Family Nurse Practitioner (FNP) Board Review

The Anatomy of a Question

Question

A 52-year-old woman presents to her primary care provider’s office with complaints of a pruritic rash on her chest. She has a past medical history of morbid obesity, type 2 diabetes mellitus, and hypertension. On exam, there is a sharply demarcated area of erythema underneath both breasts. Direct microscopy of skin scrapings reveals oval budding yeast and pseudohyphae. Which of the following is the most appropriate management?

Answer choice options

A. Oral fluconazole
B. Oral prednisone
C. Topical econazole
D. Topical mupirocin

The incorrect options (distractors) are not totally wrong. These options can be diagramed as follows:

Most Correct

Least Correct

C.

Topical econazole Topical antifungals are first-line treatment
A.

Oral fluconazole Indicated in severe, recalcitrant infections and has increased side effects.
D.

Topical mupirocin Used to treat impetigo, not intertrigo.
B.

Oral prednisone Increases the risk for candidal infections.

The Anatomy of an Explanation

Background Most Commons Risk Factors Diagnostic Pathophysiology Anatomy Clinical Findings Treatment Prevention

This woman, with limited areas of candidal intertrigo, is best treated with topical econazole. While bacteria can cause intertrigo, the most common etiology is a superficial infection of Candida species. Risk factors for candidal intertrigo include obesity, tight-fitting clothing, hyperhidrosis, urinary or fecal incontinence, diabetes mellitus, topical or systemic corticosteroid use, antibiotic use, human immunodeficiency virus (HIV) infection, and chemotherapy. The diagnosis of intertrigo is mainly clinical, but potassium hydroxide (KOH) examination or direct microscopy can be used to confirm the diagnosis. Intertrigo is an inflammatory condition of two opposed skin surfaces or folds. Intertrigo can be infectious or noninfectious. The inflammatory process is induced by heat, friction, moisture, and lack of air circulation. The resulting skin breakdown creates a warm, moist environment that is ideal for overgrowth of microorganisms. Candidal intertrigo is typically located in inguinal folds, axillae, scrotum, inframammary folds, beneath a pannus, or intergluteal folds. Patients with recurrent or severe candidal infections without an obvious cause should undergo further evaluation for underlying or undiagnosed endocrinopathy, malignancy, or HIV infection. Treatment involves antifungal medication, skin care, and addressing predisposing risk factors. Topical antifungal medication is effective and well tolerated in most patients with mild to moderate infections. Oral agents may be required when topical therapy has failed or if there are multiple intertriginous areas involved. Skin care with drying agents is important for preventing recurrences of intertrigo. Commonly used drying agents are antifungal powders, like nystatin. Weight loss, loose clothing, and absorbent hygiene products may be useful preventative measures.

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