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Skin-nontumor

Infectious disorders

Fungi - Candida


Reviewer: Ha Kirstin Do, M.D., IUPUI (see Reviewers page)
Revised: 12 July 2011, last major update July 2011
Copyright: (c) 2002-2011, PathologyOutlines.com, Inc.

Definition
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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
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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
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● 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
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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

Diagnosis
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● 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

Treatment
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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)

Acute 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

Case reports
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● 2 cases of extensive cutaneous candidasis in cutaneous T-cell lymphoma patients (Ann Dermatol Venereol 2006;133:566)

Clinical description
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● 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

Clinical images
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Oral candidasis


Candidal intertrigo


Candidal paronychia

Micro description
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● Pseudohyphae (non-septated hyphae)

Micro images
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Candida


Culture

   
Lung: GMS staining

Cytology description
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● Periodic Acid-Schiff (PAS) stain reveals nonseptated hyphae, which distinguishes Candida from tinea

Cytology images
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Nonseptated hyphae

Positive stains
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● GMS, PAS

Differential diagnosis
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● Intertrigo
● Onychomycosis
● Seborrheic dermatitis
● Bacterial vaginosis
● Contact dermatitis with or without colonization
Pseudomonas nailbed infection
● Inverse psoriasis
● Radiation dermatitis
Trichomonas infection

End of Skin-nontumor / Clinical Dermatology > Infectious disorders > Fungi - Candida


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