Cutaneous Candidiasis

Symptoms

• Burning, itching, soreness in affected area
• Vulvovaginal: thick white 'cottage cheese' discharge, pruritus, dyspareunia
• Oral: white plaques that scrape off (pseudomembranous), painful red atrophic mucosa (erythematous/atrophic), or angular cheilitis (perlèche)
• Paronychia: tender swollen erythematous nail fold, chronic

Signs / physical exam

• Intertrigo: beefy-red erythematous moist plaques with peripheral collarette of scale and satellite pustules/papules — axillae, inframammary, inguinal, abdominal panniculus, intergluteal cleft
• Diaper candidiasis: beefy-red plaques INVOLVING inguinal folds with satellite pustules (vs irritant diaper dermatitis which spares folds)
• Oral thrush: white curd-like plaques that scrape off, leaving erythematous base; perlèche (angular cheilitis); median rhomboid glossitis
• Vulvovaginal: erythema, edema, fissures, thick white discharge adherent to walls
• Candidal balanitis: erythematous papules and pustules on glans with white exudate
• Chronic paronychia: erythematous swollen proximal nail fold, loss of cuticle, secondary nail dystrophy

Classic findings

Beefy-red plaque with satellite pustules in skin folds; INVOLVES skin folds (unlike irritant or tinea); 'cottage cheese' vaginal discharge.

Diagnostic criteria

Clinical presentation + KOH/culture in characteristic site.

Labs

• Clinical diagnosis usually sufficient
• KOH preparation: budding yeasts with pseudohyphae
• Fungal culture if refractory or to identify species (e.g., C. glabrata, C. krusei resistant to fluconazole)
• Wet mount + pH for vaginal candidiasis (pH normal 3.8-4.5 in candida; >4.5 suggests BV/trichomonas)
• HIV testing and diabetes screening for recurrent or refractory adult disease
• TSH, ferritin, calcium if chronic mucocutaneous candidiasis suspected

Imaging

• Not indicated

First-line

• Cutaneous intertrigo: topical antifungal — nystatin cream/ointment, clotrimazole 1%, miconazole 2%, ketoconazole 2% — BID until clear plus 1 week; keep area DRY (absorbent powder, hair dryer on cool, breathable fabrics, weight loss for chronic intertrigo)
• Diaper candidiasis: nystatin or clotrimazole ointment with each diaper change; frequent diaper changes, air time, barrier paste (zinc oxide)
• Oral thrush: nystatin suspension 4-6 mL swish-and-swallow QID × 7-14 days, OR clotrimazole troches 10 mg 5x/day, OR oral fluconazole 100-200 mg daily × 7-14 days (for moderate-severe disease)
• Vulvovaginal (uncomplicated): single dose oral fluconazole 150 mg OR topical azole (clotrimazole, miconazole) intravaginal 1-7 days
• Vulvovaginal (severe/recurrent): fluconazole 150 mg every 72 h × 3 doses; maintenance fluconazole 150 mg weekly × 6 months for recurrent disease (≥4 episodes/year)
• Candidal balanitis: topical clotrimazole + treat sexual partner; circumcision occasionally for refractory disease
• Chronic paronychia: keep hands dry, avoid wet work, topical antifungal + low-potency steroid; oral fluconazole 150 mg weekly for severe

Esophageal / immunocompromised

• Oral fluconazole 200-400 mg daily × 14-21 days
• Echinocandin (caspofungin, micafungin) or amphotericin B for resistant species or systemic candidiasis
• Address underlying immunosuppression

Chronic mucocutaneous candidiasis

• Long-term oral azole therapy
• Evaluate for autoimmune polyendocrine syndrome type 1 (APECED), STAT1 gain-of-function mutations, HIV

Second-line / adjunct

• Address underlying risk factors: glycemic control, weight loss, eliminate occlusion, dry intertriginous areas
• Probiotics — limited evidence
• Fluconazole-resistant species (C. glabrata): boric acid 600 mg vaginal capsule nightly × 14 days, nystatin vaginal tablets, or echinocandin