What is cutaneous candidiasis

Cutaneous candidias is a medical term for Candida albicans (yeast) infection of the skin. Cutaneous candidiasis is a yeast infection of the skin that is characterized by red plaques, often with satellite papules, pustules, collarettes. In cutaneous candidiasis, the skin is infected with Candida albicans fungi. This type of infection is fairly common. Cutaneous candidiasis can involve almost any skin on your body, but most often it occurs in warm, moist, creased areas such as the armpits and groin.

Cutaneous candidiasis is best treated with topical antifungal such as clotrimazole, miconazole, ketoconazole, econazole cream or lotion twice daily. If concern for
vaginal yeast, treat with oral fluconazole 150 mg x1.

Cutaneous candidiasis causes

Your body normally hosts a variety of germs, including bacteria and fungi. Some of these are useful to your body, some produce no harm or benefit, and some can cause harmful infections. Some fungal infections are caused by fungi that often live on the hair, nails, and outer skin layers. They include yeast-like fungi such as Candida albicans. Sometimes, these yeast penetrate beneath the surface of the skin and cause infection. The fungus that most often causes cutaneous candidiasis is Candida albicans.

Cutaneous candidiasis is triggered by a combination of the following factors:

• The hot and damp environment of skin folds, which is conducive to the growth of candida species, particularly Candida albicans ¹
• Increased skin friction ²
• Immunocompromised ³. T-lymphocyte–mediated immunity plays an important immunologic role against infection through phagocytosis and killing by polymorphonuclear cells and macrophages. Individuals with deficient T-lymphocyte function, such as patients with AIDS, appear to be particularly vulnerable to mucosal or cutaneous candidiasis but not to systemic infection. Patients with primary immune deficiencies, such as lymphocytic abnormalities, phagocytic dysfunction, IgA deficiency, viral-induced immune paralysis, and severe congenital immunodeficiencies, often are affected by oropharyngeal candidiasis and other fungal mycoses.
• Nutritional deficiencies may alter host defense mechanisms or epithelial barrier integrity, allowing increased adherence or penetration. Iron deficiency anemia and deficiencies including vitamins B1, B2, B6, C, and folic acid are associated with heightened infection rates.
• Endocrine diseases such as diabetes mellitus, Cushing syndrome, hypoparathyroidism, hypothyroidism, and polyendocrinopathy are associated with increased susceptibility to infection. The mechanism by which diabetes mellitus is believed to raise infection rates is through increased tissue glucose, altered yeast adhesion, and decreased phagocytosis.

Cutaneous candidiasis commonly involes crural creases, vulva, scrotum. Glans penis is frequently involved in uncircumsized men.

Candida is the most common cause of diaper rash in infants. The fungi take advantage of the warm, moist conditions inside the diaper. Candida infection is also particularly common in people with diabetes and in those who are obese. Antibiotics, steroid therapy, and chemotherapy increase the risk of cutaneous candidiasis. Candida can also cause infections of the nails, edges of the nails, and corners of the mouth.

Oral thrush, a form of candida infection of the moist lining of the mouth, usually occurs when people take antibiotics. It may also be a sign of an HIV infection or other weakened immune system disorders when it occurs in adults. Individuals with candida infections are not usually contagious, though in some settings people with weakened immune systems may catch the infection.

Candida is also the most frequent cause of vaginal yeast infections. These infections are common and often occur with antibiotic use.

Cutaneous candidiasis symptoms

A cutaneous candidiasis can cause intense itching.

Cutaneous candidiasis symptoms also include:

• Red, growing skin rash
• Rash on the skin folds, genitals, middle of the body, buttocks, under the breasts, and other areas of skin
• Infection of the hair follicles that may look like pimples.

Cutaneous candidiasis possible complications

These complications may occur:

• Infection of the nails (onychomycosis) may cause the nails to become oddly shaped and may cause an infection around the nail.
• Candida skin infections may return.
• Widespread candidiasis may occur in people with weakened immune systems.

Cutaneous candidiasis diagnosis

Your doctor can usually diagnose cutaneous candidiasis by looking at your skin. Your doctor may gently scrape off a sample of your skin for testing. Microscopic exam demonstrating pseudohyphae or yeast is diagnostic. Hyphae and pseudohyphae in stratum corneum, neutrophilic inflammation and subcorneal pustules.

Older children and adults with a cutaneous candidiasis should be tested for diabetes. High sugar levels, seen in people with diabetes, act as food for the yeast fungus, and help it grow.

Cutaneous candidiasis treatments

Good general health and hygiene are very important for treating cutaneous candidiasis. Keeping your skin dry and exposed to air is helpful. Drying (absorbent) powders may help prevent fungal infections.

Losing weight may help eliminate the problem if you are overweight.

Proper blood sugar control may also be helpful to those with diabetes.

Antifungal skin creams, ointments, or powders such as miconazole nitrate (Micatin, Monistat-Derm) or clotrimazole (Lotrimin, Mycelex) may be used to treat a yeast infection of the skin, mouth, or vagina. You may need to take antifungal medicine by mouth for severe candida infections in the mouth, throat, or vagina. Severe, generalized and/or refractory cases may require oral antifungal treatments such as fluconazole or itraconazole ⁴. One-time oral therapy with fluconazole (150 mg) or itraconazole (600 mg) is effective and may be a more attractive alternative to some patients, but it is more costly ⁵.

Candidal balanitis

Topical therapy is sufficient in most patients. Evaluate asymptomatic sexual partners and treat them if they are affected. If persistent lesions spread beyond the genitalia, consider the possibility of diabetes, and assess for the disease.

Congenital candidosis

Topical preparations usually are effective. Some authors recommend the use of oral nystatin in conjunction with topical agents to lower the risk of systemic infection.

Oropharyngeal candidiasis in the infant

Most patients can be treated with nystatin oral suspension. Treat for 10-14 days or until 48-72 hours after resolution of symptoms. Dosage for preterm infants is 0.5 mL (50,000 U) to each side of mouth 4 times/day; dosage for infants is 1 mL (100,000 U) to each side of the mouth 4 times/d.

Candidosis of the nipple

Treat nipple candidosis for 2 weeks using an antifungal cream after each feeding. The baby must be treated simultaneously with nystatin swabbed on all 4 gum lines and in the oral cavity, along with a few ingested drops, for 2 weeks. Babies may have no symptoms of oropharyngeal candidiasis and still be reinfecting their mothers. Careful hygiene is also important. Frequent changing and washing of bras in boiling water (along with anything the baby puts in its mouth, eg, pacifiers) is necessary. Gentian violet is not used because it stains badly and may irritate the infant’s mouth. If candidosis of the nipple goes untreated, it may extend, and oral treatment for the mother may be necessary. Cultures often are not pure and usually are not helpful.

Candidal diaper dermatitis

Treatment for candidal diaper dermatitis includes practical measures that reduce the amount of time the diaper area is exposed to hot and humid conditions. Air drying, frequent diaper changes, and generous use of baby powders and zinc oxide paste are adequate preventive measures. For topical therapy of candidal diaper dermatitis, nystatin, amphotericin B, miconazole, and clotrimazole are effective and almost equivalent in efficacy.

Oral candidiasis in adults

Treatment with a topical agent such as nystatin (1:100,000 U/mL, 5 mL oral rinse and swallow qid) or clotrimazole troches (10 mg 5 times/d) usually is effective. In most patients, extend the duration of antifungal therapy at least twice as long as the termination of clinical signs and symptoms of candidosis. Reserve oral fluconazole, 100 mg once daily for 2 weeks, for patients with more severe disease.

With denture stomatitis, improved oral hygiene with removal of dentures at night, vigorous brushing to remove plaque, and disinfecting (swish and spit) with chlorhexidine gluconate (Peridex) usually is adequate treatment. Topical therapy with clotrimazole troches or nystatin may be used for lesions that do not respond to the above measures. For more resistant cases oral fluconazole, 100 mg/day for several weeks, in addition to the above measures, may prove effective.

Candidal intertrigo

Treatment is targeted to keeping the skin dry, with the addition of topical nystatin powder, clotrimazole, or miconazole twice daily, often in conjunction with a midpotency corticosteroid. Patients with extensive infection may require the addition of fluconazole (100 mg oral once daily for 1-2 weeks) or itraconazole (100 mg oral once daily for 1-2 weeks). Many anecdotally based remedies exist for candidal intertrigo that have been used in dermatology offices for years with success. The remedies have focused on both drying the moist inflamed area and treating the candidosis. The treatments are adjusted based on whether the inflammation is acute (wet and red), subacute (red +/- maceration), or chronic (red and dry)

For acute candidal intertrigo, Domeboro solution, Castellani paint, or vinegar/water (1 tbsp vinegar per qt room-temperature water) may be applied twice per day for 5-10 minutes for 3-5 days as needed. Dry the area with a hair dryer (no heat). Apply a shake lotion twice per day (mixture: 40 g USP talc, 40 g zinc oxide, 10 g glycerin; mix into slurry or milkshake consistency, add distilled water up to 120 mL, dispense in 180-mL [6 oz] bottle). Place a large bath towel under breasts or in pendulous areas twice per day. Castellani paint (carbol fuchsin) is messy, but nightly painting may help when nothing else does. Some patients respond well to triamcinolone-nystatin cream.

For subacute candidal intertrigo, benzoyl peroxide wash may be used to cleanse the area instead of application of vinegar or Castellani paint. A topical anticandidal cream of choice is applied twice per day, with or without a mild hydrocortisone cream (no refills for the latter).

For chronic candidal intertrigo, the zinc-talc shake lotion may be used once or twice daily, and the hydrocortisone cream/antifungal mixture may be applied at night. Local hyperhidrosis may be treated with antiperspirants (ie, Arrid Extra Dry Unscented, Dry Idea) on a long-term basis. These products, along with the more concentrated Drysol (aluminum chloride 20%), may sting macerated skin. Nystatin in talc (100,000 U/g or 15 g) may be applied twice per day for a few days, then tapered and replaced with unscented baby powder as a powder-approach alternative.

Sundaram et al ⁶ noted that candidal intertrigo can be treated with filter paper soaked in Castellani paint.

Candidal paronychia

Treatment with topical agents usually is not effective but should be tried for chronic candidal paronychia. Drying solutions or antifungal solutions are used. Oral therapy with either itraconazole (pulse dosing with 200 mg bid for 1 wk of each of 3 consecutive mo) or terbinafine (250 mg once daily for 3 months) is recommended.

Candidosis and HIV

Topical therapy with agents such as nystatin and clotrimazole require a minimum of 20-30 minutes of drug contact with the oral mucosa. Treatment with topical therapies may be effective in the early stages of HIV infection, and it becomes less effective with disease progression. Oral treatment with a 2-week course of antifungal therapy (itraconazole, fluconazole, ketoconazole) is indicated in more refractory cases. In patients who are significantly immunocompromised, maintenance therapy on an intermittent (alternate days to twice weekly dosing of ketoconazole 200 mg or fluconazole 100 mg) or continuous basis may be required to provide symptomatic relief. In general, the goal is the cessation of therapy once clinical symptoms have subsided, since prolonged therapy increases the likelihood of the development of drug-resistant organisms.

Cutaneous candidiasis prognosis

Cutaneous candidiasis often goes away with treatment, especially if the underlying cause is corrected. Repeat infections are common.

Cutaneous candidiasis can cause significant morbidity in older adults, which becomes a particular problem with the use of certain types of medication, poor self-care, and decreased salivary flow. Age alone is not sufficient for the development of candidal infection; however, increased morbidity is associated with both superficial and invasive forms of disease. This is a result of an increased risk in patients of developing an underlying immunosuppressed state, such as cancer.

References

1. Yaar M, Gilchrest BA. Aging of skin. In: Fitzpatrick’s Dermatology in General Medicine, Freedberg IM, Eisen AZ, Wolff K, et al (Eds), McGraw-Hill, New York 2003. p.1386
2. Garcia Hidalgo L. Dermatologic complications of obesity. Am J Clin Dermatol. 2002;3(7):497.
3. Jautova J, Baloghova J, Dorko E, et al. Cutaneous candiosis in immunosuppressed patients. Folia Microbiol. 2001;46(4):359.
4. Metin A, Dilek N, Demireseven DD. Fungal infections of the folds (intertriginous areas). Clin Dermatol. 2015;33(4):437-47.
5. Cutaneous candidiasis. https://emedicine.medscape.com/article/1090632-treatment
6. Sundaram SV, Srinivas CR, Thirumurthy M. Candidal intertrigo: treatment with filter paper soaked in Castellani’s paint. Indian J Dermatol Venereol Leprol. 2006 Sep-Oct. 72(5):386-7.