Refractory Intertrigo in the Right Inguinal Crease: Challenge

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A 70-year-old man was seen for a refractory rash occurring in his right groin for 3 years. His medical history included acne keratosis and basal cell carcinoma on his trunk. He had no other systemic disease and was not taking any medications. There were no known environmental or medication allergies.
Skin examination was unremarkable except that he was noted to have a 4 × 6-cm right groin erythematous, focally eroded oozing plaque without scale, which was covered with purulent material (Fig. 1). There was no involvement of the opposite groin fold.
Laboratory tests, including complete blood count, renal, thyroid and liver function tests, were normal. Fungal and bacterial cultures were obtained from the rash. Initial impression was likely intertrigo with candida, or tinea cruris.
He was started on econazole 1% cream, miconazole powder, and Burrow's solution soaks. Initial culture grew Trichophyton rubrum and Candida (Torulopsis) glabrata. He was advised to keep the groin area dry. After a month, the rash had improved but then recurred. He then was initiated on oral fluconazole 150 mg daily for 1 month along with topical aluminum chloride 20% solution to help control moisture. His rash did not improve, and repeat culture grew Enterococcus and Escherichia coli. He was then started on oral cephalexin. Topical Polysporin was later added, without much help.
Despite multiple treatments over many months, the rash persisted. A shave biopsy was then performed of this rash.
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