Candidiasis is a skin and/or mucous membrane infection involving Candida species, most commonly Candida albicans. Infections most often occur in skinfolds (intertriginous regions such as axillary, inguinal, inframammary, and other body fold areas), digital web spaces, on genital skin, in the cuticles, and on oral mucosa. Symptoms and signs vary by site. Diagnosis is primarily based on clinical appearance and is supported by testing such as potassium hydroxide wet mount of skin scrapings or fungal culture. Treatment is most often with drying agents, cutaneous barrier enhancement, and topical or systemic antifungals.
Mucocutaneous candidiasis is a superficial fungal infection of the skin caused by Candida species, most commonly Candida albicans. It typically presents as erythematous, macerated, and sometimes pustular lesions in intertriginous or other moist areas and is often associated with predisposing factors such as moisture, occlusion, immunosuppression, or recent antibiotic use. Most candidal infections involve the skin and mucous membranes, but invasive candidiasis may occur among patients who are immunosuppressed; it can be life threatening. In contrast to typical mucocutaneous candidiasis, chronic mucocutaneous candidiasis is a rare, often genetically determined, primary immunodeficiency disorder characterized by recurrent or persistent Candida infections affecting the skin, nails (including the cuticle), and mucous membranes.
Systemic candidiasis is discussed in Fungi. Vulvovaginal candidiasis is discussed in Candidal Vaginitis.
Etiology of Mucocutaneous Candidiasis
Candida is a group of approximately 150 yeast species. C. albicans is responsible for approximately 70 to 80% of all candidal infections (1). Other significant species include C. auris, C. glabrata, C. tropicalis, C. krusei, C. parapsilosis, and C. dubliniensis.
Candida is a ubiquitous commensal yeast that resides harmlessly on skin and mucous membranes until dampness, heat, and impaired local and systemic immune defenses provide a conducive environment for it to grow.
Risk factors for candidiasis include:
Hot and humid weather
Restrictive clothing
Poor hygiene
Infrequent diaper or undergarment changes in children and older adults
Altered mucocutaneous flora resulting from antibiotic therapy
Inflammatory diseases (eg, psoriasis) that occur in skinfolds
Immunosuppression resulting from glucocorticoids and immunosuppressive medications, pregnancy, diabetes, other endocrinopathies (eg, Cushing disease, hypoadrenalism, hypothyroidism), blood dyscrasias, advanced HIV, 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. In people with obesity, candidal infections may occur beneath the pannus (abdominal fold). Oropharyngeal candidiasis is a common sign of local or systemic immunosuppression.
Chronic mucocutaneous candidiasis is a primary immunodeficiency disorder that typically affects the nails, skin, and oropharynx. In some cases, it is linked to mutations in the AIRE gene, which plays a role in T-cell tolerance, and occurs is a part of autoimmune polyglandular syndrome type 1 (APS1) in association with hypoparathyroidism and Addison disease (also called Candida-endocrinopathy syndrome). It is typically inherited in an autosomal recessive pattern when it occurs as part of an autoimmune polyendocrinopathy. Chronic mucocutaneous candidiasis can also occur in a form without other associated systemic features. This form is most commonly due to inborn errors of interleukin (IL)-17 immunity and may be inherited in an autosomal recessive or dominant pattern. Patients with chronic mucocutaneous candidiasis have cutaneous anergy to Candida, absent lymphoproliferative responses to Candida antigen (but normal proliferative responses to mitogens), but an intact antibody response to Candida and other antigens. They also have impaired T-cell–mediated immunity.
Etiology reference
1. Talapko J, Juzbašić M, Matijević T, et al. Candida albicans-The Virulence Factors and Clinical Manifestations of Infection. J Fungi (Basel). 2021;7(2):79. Published 2021 Jan 22. doi:10.3390/jof7020079
Symptoms and Signs of Mucocutaneous Candidiasis
Intertriginous infections manifest as pruritic, well-demarcated, erythematous patches of varying size and shape; erythema may be difficult to detect in dark-skinned patients. Primary patches may have adjacent satellite papules and pustules.
CDC/ Dr. Hardin
Perianal candidiasis produces white maceration and pruritus ani.
Image provided by Thomas Habif, MD.
© Springer Science+Business Media
Vulvovaginal candidiasis causes pruritus and discharge (see Candidal Vaginitis).
Characteristic findings in vulvovaginal candidiasis include a white discharge and vulvar erythema.
Candidal nail infections can affect the nail plate, edges of the nail, or both. 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.
Candidal nail infections can involve the full thickness of the nail plate (onychomycosis), the edges of the nail (paronychia), or both.
Oropharyngeal candidiasis causes white plaques on oral mucous membranes that may bleed when scraped (see Interpretation of findings).
Creamy white patches are seen inside the mouth and may bleed when scraped off. This finding is typical of thrush, which is caused by infection with Candida.
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 Candida can grow.
Perlèche is candidiasis at the corners of the mouth, causing tiny cracks and fissures.
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.
Patients with chronic mucocutaneous candidiasis demonstrate cutaneous anergy to Candida. They develop red, pustular, thickened, crusted plaques that may appear psoriatic. Plaques may appear on the nose, forehead, and elsewhere.
Diagnosis of Mucocutaneous Candidiasis
Primarily physical examination
Potassium hydroxide wet mounts
Fungal culture in recurrent or recalcitrant cases
Diagnosis of mucocutaneous candidiasis is based on clinical appearance and identification of yeast and pseudohyphae in potassium hydroxide wet mounts of scrapings from a lesion.
Lesional culture is useful for species identification, especially in recurrent or treatment-resistant cases where clinical suspicion for the infection is high. Positive culture alone is usually not as helpful for mucocutaneous infections because Candida is omnipresent on these surfaces as a commensal organism.
Treatment of Mucocutaneous Candidiasis
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 minutes for exudative lesions) and topical antifungals (see table Options for Treatment of Superficial Fungal Infections). Powdered formulations are also helpful (eg, miconazole powder 2 times a day for 2 to 3 weeks). Fluconazole orally once a week for 2 to 4 weeks can be used for extensive intertriginous candidiasis; topical antifungals may be used at the same time.). Powdered formulations are also helpful (eg, miconazole powder 2 times a day for 2 to 3 weeks). Fluconazole orally once a week for 2 to 4 weeks can be used for extensive intertriginous candidiasis; topical antifungals may be used at the same time.
Options for Treatment of Superficial Fungal Infections*
Medications | Formulations | Uses† |
|---|---|---|
Allylamines | ||
Amorolfine‡ | 5% solution | |
NaftifineNaftifine | 1% cream or gel | Dermatophytoses, skin candidiasis |
TerbinafineTerbinafine | Topical: 1% cream or solution | |
Oral: 250-mg tablet | ||
Benzylamine | ||
ButenafineButenafine | 1% cream | |
Imidazoles | ||
ButoconazoleButoconazole | 2% cream | |
ClotrimazoleClotrimazole | Topical: 1% cream, lotion, or solution; 100-, 200-, and 500-mg vaginal suppository tablets | Dermatophytoses, candidiasis (oropharyngeal, skin, vulvovaginal) |
Oral: 10-mg lozenges | ||
EconazoleEconazole | 1% cream | |
EfinaconazoleEfinaconazole | 10% solution | Onychomycosis due to dermatophytes |
FluconazoleFluconazole | 50 and 200 mg/5 mL solution; 50-, 100-, 150-, and 200-mg tablets | Candidiasis (vulvovaginal, skin, oropharyngeal) |
ItraconazoleItraconazole | 100-mg capsules, 10 mg/mL solution | Tinea unguium, other onychomycoses |
KetoconazoleKetoconazole | 2% cream, 1 to 2% shampoo | Dermatophytoses, skin candidiasis |
MiconazoleMiconazole | 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, powder and desiccant combination | Dermatophytoses, candidiasis (skin, vulvovaginal), intertrigo |
OxiconazoleOxiconazole | 1% cream or lotion | |
SulconazoleSulconazole | 1% cream or solution | |
TerconazoleTerconazole | 0.4% and 0.8% cream, 80-mg suppositories | |
TioconazoleTioconazole | 6.5% ointment | |
Polyene | ||
NystatinNystatin | Topical: 100,000 units/g cream, ointment, powder, or vaginal tablet | Candidiasis (oropharyngeal, skin) |
Oral: 100,000 units/mL suspension, 500,000-unit tablets | Candidiasis (oropharyngeal, gastrointestinal) | |
Miscellaneous | ||
Amorolfine¶ | 5% lacquer | Onychomycosis caused by dermatophytes |
Carbolfuchsin | Solution | Chronic dermatophytoses, intertrigo |
CiclopiroxCiclopirox | 0.77% gel, 8% lacquer solution | Dermatophytoses, candidiasis, tinea versicolor, onychomycosis |
Clioquinol¶ | 3% cream | |
Gentian violetGentian violet | 1 or 2% solution | Dermatophytoses, especially tinea pedis; sometimes candidiasis |
GriseofulvinGriseofulvin | 125-, 165-, 250-, 330-, and 500-mg tablets | |
TavaboroleTavaborole | 5% lacquer | Onychomycosis caused by dermatophytes |
TolnaftateTolnaftate | 1% liquid, powder, liquid or aerosol spray, cream, or solution | |
Zinc | ||
Undecylenate/undecylenate acid (undecylenic acid, undecylenate salts, zincundecate)Undecylenate/undecylenate acid (undecylenic acid, undecylenate salts, zincundecate) | 25% solution, 10% tincture | Superficial dermatophyte infections (eg, tinea pedis) |
* Advantages of one topical medication 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. Doses may vary by indication. Oral antifungals can cause hepatitis and neutropenia. Periodic laboratory monitoring of hepatic function and of complete blood count is recommended when oral antifungals (eg, itraconazole, terbinafine) are given for Oral antifungals can cause hepatitis and neutropenia. Periodic laboratory monitoring of hepatic function and of complete blood count is recommended when oral antifungals (eg, itraconazole, terbinafine) are given for> 1 month. Oral itraconazole, terbinafine, and fluconazole are metabolized through the cytochrome P-450 enzyme system and thus have many potential drug interactions. Some interactions may be severe; cardiac arrhythmias are a risk for some people. Care should be taken to minimize the effects of interactions with these medications. Oral itraconazole, terbinafine, and fluconazole are metabolized through the cytochrome P-450 enzyme system and thus have many potential drug interactions. Some interactions may be severe; cardiac arrhythmias are a risk for some people. Care should be taken to minimize the effects of interactions with these medications. | ||
† Fungal pathogens include yeast (eg, Candida) and dermatophytes. | ||
‡ This medication is not available in the United States or Canada but is available elsewhere. | ||
¶ This medication is not available in the United States. | ||
Candidal diaper rash is treated with more frequent changes of diapers, use of super- or ultra-absorbent disposable diapers, and an imidazole cream 2 times a day. Oral nystatin is an option for infants with coexisting oropharyngeal candidiasis. Adjunctive therapies help create a barrier that is useful for patients who have diaper-associated candidal infections (eg, zinc oxide creams ranging from 10 to 40% strength, available over the counter).is treated with more frequent changes of diapers, use of super- or ultra-absorbent disposable diapers, and an imidazole cream 2 times a day. Oral nystatin is an option for infants with coexisting oropharyngeal candidiasis. Adjunctive therapies help create a barrier that is useful for patients who have diaper-associated candidal infections (eg, zinc oxide creams ranging from 10 to 40% strength, available over the counter).
Candidal paronychia is treated by protecting the area from wetness and giving topical or oral antifungals. These infections are often resistant to treatment. Thymol 4% in alcohol applied to the affected area 2 times a day is often helpful.
Oral candidiasis can be treated by dissolving a clotrimazole troche in the mouth 4 to 5 times a day for 14 days. Another option is nystatin oral suspension. A systemic antifungal may also be used (eg, oral fluconazole).can be treated by dissolving a clotrimazole troche in the mouth 4 to 5 times a day for 14 days. Another option is nystatin oral suspension. A systemic antifungal may also be used (eg, oral fluconazole).
Chronic mucocutaneous candidiasis requires long-term oral antifungal treatment with oral fluconazole.requires long-term oral antifungal treatment with oral fluconazole.
Key Points
Candida are normal skin flora that can become infective under certain conditions (eg, excessive moisture, alteration of normal flora, host immunosuppression).
Consider a diagnosis of 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.Treat oral candidiasis with clotrimazole troches, nystatin oral suspension, or an oral antifungal.
Drugs Mentioned In This Article
