Skin-nontumor / Clinical dermatology
Infectious disorders
Fungi - Candida

Author: Ha Kirstin Do, M.D. (see Authors page)

Revised: 23 May 2016, last major update July 2011

Copyright: (c) 2002-2016, PathologyOutlines.com, Inc.

PubMed Search: Fungi - Candida [title]

Cite this page: Fungi - Candida. PathologyOutlines.com website. http://pathologyoutlines.com/topic/skinnontumorfungicandida.html. Accessed December 8th, 2016.
Definition / General
  • Candida albicans is a part of the normal human skin flora
  • Cutaneous candidiasis is a superficial infection of skin and mucous membranes and the most common Candidal infection
Terminology
  • Cutaneous candidal infections include:
    • Oral candidasis
    • Candidal intertrigo (affects body folds): acute (wet and red), subacute (red +/- maceration), or chronic (red and dry)
    • Candidal diaper dermatitis
    • Candidal vulvovaginitis
    • Candidal balanitis
    • Candidal nail infection: chronic paronychia, onycholysis
Epidemiology
  • In USA, Candida species are a common cause of intertrigo in both elderly and diabetic patients
  • Candida species colonize the oropharynx in 30 - 55% of healthy young adults, and are commonly found in normal fecal flora
  • 3 out of 4 women will have at least one Candidal vulvoganitis during their lifetime
  • For patients with systemic infections, Candida species is now the 4th most common pathogen from blood cultures
  • More than 90% of HIV population who are not on highly active anti-retroviral therapy will develop oropharyngeal candidiasis and 10% develop esophageal candidasis
  • Internationally, Candida species have replaced Cryptococcus species as the most common fungal pathogens affecting immunocompromised hosts
Clinical Features
  • Predisposing factors for opportunistic infection with C. albicans include:
    • Infancy or elderly
    • Warm climate
    • Occlusive clothing, poor personal hygiene, dental plates
    • Immune deficiencies (low levels of immunoglobulins, HIV, cancer)
    • Broad spectrum antibiotic treatment
    • High dose estrogen contraceptive pills or pregnancy
    • Chemotherapy or immunosuppressive medications such as systemic steroids
    • Locally applied topical steroids
    • Diabetes mellitus, obesity, Cushing's syndrome and other endocrine conditions
    • Iron deficiency
    • Malnutrition
    • Underlying dermatological disease like psoriasis, lichen planus, irritant contact dermatitis
    • Mortality is relative low for cutaneous Candidal infection in healthy patients; however, the mortality rate is up to 30 - 40% in disseminated/systemic candidasis in immunosuppressed patients

  • The characteristic skin manifestation is red and white patches on mucosal surfaces (leukoplakia)
  • In skin folds, it results in moist fissuring with a superfical erythema patch with satellite papulopustules
Diagnosis
  • KOH preparation and skin scraping is the easiest and most cost-effective method for diagnosing cutaneous candidiasis
  • Culture from intact pustule or skin biopsy tissue can support the diagnosis
Case Reports
Treatment
  • Note: please confirm accuracy of medications below before use

  • Oral candidiasis:
    • Nystatin oral suspension x 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; for infants is 1 mL (100,000 U) to each side of the mouth 4 times/d; for adults 4 - 6 mL (100,000 U) PO swish and swallow qid

  • Candidal intertrigo:
    • Keep the skin dry, with the addition of topical nystatin powder, clotrimazole, or miconazole twice daily, often in conjunction with a midpotency corticosteroid
    • Extensive infection may require the addition of fluconazole (100 mg PO qd for 1 - 2 wk) or itraconazole (100 mg PO qd for 1 - 2 wk)

  • cute intertrigo:
    • Can use Domeboro solution, Castellani paint or vinegar/water (1 tbsp vinegar per quart room-temperature water) to apply twice per day for 5 - 10 minutes for 3 - 5 days as needed
    • Dry the area with a hair dryer (low heat)
    • Can also apply triamcinolone-nystatin cream twice daily

  • Subacute intertrigo:
    • Can use benzoyl peroxide wash 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

  • Chronic intertrigo:
    • Can use zinc-talc shake lotion once or twice daily, and the hydrocortisone cream / antifungal mixture may be applied at night
    • Local hyperhidrosis may be treated with antiperspirants (ie, Arid Extra Dry Unscented, Dry Idea) on a long-term basis

  • Candidal diaper dermatitis:
    • Goal is to minimize the 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
    • Apply topical nystatin, amphotericin B, miconazole or clotrimazole to affected areas twice daily x 7 days

  • Candidal vulvovaginitis:
    • Topical antifungal agents (Micatin, Monistat-Derm), or clotrimazole (Lotrimin, Mycelex) creams twice daily x 7 days or intravaginal appliator QHS x 7 days are curative
    • 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

  • Candidal balanitis:
    • Topical therapy is effective in most patients
    • Evaluate asymptomatic sexual partners and treat them if they are infected to prevent recurrence
    • For persistent lesions beyond the genitalia, consider the possibility of underlying diabetes or other diseases

  • Candidal paronychia:
    • Topical treatment is usually 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 months) or terbinafine (250 mg qd for 3 months) is recommended

Clinical Images

Images hosted on PathOut servers:

Breast skin, courtesy of Dr. Mark R. Wick


Images hosted on other servers:

Oral candidasis

Candidal intertrigo

Micro Images

Images hosted on PathOut servers:

Breast skin, courtesy of Dr. Mark R. Wick



PAS, breast skin, courtesy of Dr. Mark R. Wick



Missing Image

Candida



Lung: GMS staining

Cytology Description
  • Periodic Acid-Schiff (PAS) stain reveals nonseptated hyphae, which distinguishes Candida from tinea
Positive Stains
  • GMS, PAS