A 45-year-old morbidly obese woman with a history of asthma and type 2 diabetes mellitus presents to her primary care physician for advice on weight loss. She thinks that her husband is having sex with other women because they have not had sex over the past year. She feels that her co-workers also disrespect her for her weight and constant sweat stains around her armpits and chest. She has noticed that the sweat stains get itchy and induce a burning sensation unless she showers or changes her shirt. She has been compliant with her medications, which include albuterol, metformin, glyburide, and atorvastatin. Her temperature is 98.6°F (37°C), blood pressure is 128/85 mmHg, pulse is 91/min, and respirations are 11/min. On physical exam, the patient has a flat affect, with moist oral mucosa and nasal polyps. She denies sinus tenderness. Her neck is thick with a posterior cervical fat pad. During cardiac auscultation, the finding in Figure A is noted below her breasts. What is the most appropriate next step in management for this finding?
Topical nystatin
Topical clobetasol
Prednisone
Fluconazole
Topical nystatin
This patient has a rash consistent with candidal intertrigo given the location and history of a damp, pruritic rash. The most appropriate next step in management is topical nystatin powder.

Intertrigo is caused by the Candida species and is characterized by pruritic, painful, and erythematous superficial patches surrounded by satellite lesions. They are commonly seen in intertriginous areas such as the breasts, groin, axilla, or abdominal pannus. Obesity and diabetes are significant risk factors. Initial management involves maintaining skin dryness along with medical treatment using topical nystatin, clotrimazole, or miconazole. Persistent lesions may require oral antifungal treatment.

Nobles and Miller review the evidence regarding the diagnosis and treatment of intertrigo. They discuss how these lesions often become infected with Candida. They recommend the use of antifungal medications.

Figure/Illustration A shows candidal intertrigo in the breast fold. Note the satellite lesions that surround the erythematous patch.

Incorrect Answers:
Answer A: Fluconazole is indicated for moderate to severe disease or if the rash is refractory to topical antifungals. Topical antifungal agents should be used before progressing to oral medications.

Answer B: Prednisone is not indicated and would potentially worsen the rash through immunosuppression and exacerbation of the patient's diabetes mellitus.

Answer C: Topical clobetasol is a high-potency corticosteroid. This would not be used because it can promote infection and lead to skin atrophy. Low-potency corticosteroids such as triamcinolone or hydrocortisone can be used as adjuncts for symptom control only.

Answer D: Topical imiquimod is indicated for autoimmune skin diseases such as alopecia areata not for candidal intertrigo. This disease would present with segmental regions of hair loss

Bullet Summary:
The treatment of candidal intertrigo involves topical antifungals including nystatin, clotrimazole, and miconazole.