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Candidiasis (Mucocutaneous)

by Denise M Aaron, MD

Candidiasis (moniliasis) is skin infection with Candida sp, most commonly Candida albicans. Infections can occur anywhere and are most common in skinfolds, digital web spaces, genitals, cuticles, and oral mucosa. Symptoms and signs vary by site. Diagnosis is by clinical appearance and potassium hydroxide wet mount of skin scrapings. Treatment is with drying agents and antifungals.

Most candidal infections are of the skin and mucous membranes, but invasive candidiasis is common among immunosuppressed patients and can be life threatening. Systemic candidiasis is discussed in Fungi. Vulvovaginal candidiasis is discussed elsewhere.

Etiology

Candida is a group of about 150 yeast species. C. albicans is responsible for about 70 to 80% of all candidal infections. Other significant species include C. glabrata, C. tropicalis, C. krusei, and C. dubliniensis.

Candida is a ubiquitous yeast that resides harmlessly on skin and mucous membranes until dampness, heat, and impaired local and systemic defenses provide a fertile environment for it to grow. Risk factors for candidiasis include

  • Hot weather

  • Restrictive clothing

  • Poor hygiene

  • Infrequent diaper or undergarment changes in children and elderly patients

  • Altered flora resulting from antibiotic therapy

  • Inflammatory diseases (eg, psoriasis) that occur in skinfolds

  • Immunosuppression resulting from corticosteroids and immunosuppressive drugs, pregnancy, diabetes, other endocrinopathies (eg, Cushing disease, hypoadrenalism, hypothyroidism), blood dyscrasias, or T-cell defects

Candidiasis occurs most commonly in intertriginous areas such as the axillae, groin, and gluteal folds (eg, diaper rash), in digital web spaces, on the glans penis, and beneath the breasts. Vulvovaginal candidiasis is common among women. Candidal nail infections and paronychia may develop after improperly done manicures and in kitchen workers and others whose hands are continually exposed to water (see Onychomycosis). In obese people, candidal infections may occur beneath the pannus (abdominal fold). Oropharyngeal candidiasis is a common sign of local or systemic immunosuppression.

Chronic mucocutaneous candidiasis typically affects the nails, skin, and oropharynx. Patients have cutaneous anergy to Candida, absent proliferative responses to Candida antigen (but normal proliferative responses to mitogens), and an intact antibody response to Candida and other antigens. Chronic mucocutaneous candidiasis may occur as an autosomal recessive illness associated with hypoparathyroidism and Addison disease ( Candida-endocrinopathy syndrome).

Symptoms and Signs

Intertriginous infections manifest as pruritic, well-demarcated, erythematous patches of varying size and shape; erythema may be difficult to detect in darker-skinned patients. Primary patches may have adjacent satellite papules and pustules. Perianal candidiasis produces white maceration and pruritus ani. Vulvovaginal candidiasis causes pruritus and discharge (see Candidal Vaginitis).

Candidal infection is a frequent cause of chronic paronychia, which manifests as painful red periungual swelling. Subungual infections are characterized by distal separation of one or several fingernails (onycholysis), with white or yellow discoloration of the subungual area (see Acute Paronychia).

Oropharyngeal candidiasis causes white plaques on oral mucous membranes that may bleed when scraped (see Symptoms of Dental and Oral Disorders:Interpretation of findings).

Perl├Ęche is candidiasis at the corners of the mouth, which causes cracks and tiny fissures. It may stem from chronic lip licking, thumb sucking, ill-fitting dentures, or other conditions that make the corners of the mouth moist enough that yeast can grow.

Chronic mucocutaneous candidiasis is characterized by red, pustular, crusted, and thickened plaques resembling psoriasis, especially on the nose and forehead, and is invariably associated with chronic oral candidiasis.

Diagnosis

  • Clinical appearance

  • Potassium hydroxide wet mounts

Diagnosis is based on clinical appearance and identification of yeast and pseudohyphae in potassium hydroxide wet mounts of scrapings from a lesion. Positive culture alone is usually meaningless because Candida is omnipresent.

Treatment

  • Sometimes drying agents

  • Topical or oral antifungals

Intertriginous infection is treated with drying agents as needed (eg, Burow solution compresses applied for 15 to 20 min for oozing lesions) and topical antifungals (see Options for Treatment of Superficial Fungal Infections*). Powdered formulations are also helpful (eg, miconazole powder bid for 2 to 3 wk). Fluconazole 150 mg po once/wk for 2 to 4 wk can be used for extensive intertriginous candidiasis; topical antifungal agents may be used at the same time.

Options for Treatment of Superficial Fungal Infections*

Drugs

Formulations

Uses

Allylamines

Amorolfine

5% solution

Tinea unguium

Naftifine

1% cream or gel

Dermatophytoses, skin candidiasis

Terbinafine

Topical: 1% cream or solution

Dermatophytoses

Oral: 250-mg tablet

Benzylamine

Butenafine

1% cream

Dermatophytoses

Imidazoles

Butoconazole

2% cream

Vulvovaginal candidiasis

Clotrimazole

Topical: 1% cream, lotion, or solution; 100-, 200-, and 500-mg vaginal suppository tablets

Dermatophytoses, candidiasis (oropharyngeal, skin, vulvovaginal)

Oral: 10-mg lozenges

Econazole

1% cream

Dermatophytoses, skin candidiasis, tinea versicolor

Fluconazole

50 and 200 mg/5 mL solution; 50-, 100-, 150-, and 200-mg tablets

Candidiasis (vulvovaginal, skin, oropharyngeal)

Itraconazole

100-mg capsules, 10 mg/mL solution

Tinea unguium, other onychomycoses

Ketoconazole

2% cream, 1 to 2% shampoo, 200-mg tablet

Dermatophytoses, skin candidiasis

Miconazole

1 to 2% liquid (aerosol), 2% powder (aerosol), 1 to 2% cream and lotion, 1% solution, 2% powder or tincture, 100- or 200-mg vaginal suppositories

Dermatophytoses, candidiasis (skin, vulvovaginal)

Oxiconazole

1% cream or lotion

Dermatophytoses, tinea versicolor

Sulconazole

1% cream or solution

Dermatophytoses, tinea versicolor

Terconazole

0.4% and 0.8% cream, 80-mg suppositories

Vulvovaginal candidiasis

Tioconazole

6.5% ointment

Vulvovaginal candidiasis

Polyene

Nystatin

Topical: 100,000 U/g cream, ointment, powder, or vaginal tablet

Candidiasis (oropharyngeal, skin)

Oral: 100,000 U/mL suspension, 500,000-U tablets

Miscellaneous

Carbolfuchsin

Solution

Chronic dermatophytoses, intertrigo

Ciclopirox

0.77% gel, 8% lacquer solution

Dermatophytoses, candidiasis, tinea versicolor, onychomycosis

Clioquinol

3% cream

Dermatophytoses

Gentian violet

1 or 2% solution

Dermatophytoses, especially tinea pedis; sometimes candidiasis

Griseofulvin

125-, 165-, 250-, 330-, and 500-mg tablets

Dermatophytoses

Tolnaftate

1% liquid, powder, liquid or aerosol spray, cream, or solution

Dermatophytoses, tinea versicolor

Zinc

Undecylenate/undecylenate acid

25% solution, 10% tincture

Superficial dermatophyte infections (eg, tinea pedis)

*Advantages of one topical drug over another for most infections are not clear. For skin infections, allylamines have good activity against dermatophytes but weaker activity against Candida; imidazoles have better activity against both dermatophytes and Candida. Adverse effects are rare, but all topical antifungals can cause skin irritation, burning, and contact dermatitis. Drug doses may vary by indication.

Oral antifungals can cause hepatitis and neutropenia. Periodic laboratory monitoring of hepatic function and of CBC is recommended when oral antifungals (eg, itraconazole, terbinafine) are given for > 1 mo.

Drug interactions may occur. For example, itraconazole may interact with lovastatin, midazolam, simvastatin, and triazolam. Cisapride, dofetilide, pimozide, or quinidine should not be used with itraconazole; taking these drugs with itraconazole may cause cardiac arrhythmias.

Candidal diaper rash is treated with more frequent changes of diapers, use of super- or ultra-absorbent disposable diapers, and an imidazole cream bid. Oral nystatin is an option for infants with coexisting oropharyngeal candidiasis; 1 mL of suspension (100,000 units/mL) is placed in each buccal pouch qid.

Candidal paronychia is treated by protecting the area from wetness and giving topical or oral antifungals. These infections are often resistant to treatment.

Oral candidiasis can be treated by dissolving 1 clotrimazole 10-mg troche in the mouth 4 to 5 times/day for 14 days. Another option is nystatin oral suspension (4 to 6 mL of a 100,000 unit/mL solution) held in the mouth for as long as possible and then swallowed or expectorated 3 to 4 times/day, continuing for 7 to 14 days after symptoms and signs have resolved. A systemic antifungal may also be used (eg, fluconazole 200 mg po on the first day, then 100 mg po once/day for 2 to 3 wk thereafter).

Chronic mucocutaneous candidiasis requires long-term oral antifungal treatment with ketoconazole 400 mg once/day or itraconazole 200 mg once/day.

Key Points

  • Candida are normal skin flora that can become infective under certain conditions (eg, excessive moisture, alteration of normal flora, host immunosuppression).

  • Consider candidiasis with erythematous, scaling, pruritic patches in intertriginous areas and with lesions in the mucous membranes, around the nails, or at the corners of the mouth.

  • If clinical appearance is not diagnostic, try to identify yeast and pseudohyphae in potassium hydroxide wet mounts of scrapings from a lesion.

  • Treat most intertriginous candidiasis with a drying agent and a topical antifungal.

  • Treat most diaper rash with frequent changes of absorbent disposable diapers and an imidazole cream.

  • Treat oral candidiasis with clotrimazole troches, nystatin oral suspension, or an oral antifungal.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ZOCOR
  • TIKOSYN
  • VAGISTAT-1
  • EXELDERM
  • NYSTOP
  • NIZORAL
  • No US brand name
  • PROPULSID
  • MYCELEX
  • GRIFULVIN V
  • LOPROX, PENLAC
  • HALCION
  • ECOZA
  • TERAZOL 3
  • MONISTAT 3
  • DIFLUCAN
  • ORAP
  • MENTAX
  • ALTOPREV
  • SPORANOX
  • OXISTAT
  • FEMSTAT 3
  • LAMISIL

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