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 in Vaginitis, Cervicitis, and Pelvic Inflammatory Disease (PID): Candidal Vaginitis.

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 Nail Disorders: 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 Vaginitis, Cervicitis, and Pelvic Inflammatory Disease (PID): 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 Nail Disorders: 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).

Perlèche 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.

Candidiasis (Diaper Rash)

Candidiasis (Nail Infection)

Candidiasis (Oropharyngeal)

Candidiasis (Chronic Mucocutaneous)

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 Table 1: Fungal Skin Infections: 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.

Table 1
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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. 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.

Last full review/revision March 2013 by Denise M Aaron, MD