparities electronic health records Figures Figure 1 Figure 2 Introduction Intertrigo is a recurrent inflammatory condition commonly affecting skin-to-skin contact areas, including the inframammary, axillary, and inguinal folds. Friction-retained moisture and occlusion contribute to its onset and may increase susceptibility to infection [ 3 , 4 , 5 ]. While the clinical presentation is well characterized, gaps in understanding its risk factors and treatment strategies remain. Most existing literature has focused on care-dependent populations, such as in hospital and nursing home settings [ 3 , 4 ]. Few studies have evaluated intertrigo in broader ambulatory populations, limiting the generalizability of current literature. Treatment practices also vary. Topical antifungal and corticosteroid therapies are often recommended [ 5 , 7 ], however comparative studies are limited. Although some recommend adding a low-potency corticosteroid to topical antifungals, evidence supporting the use of topical corticosteroids in intertrigo is limited [ 5 , 7 ]. Despite an array of treatment options, no standardized approach exists, and real-world management guidelines remain poorly defined [ 7 ]. We aimed to identify risk factors for intertrigo and describe real-world treatment practices using data from a large, diverse sample of U.S. adults enrolled in the National Institute of Health’s All of Us Research Program. Methods We analyzed de-identified participant data from the National Institutes of Health’s All of Us Research Program, controlled tier version 8, which contains electronic health record data for over 390,000 patients. We identified 5,487 participants with a diagnosis of intertrigo (International Classification of Diseases [ICD]-10 code L30.4) with at least one measurement for body mass index (BMI). Covariates and treatments Demographic covariates included patient age, BMI, sex assigned at birth, self-reported race, self-reported ethnicity, and self-reported income. For participants who declined to report their income, the median household income from the participant’s postal code was used. Medical history covariates included diabetes mellitus, incontinence, hyperhidrosis, and vitamin D deficiency (Online Resource 1). Diabetes and incontinence have previously been identified as risk factors for intertrigo [ 3 , 4 ]. Though hyperhidrosis is directly related to the pathophysiology of intertrigo and is known to increase the risk of cutaneous infections [ 13 ], we did not identify extant literature showing the magnitude of the association between hyperhidrosis and intertrigo. Vitamin D deficiency is associated with other inflammatory skin conditions [ 11 ], but has not been evaluated as a predictor of intertrigo to our knowledge. Treatments for intertrigo were evaluated using individual visits: topical antifungal drugs (nystatin, imidazoles, terbinafine), topical corticosteroids, oral antibiotics (beta lactams, macrolides, tetracyclines), oral antifungals (fluconazole, terbinafine), topical antibiotics (bacitracin, clindamycin, erythromycin, mupirocin), topical corticosteroid sparing agents (crisaborole, pimecrolimus, roflumilast, ruxolitinib, tacrolimus, tapinarof), and topical skin protectants (as given in the United States Food and Drug Administration Skin Protectants Monograph [ 12 ]). Topical corticosteroid potency classifications are shown in Online Resource 2. To identify treatments that were likely prescribed only for intertrigo, visits with a concurrent diagnosis of one of the top five chronic inflammatory skin conditions (acne, atopic dermatitis, psoriasis, rosacea, seborrheic dermatitis, as determined by Wilmer et al. [ 14 ]) or a skin infection (tinea, cellulitis, abscess, candidiasis, impetigo, pyoderma, erythrasma, or other local infections) were excluded. Statistical analysis Descriptive statistics were calculated for the characteristics of patients with intertrigo and controls (patients with no history of intertrigo). Independent two-sample T-tests or 𝛸 2 tests compared characteristics: age, BMI, sex, race, ethnicity, patient-reported income, history of incontinence, diabetes mellitus, hyperhidrosis, and vitamin D deficiency. To determine the strength of these risk factors, multivariable logistic regression was performed with the above independent variables and the outcome as having at least one diagnosis of intertrigo. Frequencies and percentages were calculated for treatments prescribed at a visit for intertrigo. Significance was set at two-tailed p < .05, and all analysis was performed in the SAS Studio environment within the All of Us Researcher Workbench. Results We included 5,487 participants with at least one diagnosis of intertrigo out of 370,639 eligible participants (1.5%) (Table 1 ). Higher BMI, older age, female or other sex, white race, non-Hispanic or non-Latino ethnicity, incontinence, hyperhidrosis, diabetes, and vitamin D deficiency predicted higher odds of having intertrigo in the multivariable logistic regression (Fig. 1 ). The greatest risk factors for intertrigo were class III obesity (odds ratio 5.55 [95% confidence interval 4.96–6.22]), incontinence (5.24 [4.89–5.60]), and class II obesity (3.73 [3.33–4.19]). Vitamin D deficiency (2.14 [2.02–2.27]) was a greater risk factor than hyperhidrosis (1.92 [1.75–2.12]) or diabetes mellitus (1.52 [1.43–1.62]). Income was lower for patients with intertrigo compared with controls in 𝛸 2 tests, but there was no significant association in the multivariable model. Tinea was the most common comorbid skin infection at 3.4%, and other infectious diagnoses were only present in < 1% of visits (Table 2 ). Table 1 Demographics of patients with a history of intertrigo, patients without a history of intertrigo, and controls matched on age, sex assigned at birth, race, ethnicity, income, and additional risk factors for intertrigo (BMI, diabetes mellitus, incontinence, and hyperhidrosis). Variable/Subcategory Intertrigo n = 5,487 (%) No Intertrigo Controls n = 365,152 (%) P‑value a Age (years) 63 (62, 63) 54 (54, 54) < .0001 BMI (kg/m²) 35 (35, 35) 30 (30, 30) < .0001 Sex Female 74% 60% < .0001 Male 25% 39% Other 1.2% 1.1% Race Asian 0.97% 3.0% < .0001 Black 17% 18% Other race b 18% 24% White 65% 54% Ethnicity Hispanic or Latino 11% 18% < .0001 Not Hispanic or Latino 89% 82% Income Less than $ 25k 27% 25% < .0001 $ 25–50k 20% 17% $ 50–100k 35% 35% $ 100k–200k 14% 16% Over $ 200k 4.6% 6.7% Conditions Any incontinence 27% 3.4% < .0001 Diabetes mellitus 45% 20% < .0001 Hyperhidrosis 10% 3.1% < .0001 Vitamin D deficiency 48% 18% < .0001 a P-values were obtained from two-sample independent T-tests for continuous variables or 𝛸 2 tests for categorical variables. b Race and ethnicity were obtained from self-report and were included in this analysis as a goal of All of Us to collect and report data from a diverse group of participants. “Other” races included American Indian or Alaskan Native, Middle Eastern or North African, Native Hawaiian or Other Pacific Islander, race not specified, and more than one population. Table 2 Infectious comorbidities of intertrigo. Diagnosis Number (%) of intertrigo visits (n = 14,768) with given infectious diagnosis Number of Visits for diagnosis in n = 5,487 patients with intertrigo Tinea 508 (3.4%) 12,579 Cellulitis 127 (0.86%) 18,479 Abscess 93 (0.63%) 4,437 Candidiasis of skin and nails 93 (0.63%) 5,204 Other local infections 53 (0.36%) 2,077 Impetigo 34 (0.23%) 576 Pyoderma 12 (0.08%) 264 Erythrasma 5 (0.03%) 59 Table 3 Treatment frequencies at intertrigo visits (n = 14,173). Visits with comorbid infectious diagnoses or a chronic skin condition were excluded. Main Category Frequency (Percent) Subcategory Frequency (Percent) Topical Antifungals 5093 (36%) Topical imidazoles a 3561 (25%) Topical nystatin 1875 (13%) Topical terbinafine 76 (0.53%) Topical Corticosteroids 3499 (24%) Medium potency (Class III, IV, V) 2049 (14%) Low potency (Class VI, VII) 1623 (11%) Ultrahigh potency (Class I) 363 (2.5%) High potency (Class II) 358 (2.5%) Oral Antibiotics 1133 (7.9%) Oral beta lactams 853 (6.0%) Oral tetracyclines 270 (1.9%) Oral macrolides 146 (1.0%) Topical Antibiotics 1028 (7.2%) Clindamycin 454 (3.2%) Mupirocin 444 (3.1%) Bacitracin 193 (1.4%) Erythromycin < 20 b Oral Antifungals 752 (5.3%) Oral fluconazole 709 (5.0%) Oral terbinafine 44 (0.3%) Topical Corticosteroid Sparing Agents c 647 (4.5%) Tacrolimus 548 (3.8%) Pimecrolimus 277 (1.9%) Crisaborole < 20 b Ruxolitinib < 20 b Skin Protectants 377 (2.7%) a Imidazoles appearing in the dataset: clotrimazole, econazole, ketoconazole, miconazole, oxiconazole b To protect patient privacy, values under 20 are hidden per guidelines from the All of Us research program c No visits for roflumilast or tapinarof The 5,487 patients with at least one diagnosis of intertrigo had 14,768 visits for the condition. Visits also having a diagnostic code for a skin infection or chronic inflammatory skin condition were excluded, yielding a final sample of 14,173 visits. The most common treatments for intertrigo were topical antifungals (36%), in particular topical imidazoles (25%). The most common combination therapy was a topical imidazole and a medium potency topical corticosteroid (7.2%). Oral or topical antibiotics were prescribed at 15% of visits, and only rarely as a single therapy (3.5% and 2.7%, respectively). Discussion Higher body mass index, incontinence, older age, female sex, and diabetes were associated with an increased risk of intertrigo. Hyperhidrosis and vitamin D deficiency were also associated with intertrigo in this cohort. Obesity, diabetes, and incontinence have been described in prior studies as risk factors in care-dependent populations [ 3 ]. In contrast to findings from a study of nursing home residents in which obesity and sex were not associated with intertrigo, we observed both variables to be relevant in this broader population [ 3 ]. This analysis also adds hyperhidrosis and vitamin D deficiency as potential risk factors. Hyperhidrosis increases skin moisture and friction, which predisposes individuals to barrier disruption [ 6 , 7 , 10 ]. Vitamin D deficiency is associated with impaired immune function and skin barrier integrity, which increases susceptibility to inflammatory skin disease [ 9 , 15 ]. White race and non-Hispanic or non-Latino ethnicity were also predictors of intertrigo. These findings may reflect differences in healthcare access rather than differences in disease burden. White, non-Hispanic individuals have higher utilization of ambulatory care and receive more ambulatory care spending compared to Black and Hispanic individuals [ 2 ]. Black and Hispanic populations are more likely to receive care in emergency or inpatient settings, which may contribute to underdiagnosis of conditions like intertrigo that are typically evaluated and treated in outpatient settings [ 1 ]. The absence of an association with income after adjustment may indicate that access to ambulatory care, rather than socioeconomic status itself, is more closely related to diagnosis frequency. Treatment strategies for intertrigo varied widely. Topical antifungals, particularly imidazoles, were the most commonly prescribed agents, used alone or in combination with topical corticosteroids. The anti-inflammatory properties of imidazole antifungals support their use in intertrigo [ 8 ]. Antibiotics were commonly prescribed, including in the absence of diagnostic codes for infection. This may reflect incomplete coding, a lack of familiarity with intertrigo as a primarily inflammatory condition, or the perception of coexistent/underlying infection. Skin protectants were prescribed infrequently, which may be related to their availability over the counter and thus not captured in the study data. This study has limitations. Diagnostic coding is dependent on clinician documentation and may vary by provider or setting, particularly in distinguishing intertrigo with or without superinfection. Thus, we cannot comment on the appropriateness of specific treatment regimens observed herein or the outcomes of the treatment. Over-the-counter treatments are not captured in this dataset, which is of particular importance when considering many intertrigo treatment options which are available over the counter. Participation in the All of Us program is voluntary, and although the sample is racially and ethnically diverse, it may not be nationally representative. This analysis identified multiple risk factors for intertrigo and variability in its clinical management. The diversity of treatment approaches underscores the lack of standardized guidelines. The development of evidence-based recommendations could support more consistent care for patients with intertrigo. Declarations Funding: The authors received no funding for this study. Data Availability Statement: This study used the All of Us Research Program’s Controlled Tier Dataset version 8, available to authorized users on the Researcher Workbench. Conflict of Interest: Steven Feldman has received research, speaking and/or consulting support from Eli Lilly and Company, GlaxoSmithKline/Stiefel, AbbVie, Janssen, Alovtech, vTv Therapeutics, Bristol-Myers Squibb, Samsung, Pfizer, Boehringer Ingelheim, Amgen, Dermavant, Arcutis, Novartis, Novan, UCB, Helsinn, Sun Pharma, Almirall, Galderma, Leo Pharma, Mylan, Celgene, Ortho Dermatology, Menlo, Merck & Co, Qurient, Forte, Arena, Biocon, Accordant, Argenx, Sanofi, Regeneron, the National Biological Corporation, Caremark, Teladoc, BMS, Ono, Micreos, Eurofins, Informa, UpToDate, Verrica, and the National Psoriasis Foundation. He is founder and part owner of Causa Research and holds stock in Sensal Health. Alan Fleischer is a consultant for Bluefin and Incyte (fees). He is an investigator for Amgen, Avalo, Bayer, Biogen, CellDex, Galderma, Incyte, Leo, and UCB (research support). He is a speaker for Imedic Healthcare Solutions (Hyderabad, India). Brad Woodie and Megan Mukenge have no conflicts of interest to declare. Ethical Approval: Not needed, as this was non-human subject research. Patient Consent: Not applicable, as this was non-human subject research. References Dickman SL, Gaffney A, McGregor A et al (2022) Trends in Health Care Use Among Black and White Persons in the US, 1963–2019. JAMA Netw Open 5(6):e2217383. 10.1001/jamanetworkopen.2022.17383 Dieleman JL, Chen C, Crosby SW et al (2021) US Health Care Spending by Race and Ethnicity, 2002–2016. JAMA 326(7):649–659. 10.1001/jama.2021.9937 Gabriel S, Hahnel E, Blume-Peytavi U, Kottner J (2019) Prevalence and associated factors of intertrigo in aged nursing home residents: a multi-center cross-sectional prevalence study. BMC Geriatr 19(1):1–8. 10.1186/s12877-019-1100-8 Kottner J, Everink I, van Haastregt J, Blume-Peytavi U, Schols J (2020) Prevalence of intertrigo and associated factors: A secondary data analysis of four annual multicentre prevalence studies in the Netherlands. Int J Nurs Stud 104:103437. 10.1016/j.ijnurstu.2019.103437 Mistiaen P, van Halm-Walters M (2010) Prevention and treatment of intertrigo in large skin folds of adults: a systematic review. BMC Nurs 9(1):12. 10.1186/1472-6955-9-12 Nawrocki S, Cha J (2019) The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Etiology and clinical work-up. J Am Acad Dermatol 81(3):657–666. 10.1016/j.jaad.2018.12.071 Romanelli M, Voegeli D, Colboc H et al (2023) The diagnosis, management and prevention of intertrigo in adults: a review. J Wound Care 32(7):411–420. 10.12968/jowc.2023.32.7.411 Rosen T, Schell BJ, Orengo I (1997) Anti-inflammatory activity of antifungal preparations. 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Skin Pharmacol Physiol 31(2):74–86. 10.1159/000485132 Food US, Administration D (2021) Over-the-Counter (OTC) Monograph M016: Skin Protectant Drug Products for Over-the-Counter Human Use .; Accessed March 15, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/omuf/OTCMonograph_M016SkinProtectantDrugProductsforOTCHumanUse09242021.pdf Walling HW (2009) Primary hyperhidrosis increases the risk of cutaneous infection: A case-control study of 387 patients. J Am Acad Dermatol 61(2):242–246. 10.1016/j.jaad.2009.02.038 Wilmer EN, Gustafson CJ, Ahn CS, Davis SA, Feldman SR, Huang WW (2014) Most common dermatologic conditions encountered by dermatologists and nondermatologists. Cutis 94(6):285–292 Zeng Y, Yang S, Liu Y et al (2023) The Role of VD/VDR Signaling Pathway in Autoimmune Skin Diseases. Mini Rev Med Chem 23(6):652–661. 10.2174/1389557523666221124123206 Additional Declarations Competing interest reported. Steven Feldman has received research, speaking and/or consulting support from Eli Lilly and Company, GlaxoSmithKline/Stiefel, AbbVie, Janssen, Alovtech, vTv Therapeutics, Bristol-Myers Squibb, Samsung, Pfizer, Boehringer Ingelheim, Amgen, Dermavant, Arcutis, Novartis, Novan, UCB, Helsinn, Sun Pharma, Almirall, Galderma, Leo Pharma, Mylan, Celgene, Ortho Dermatology, Menlo, Merck & Co, Qurient, Forte, Arena, Biocon, Accordant, Argenx, Sanofi, Regeneron, the National Biological Corporation, Caremark, Teladoc, BMS, Ono, Micreos, Eurofins, Informa, UpToDate, Verrica, and the National Psoriasis Foundation. He is founder and part owner of Causa Research and holds stock in Sensal Health. Alan Fleischer is a consultant for Bluefin and Incyte (fees). He is an investigator for Amgen, Avalo, Bayer, Biogen, CellDex, Galderma, Incyte, Leo, and UCB (research support). He is a speaker for Imedic Healthcare Solutions (Hyderabad, India). Brad Woodie and Megan Mukenge have no conflicts of interest to declare. Supplementary Files Onlineresourcesintertrigo.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 28 Jul, 2025 Reviews received at journal 24 Jul, 2025 Reviewers agreed at journal 19 Jul, 2025 Reviewers invited by journal 17 Jul, 2025 Editor assigned by journal 11 Jun, 2025 Submission checks completed at journal 11 Jun, 2025 First submitted to journal 10 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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02:34:13","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94340,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2intertrigo.png","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/3d03d2cdb80bf257694195dc.png"},{"id":91930602,"identity":"6d4622fa-0549-4320-bbf3-118a546a0d91","added_by":"auto","created_at":"2025-09-23 02:26:28","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":64796,"visible":true,"origin":"","legend":"","description":"","filename":"66ffd618edce42eeaccae99e49b632c41structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/35b7af8e24417a798794e779.xml"},{"id":91930631,"identity":"bb667d44-0758-41c0-af7f-19992771b65d","added_by":"auto","created_at":"2025-09-23 02:26:31","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75709,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/4799abf38b4a1f59c9b76ce7.html"},{"id":91930651,"identity":"ec0c1db6-9f13-46c7-8af3-7be5fd3178a6","added_by":"auto","created_at":"2025-09-23 02:26:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":420485,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePredictors for having at least one diagnosis of intertrigo.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1intertrigo.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/689ede0f32ea930536dbd79a.jpg"},{"id":91930547,"identity":"c1ab9367-1096-4e59-997f-398564dacf4f","added_by":"auto","created_at":"2025-09-23 02:26:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":343896,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMost common treatments and treatment combinations for intertrigo visits. The top 20 are shown out of 168.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2intertrigo.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/170bdd13c916912c17413402.jpg"},{"id":91932251,"identity":"35771e15-7348-4db0-b443-db3b84f44925","added_by":"auto","created_at":"2025-09-23 02:34:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1486233,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/94ec34c2-1592-4a5b-afb7-eb76bba18bfd.pdf"},{"id":91930639,"identity":"4eee65af-8664-4be1-a984-7a754e8ece5a","added_by":"auto","created_at":"2025-09-23 02:26:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18945,"visible":true,"origin":"","legend":"","description":"","filename":"Onlineresourcesintertrigo.docx","url":"https://assets-eu.researchsquare.com/files/rs-6866473/v1/92fe94f6fbcfd0751487c459.docx"}],"financialInterests":"Competing interest reported. Steven Feldman has received research, speaking and/or consulting support from Eli Lilly and Company, GlaxoSmithKline/Stiefel, AbbVie, Janssen, Alovtech, vTv Therapeutics, Bristol-Myers Squibb, Samsung, Pfizer, Boehringer Ingelheim, Amgen, Dermavant, Arcutis, Novartis, Novan, UCB, Helsinn, Sun Pharma, Almirall, Galderma, Leo Pharma, Mylan, Celgene, Ortho Dermatology, Menlo, Merck \u0026 Co, Qurient, Forte, Arena, Biocon, Accordant, Argenx, Sanofi, Regeneron, the National Biological Corporation, Caremark, Teladoc, BMS, Ono, Micreos, Eurofins, Informa, UpToDate, Verrica, and the National Psoriasis Foundation. He is founder and part owner of Causa Research and holds stock in Sensal Health. \n\nAlan Fleischer is a consultant for Bluefin and Incyte (fees). He is an investigator for Amgen, Avalo, Bayer, Biogen, CellDex, Galderma, Incyte, Leo, and UCB (research support). He is a speaker for Imedic Healthcare Solutions (Hyderabad, India). \n\nBrad Woodie and Megan Mukenge have no conflicts of interest to declare.","formattedTitle":"Risk factors and diverse management approaches for intertrigo: Analysis of the “All of Us” research cohort","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntertrigo is a recurrent inflammatory condition commonly affecting skin-to-skin contact areas, including the inframammary, axillary, and inguinal folds. Friction-retained moisture and occlusion contribute to its onset and may increase susceptibility to infection [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While the clinical presentation is well characterized, gaps in understanding its risk factors and treatment strategies remain. Most existing literature has focused on care-dependent populations, such as in hospital and nursing home settings [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Few studies have evaluated intertrigo in broader ambulatory populations, limiting the generalizability of current literature.\u003c/p\u003e\u003cp\u003eTreatment practices also vary. Topical antifungal and corticosteroid therapies are often recommended [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], however comparative studies are limited. Although some recommend adding a low-potency corticosteroid to topical antifungals, evidence supporting the use of topical corticosteroids in intertrigo is limited [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite an array of treatment options, no standardized approach exists, and real-world management guidelines remain poorly defined [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. We aimed to identify risk factors for intertrigo and describe real-world treatment practices using data from a large, diverse sample of U.S. adults enrolled in the National Institute of Health\u0026rsquo;s \u003cem\u003eAll of Us\u003c/em\u003e Research Program.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe analyzed de-identified participant data from the National Institutes of Health\u0026rsquo;s \u003cem\u003eAll of Us\u003c/em\u003e Research Program, controlled tier version 8, which contains electronic health record data for over 390,000 patients. We identified 5,487 participants with a diagnosis of intertrigo (International Classification of Diseases [ICD]-10 code L30.4) with at least one measurement for body mass index (BMI).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCovariates and treatments\u003c/h2\u003e\u003cp\u003eDemographic covariates included patient age, BMI, sex assigned at birth, self-reported race, self-reported ethnicity, and self-reported income. For participants who declined to report their income, the median household income from the participant\u0026rsquo;s postal code was used. Medical history covariates included diabetes mellitus, incontinence, hyperhidrosis, and vitamin D deficiency (Online Resource 1). Diabetes and incontinence have previously been identified as risk factors for intertrigo [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Though hyperhidrosis is directly related to the pathophysiology of intertrigo and is known to increase the risk of cutaneous infections [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], we did not identify extant literature showing the magnitude of the association between hyperhidrosis and intertrigo. Vitamin D deficiency is associated with other inflammatory skin conditions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], but has not been evaluated as a predictor of intertrigo to our knowledge.\u003c/p\u003e\u003cp\u003eTreatments for intertrigo were evaluated using individual visits: topical antifungal drugs (nystatin, imidazoles, terbinafine), topical corticosteroids, oral antibiotics (beta lactams, macrolides, tetracyclines), oral antifungals (fluconazole, terbinafine), topical antibiotics (bacitracin, clindamycin, erythromycin, mupirocin), topical corticosteroid sparing agents (crisaborole, pimecrolimus, roflumilast, ruxolitinib, tacrolimus, tapinarof), and topical skin protectants (as given in the United States Food and Drug Administration Skin Protectants Monograph [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]). Topical corticosteroid potency classifications are shown in Online Resource 2. To identify treatments that were likely prescribed only for intertrigo, visits with a concurrent diagnosis of one of the top five chronic inflammatory skin conditions (acne, atopic dermatitis, psoriasis, rosacea, seborrheic dermatitis, as determined by Wilmer et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]) or a skin infection (tinea, cellulitis, abscess, candidiasis, impetigo, pyoderma, erythrasma, or other local infections) were excluded.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were calculated for the characteristics of patients with intertrigo and controls (patients with no history of intertrigo). Independent two-sample T-tests or \u0026#120568;\u003csup\u003e2\u003c/sup\u003e tests compared characteristics: age, BMI, sex, race, ethnicity, patient-reported income, history of incontinence, diabetes mellitus, hyperhidrosis, and vitamin D deficiency. To determine the strength of these risk factors, multivariable logistic regression was performed with the above independent variables and the outcome as having at least one diagnosis of intertrigo. Frequencies and percentages were calculated for treatments prescribed at a visit for intertrigo. Significance was set at two-tailed p\u0026thinsp;\u0026lt;\u0026thinsp;.05, and all analysis was performed in the SAS Studio environment within the All of Us Researcher Workbench.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe included 5,487 participants with at least one diagnosis of intertrigo out of 370,639 eligible participants (1.5%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Higher BMI, older age, female or other sex, white race, non-Hispanic or non-Latino ethnicity, incontinence, hyperhidrosis, diabetes, and vitamin D deficiency predicted higher odds of having intertrigo in the multivariable logistic regression (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The greatest risk factors for intertrigo were class III obesity (odds ratio 5.55 [95% confidence interval 4.96\u0026ndash;6.22]), incontinence (5.24 [4.89\u0026ndash;5.60]), and class II obesity (3.73 [3.33\u0026ndash;4.19]). Vitamin D deficiency (2.14 [2.02\u0026ndash;2.27]) was a greater risk factor than hyperhidrosis (1.92 [1.75\u0026ndash;2.12]) or diabetes mellitus (1.52 [1.43\u0026ndash;1.62]). Income was lower for patients with intertrigo compared with controls in \u0026#120568;\u003csup\u003e2\u003c/sup\u003e tests, but there was no significant association in the multivariable model. Tinea was the most common comorbid skin infection at 3.4%, and other infectious diagnoses were only present in \u0026lt;\u0026thinsp;1% of visits (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of patients with a history of intertrigo, patients without a history of intertrigo, and controls matched on age, sex assigned at birth, race, ethnicity, income, and additional risk factors for intertrigo (BMI, diabetes mellitus, incontinence, and hyperhidrosis).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable/Subcategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntertrigo\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;5,487 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo Intertrigo Controls n\u0026thinsp;=\u0026thinsp;365,152 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP‑value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63 (62, 63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (54, 54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (35, 35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (30, 30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c2\"\u003e\u003cp\u003e1.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.97%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther race\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic or Latino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot Hispanic or Latino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than \u003cspan\u003e$\u003c/span\u003e25k\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25\u0026ndash;50k\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50\u0026ndash;100k\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e100k\u0026ndash;200k\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOver \u003cspan\u003e$\u003c/span\u003e200k\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConditions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny incontinence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyperhidrosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVitamin D deficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e P-values were obtained from two-sample independent T-tests for continuous variables or \u0026#120568;\u003csup\u003e2\u003c/sup\u003e tests for categorical variables.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Race and ethnicity were obtained from self-report and were included in this analysis as a goal of \u003cem\u003eAll of Us\u003c/em\u003e to collect and report data from a diverse group of participants. \u0026ldquo;Other\u0026rdquo; races included American Indian or Alaskan Native, Middle Eastern or North African, Native Hawaiian or Other Pacific Islander, race not specified, and more than one population.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInfectious comorbidities of intertrigo.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (%) of intertrigo visits (n\u0026thinsp;=\u0026thinsp;14,768) with given infectious diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of Visits for diagnosis in n\u0026thinsp;=\u0026thinsp;5,487 patients with intertrigo\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTinea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e508 (3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12,579\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCellulitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e127 (0.86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18,479\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbscess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e93 (0.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,437\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCandidiasis of skin and nails\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e93 (0.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,204\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther local infections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e53 (0.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,077\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImpetigo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34 (0.23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e576\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePyoderma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (0.08%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e264\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eErythrasma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (0.03%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTreatment frequencies at intertrigo visits (n\u0026thinsp;=\u0026thinsp;14,173). Visits with comorbid infectious diagnoses or a chronic skin condition were excluded.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency (Percent)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSubcategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFrequency (Percent)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eTopical Antifungals\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e5093 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTopical imidazoles\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3561 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTopical nystatin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1875 (13%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTopical terbinafine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76 (0.53%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTopical Corticosteroids\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e3499 (24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedium potency (Class III, IV, V)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2049 (14%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow potency (Class VI, VII)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1623 (11%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUltrahigh potency (Class I)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e363 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh potency (Class II)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e358 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eOral Antibiotics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e1133 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral beta lactams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e853 (6.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral tetracyclines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e270 (1.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral macrolides\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e146 (1.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTopical Antibiotics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e1028 (7.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClindamycin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e454 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMupirocin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e444 (3.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBacitracin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e193 (1.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eErythromycin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eOral Antifungals\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e752 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral fluconazole\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e709 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral terbinafine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTopical Corticosteroid Sparing Agents\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e647 (4.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTacrolimus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e548 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePimecrolimus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e277 (1.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCrisaborole\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRuxolitinib\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSkin Protectants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e377 (2.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Imidazoles appearing in the dataset: clotrimazole, econazole, ketoconazole, miconazole, oxiconazole\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e To protect patient privacy, values under 20 are hidden per guidelines from the \u003cem\u003eAll of Us\u003c/em\u003e research program\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e No visits for roflumilast or tapinarof\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe 5,487 patients with at least one diagnosis of intertrigo had 14,768 visits for the condition. Visits also having a diagnostic code for a skin infection or chronic inflammatory skin condition were excluded, yielding a final sample of 14,173 visits. The most common treatments for intertrigo were topical antifungals (36%), in particular topical imidazoles (25%). The most common combination therapy was a topical imidazole and a medium potency topical corticosteroid (7.2%). Oral or topical antibiotics were prescribed at 15% of visits, and only rarely as a single therapy (3.5% and 2.7%, respectively).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHigher body mass index, incontinence, older age, female sex, and diabetes were associated with an increased risk of intertrigo. Hyperhidrosis and vitamin D deficiency were also associated with intertrigo in this cohort. Obesity, diabetes, and incontinence have been described in prior studies as risk factors in care-dependent populations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In contrast to findings from a study of nursing home residents in which obesity and sex were not associated with intertrigo, we observed both variables to be relevant in this broader population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This analysis also adds hyperhidrosis and vitamin D deficiency as potential risk factors. Hyperhidrosis increases skin moisture and friction, which predisposes individuals to barrier disruption [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Vitamin D deficiency is associated with impaired immune function and skin barrier integrity, which increases susceptibility to inflammatory skin disease [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhite race and non-Hispanic or non-Latino ethnicity were also predictors of intertrigo. These findings may reflect differences in healthcare access rather than differences in disease burden. White, non-Hispanic individuals have higher utilization of ambulatory care and receive more ambulatory care spending compared to Black and Hispanic individuals [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Black and Hispanic populations are more likely to receive care in emergency or inpatient settings, which may contribute to underdiagnosis of conditions like intertrigo that are typically evaluated and treated in outpatient settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The absence of an association with income after adjustment may indicate that access to ambulatory care, rather than socioeconomic status itself, is more closely related to diagnosis frequency.\u003c/p\u003e\u003cp\u003eTreatment strategies for intertrigo varied widely. Topical antifungals, particularly imidazoles, were the most commonly prescribed agents, used alone or in combination with topical corticosteroids. The anti-inflammatory properties of imidazole antifungals support their use in intertrigo [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Antibiotics were commonly prescribed, including in the absence of diagnostic codes for infection. This may reflect incomplete coding, a lack of familiarity with intertrigo as a primarily inflammatory condition, or the perception of coexistent/underlying infection. Skin protectants were prescribed infrequently, which may be related to their availability over the counter and thus not captured in the study data.\u003c/p\u003e\u003cp\u003eThis study has limitations. Diagnostic coding is dependent on clinician documentation and may vary by provider or setting, particularly in distinguishing intertrigo with or without superinfection. Thus, we cannot comment on the appropriateness of specific treatment regimens observed herein or the outcomes of the treatment. Over-the-counter treatments are not captured in this dataset, which is of particular importance when considering many intertrigo treatment options which are available over the counter. Participation in the \u003cem\u003eAll of Us\u003c/em\u003e program is voluntary, and although the sample is racially and ethnically diverse, it may not be nationally representative.\u003c/p\u003e\u003cp\u003eThis analysis identified multiple risk factors for intertrigo and variability in its clinical management. The diversity of treatment approaches underscores the lack of standardized guidelines. The development of evidence-based recommendations could support more consistent care for patients with intertrigo.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no funding for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThis study used the\u003cem\u003e\u0026nbsp;All of Us\u003c/em\u003e Research Program’s Controlled Tier Dataset version 8, available to authorized users on the Researcher Workbench.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSteven Feldman has received research, speaking and/or consulting support from Eli Lilly and Company, GlaxoSmithKline/Stiefel, AbbVie, Janssen, Alovtech, vTv Therapeutics, Bristol-Myers Squibb, Samsung, Pfizer, Boehringer Ingelheim, Amgen, Dermavant, Arcutis, Novartis, Novan, UCB, Helsinn, Sun Pharma, Almirall, Galderma, Leo Pharma, Mylan, Celgene, Ortho Dermatology, Menlo, Merck \u0026amp; Co, Qurient, Forte, Arena, Biocon, Accordant, Argenx, Sanofi, Regeneron, the National Biological Corporation, Caremark, Teladoc, BMS, Ono, Micreos, Eurofins, Informa, UpToDate, Verrica, and the National Psoriasis Foundation. He is founder and part owner of Causa Research and holds stock in Sensal Health. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlan Fleischer is a consultant for Bluefin and Incyte (fees). He is an investigator for Amgen, Avalo, Bayer, Biogen, CellDex, Galderma, Incyte, Leo, and UCB (research support). He is a speaker for Imedic Healthcare Solutions (Hyderabad, India).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrad Woodie and Megan Mukenge have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eNot needed, as this was non-human subject research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent:\u0026nbsp;\u003c/strong\u003eNot applicable, as this was non-human subject research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDickman SL, Gaffney A, McGregor A et al (2022) Trends in Health Care Use Among Black and White Persons in the US, 1963\u0026ndash;2019. 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Mini Rev Med Chem 23(6):652\u0026ndash;661. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2174/1389557523666221124123206\u003c/span\u003e\u003cspan address=\"10.2174/1389557523666221124123206\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"antifungal agents, corticosteroids, topical, antibiotics, body mass index, obesity, diabetes mellitus, incontinence, hyperhidrosis, vitamin D deficiency, socioeconomic factors, health care disparities, electronic health records","lastPublishedDoi":"10.21203/rs.3.rs-6866473/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6866473/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntertrigo is an inflammatory dermatosis of skin folds whose risk factors and real-world management are incompletely defined. We analyzed electronic health records for 370,639 adults in the National Institutes of Health \u003cem\u003eAll of Us \u003c/em\u003eResearch Program controlled tier version 8 and identified 5,487 participants with at least one diagnostic code for intertrigo and a recorded body-mass index (BMI). Demographic, socioeconomic, and clinical covariates were compared with 365,152 controls using 𝛸\u003csup\u003e2\u003c/sup\u003e tests and multivariable logistic regression. Treatment patterns were assessed at the visit level; encounters containing concurrent codes for common chronic inflammatory dermatoses or cutaneous infections were excluded to identify prescriptions intended for non-infected intertrigo. Higher BMI, older age, female or other sex, White race, non-Hispanic or Latino ethnicity, diabetes mellitus, incontinence, hyperhidrosis and vitamin D deficiency were all risk factors for intertrigo. A total of 14,173 visits for intertrigo were analyzed to identify treatment utilization. Topical antifungals were prescribed in 36% of visits, chiefly imidazoles (25%), and the most common combination was an imidazole plus a medium-potency corticosteroid (7.2%). Oral or topical antibiotics appeared in 15% of visits, usually as adjunctive rather than sole therapies, and skin protectants were rarely prescribed. These findings expand the spectrum of risk factors to include hyperhidrosis and vitamin D deficiency and reveal heterogeneity in real-world treatment, identifying a potential need for evidence-based intertrigo management guidelines.\u003c/p\u003e","manuscriptTitle":"Risk factors and diverse management approaches for intertrigo: Analysis of the “All of Us” research cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 02:25:09","doi":"10.21203/rs.3.rs-6866473/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-28T14:27:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T19:36:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125476849258718794370812611747079447286","date":"2025-07-19T19:32:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-17T18:56:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T08:26:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T08:22:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2025-06-10T22:48:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c2229213-431c-4953-b134-a569b6816a1b","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T17:24:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 02:25:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6866473","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6866473","identity":"rs-6866473","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}