Candidiasis


Key Points

  • Candidiasis typically affects mucosal sites and moist and/or occluded areas of skin: groin, axilla, inframammary, infra-abdominal pannus, glans penis (in uncircumcised males), and orogenital mucosal sites.
  • Predisposing factors include obesity, diabetes, antibiotic or corticosteroid treatments, immunosuppression, removable prostheses, and chronic or frequent exposure to moisture including saliva, fecal and urinary incontinence.
  • Candidal superinfection may complicate preexisting cutaneous diseases, as abnormal skin may predispose to candidal overgrowth. Failure of standard anticandidal treatment to fully clear symptoms should raise suspicion for an underlying or coexisting disease.

Introduction

Candida albicans is a normal commensal organism of the gastrointestinal and genitourinary tracts. It causes cutaneous disease in occluded, moist areas of skin and mucosa: the groin (inguinal folds, vulva, or perianal areas), axilla, inframammary areas, the glans penis (in uncircumcised males), and orogenital mucosal sites. Predisposing factors include poorly controlled diabetes, obesity, fecal and urinary incontinence, antibiotic treatment that alter normal flora, corticosteroid treatments, removable prostheses, and immunosuppression (especially due to HIV or an underlying immunodeficiency). The interdigital webspaces of the hands and feet and the proximal nail folds may also be involved, causing erosions in the interdigital web spaces (erosio interdigitalis blastomycetica) or paronychia, respectively.

The presence of widespread candidiasis, involving mucosal and skin sites (especially the nails and nail folds), may suggest an immunodeficiency disorder, such as chronic mucocutaneous candidiasis.

The differential diagnosis of candidiasis, especially in the groin area, includes important considerations such as seborrheic dermatitis, tinea (superficial dermatophyte infection), inverse psoriasis, inverse pityriasis rosea, allergic or irritant contact dermatitis, deficiency dermatitis, Hailey-Hailey or Darier’s disease, axillary granular parakeratosis, Kawasaki syndrome, as well as cutaneous malignancies such as squamous cell carcinoma, extramammary Paget’s disease, or histiocytosis. It is important to note that some of these conditions may predispose to candidal superinfection; thus failure of standard anticandidal treatment to fully clear symptoms should raise suspicion for an underlying or coexisting disease.

Skin or mucosal maceration, erosions, or fissuring with bright erythema and satellite pustulosis are characteristic features of candidal skin and mucosal infections. These typically occur in the mucosa or at sites of skin-to-skin contact or occlusion. Although the diagnosis is largely clinical, several tests may confirm the diagnosis. A KOH preparation of scale or pustule fluid contents will reveal pseudohyphae and possibly also yeast forms; oral candidiasis is caused only by the hyphal form of C. albicans. Standard bacterial cultures (with charcoal-based media) or specialized fungal cultures containing Sabouraud agar will also help to confirm the diagnosis of infection by common forms of candida, such as Candida albicans.

Initial Evaluation

Candidiasis

Intertriginous

Oral

Paronychia

Differential diagnosis

Inverse pityriasis rosea

Deficiency dermatitis (such as zinc deficiency, aka acrodermatitis enteropathica)

Allergic or irritant contact dermatitis

Inverse psoriasis

Tinea cruris

Extramammary Paget’s disease

Hailey-Hailey disease

Seborrheic dermatitis

Bowen’s disease (squamous cell carcinoma)

Treatment

First-line therapy: The first-line therapy should be specified for the affected anatomic site.

Skin

Initial therapy

  • If the skin is macerated (e.g., moist, weeping), instruct the patient to soak in (or make an applied compress of) dilute Burow’s solution 1: 40 b.i.d. for 15 minutes daily throughout the treatment course.
  • Prescribe nystatin ointment applied t.i.d. or an imidazole cream (such as clotrimazole 1% or econazole 1% creams) applied b.i.d. to the affected area. If erosive lesions are present the cream may cause burning.
  • Instruct the patient to dry the moist areas by exposing them to the air, and to keep stool and urine away from the skin. Patients should be educated to towel off completely after bathing, and may use a hairdryer (set on cool air setting) to fully dry off affected areas of skin, especially if they are located at sites where there is skin-to-skin contact (e.g., under the breasts or inguinal folds).
  • When possible, eliminate all potential irritants or sources of maceration, such as urinary or fecal incontinence.
  • Look for associated yeast vaginitis in cases of vulvar candidiasis in women.
  • Suspect GI tract overgrowth in cases of perianal candidiasis. Add oral nystatin 500,000 U q.i.d. for one week.
  • Evaluate the patient for diabetes mellitus.

Subsequent therapy

  • Nystatin ointment or zinc oxide paste applied over the topical imidazole may enhance therapy by providing a protective barrier from sweat, urine, and stool.
  • Adding hydrocortisone 1% ointment to the anticandidal agent will speed healing and reduce symptoms more rapidly.
  • Men with balanitis often have partners with candidal vaginitis; they also need treatment. In refractory cases circumcision may help, but is rarely necessary.
  • Although cosmetically unattractive, gentian violet solution b.i.d. for three days is drying and has good anticandidal activity.
  • For severe unresponsive cases, prescribe oral ketoconazole 200 mg/day or fluconazole 100mg/ day for 1 to 2 weeks.
  • Preventive therapy includes keeping the area dry by wearing loose-fitting underwear and using topical drying powders (e.g., Zeasorb).

Mucosal sites

Initial therapy

  • If the skin is macerated (moist, weeping), instruct the patient to soak in (or make an applied compress) dilute Burow’s solution 1:40 b.i.d. for 15 minutes daily throughout the treatment course.
  • Prescribe nystatin ointment applied t.i.d. or an imidazole cream (such as clotrimazole 1%, econazole 1%) applied b.i.d. to the affected area. If erosive lesions are present the cream may cause burning.
  • For vulvar candidiasis with vaginal involvement, give a single dose of oral fluconazole 150 mg. For severe cases, or in the case of oral mucosal candidiasis, give fluconazole 100 mg/day or oral nystatin 500,000 U q.i.d. for one week. Clotrimazole troches may be helpful following the treatment course to prevent recurrent oral disease.
  • Evaluate the patient for diabetes mellitus.

Nail folds

Initial therapy

  • If the skin is macerated (moist, weeping), instruct the patient to soak in (or make an applied compress of) dilute Burow’s solution 1:40 b.i.d. for 15 minutes daily throughout the treatment course.
  • Prescribe nystatin ointment applied t.i.d. or an imidazole cream (such as clotrimazole 1%, econazole 1%) applied b.i.d. to the affected area. If erosive lesions are present the cream may cause burning.
  • If highly inflammatory lesions are present (e.g., highly edematous, erythematous, or blistering), consider mixing topical anticandidal treatment in equal parts with a topical corticosteroid such as hydrocortisone 1% ointment and apply b.i.d. For severe cases, give fluconazole 100 mg/day or oral ketoconazole 200 mg/day for one to two weeks.
  • Evaluate the patient for diabetes mellitus.

Pitfalls

  • Do a KOH preparation prior to therapy to establish the diagnosis.
  • Secondary bacterial infection may require systemic antibiotics.
  • Avoid applying gels or solutions to inflamed skin, as they will cause stinging or irritation.
  • Intertrigo is a distinct inflammatory eruption affecting intertrigious sites that results from friction. Pale erythematous, macerated plaques are the clinical hallmarks of intertrigo, and they are typically KOH negative. Reduction of friction and inflammation (with topical corticosteroids) is helpful for intertrigo. It is important to note that intertrigo can be complicated by candidal or bacterial overgrowth.
  • Caution to use combined preparations containing both topical anticandidal and corticosteroid creams if the diagnosis is not clear; when the diagnosis is confirmed, rare cases of highly inflammatory candidiasis may benefit from addition of a low-to- medium potency topical corticosteroid to alleviate inflammation associated with candidal superinfection.
  • Refractory lesions may need a biopsy to rule out extramammary Paget’s disease, squamous cell carcinoma in situ (Bowen’s disease), and metabolic and other inflammatory causes of an intertriginous eruption.
  • Oral ketoconazole, in rare cases, may cause liver function abnormalities.
  • Avoid powders containing cornstarch on affected areas, as the starch promotes candidal overgrowth; use talc-based drying powders if needed.

When to consult a dermatologist

  • If the diagnosis of mucocutaneous candidiasis is not clear.
  • If a systemic immunodeficiency such as chronic mucocutaneous candidiasis is suspected.
  • For management of recurrent or recalcitrant candidiasis.
  • For management of an underlying cutaneous disorder that may predispose to candidal overgrowth.
  • For diagnostic evaluation when a cutaneous malignancy such as Bowen’s, extramammary Paget’s disease, or histiocytosis is suspected.

Clinical Cases

Case 1

  • 18-year-old healthy female
  • Obese body habitus
  • Presents for evaluation and management of long-standing “rash” underneath bilateral groin folds and infra-abdominal pannus
  • Rash slightly tender to touch

Initial evaluation

  • Healthy, obese female
  • Within the skin folds of the groin and infra-abdominal pannus, there are brightly erythematous macerated patches with minimal scale and satellite pustules
  • KOH prep of fluid taken from unroofed pustule reveals pseudohyphae and yeast forms
  • Diagnosis: Candidiasis
  • Recommendation: clotrimazole 1% cream b.i.d. to affected areas
  • Skin care reviewed: recommended to keep skin dry by toweling completely after bathing and drying skin fully with hairdryer set on cool air
  • Encourage weight reduction regimens
  • Follow-up as needed

Case 2

  • 42-year-old healthy female
  • Works as a dishwasher in a restaurant, does not wear gloves at work
  • Presents for evaluation and management of several-weeks’ history of painful erosions on the hands and nail fold changes

Initial evaluation

  • Healthy-appearing female
  • On bilateral hands, there are brightly erythematous fissured erosions in the interdigital web spaces between fingers in addition to edema and erythema of the proximal nail folds of several digits
  • KOH prep of fluid taken from an eroded fissure reveals pseudohyphae and yeast forms
  • Diagnosis: Candidiasis (erosio interdigitalis blastomycetica and paronychia)
  • Recommendation:
    • Nystatin ointment b.i.d. to interdigital web spaces
    • Nystatin ointment mixed in equal parts with topical corticosteroid triamcinolone 0.1% ointment b.i.d. to the proximal nail folds
  • Skin care reviewed: to keep skin dry by wearing protective gloves when exposing hands to water
  • Follow-up in 4 weeks

4-week follow-up evaluation

  • Erosions of the interdigital web spaces are completely cleared
  • Paronychia of multiple fingers is greatly improved; ongoing treatment is recommended
  • Follow-up in 4 weeks (resolved)

Case 3

  • 10-week-old healthy male infant
  • Tender groin rash
  • No systemic symptoms

Initial evaluation

  • Healthy-appearing male infant
  • Brightly erythematous macerated papules and plaques with satellite pustules noted in the skin folds of the groin and lower abdominal skin with extension onto the scrotum and penis
  • KOH prep of fluid taken from unroofed pustule reveals pseudohyphae and yeast forms
  • Diagnosis: Candidiasis
  • Recommendation: Topical nystatin ointment b.i.d.
  • Skin care reviewed: recommended to keep skin dry by toweling completely after bathing
  • Follow-up as needed

References

Giannini PJ, Shetty KV (2011) Diagnosis and management of oral candidiasis, Otolaryn Clin N Amer, 44:231-240.

Wolf R, Oumeish OY, Parish LC (2011) Intertriginous eruption, Clinics Derm, 29:173-179.