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Cutaneous candidiasis and chronic mucocutaneous candidiasis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Courtesy of Christos Zouzias.
Cutaneous Candidiasis
Cutaneous candidiasis is typically caused by Candida albicans , which exists as normal flora of human skin as well as in the gastrointestinal and genitourinary systems. Overgrowth of Candida species is suppressed by normal bacterial flora. Other Candida species occasionally cause mucocutaneous infections, the second most common being Candida tropicalis . Under certain conditions, these Candida species overgrow and become pathogens. Warmth and moisture of the intertriginous skin (axilla, inguinal folds, abdominal creases, inframammary creases, finger or toe webs), an increased skin pH, and the administration of antibiotics can disrupt the normal bacterial flora, allowing Candida to proliferate. Clinically, candidiasis presents as scaly, erythematous patches with satellite papules and pustules. The diagnosis is made either microscopically, with a potassium hydroxide (KOH) preparation revealing spores and pseudohyphae, or by culture.
Management Strategy
Topical antifungal agents include, but are not limited to, polyenes, azoles, allylamines, and ciclopirox olamines. Most studies required therapy twice daily for 4 weeks to ensure complete clearance in all patients. Notably, microscopic cure was often present before complete clinical clearance.
Topical corticosteroids are a source of controversy. Although the addition of corticosteroids to local antifungal therapy may reduce local inflammation in acute candidiasis, their use should be limited because of their immunosuppressant properties.
Systemic therapy may be appropriate for cutaneous infections in immunosuppressed patients, in the setting of extensive disease not responding to topical therapy, or in patients who are non-adherent to topical therapy. Fluconazole 150 mg weekly appears to be as efficacious as fluconazole 50 mg daily. As in topical therapy, microscopic cure often precedes complete clinical clearance. Since 2013, the Food and Drug Administration (FDA) has removed the indication for oral ketoconazole to be used in Candida and dermatophyte infections due to the risk of severe hepatotoxicity and adrenal insufficiency.
First-Line Therapies
The efficacy and safety of sertaconazole cream in diaper dermatitis
Bonifaz A, Tiredo-Sánchez A, Graniel MJ, et al. Mycopathologia 2013; 175: 249–54.
Twenty-seven patients with a clinical and mycologic diagnosis of Candida diaper dermatitis were treated twice daily for 2 weeks with sertaconazole. Eighty-nine percent of patients showed a clinical and mycologic cure by the end of 4 weeks (2 weeks after treatment ended).
A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans
Gallup E, Plott T. J Drugs Dermatol 2005; 4: 29–34.
A multicenter, open-label study that included 44 male and female subjects aged 6–29 months with diaper dermatitis due to C. albicans. The study medication was applied topically to the affected area twice daily for 1 week. The results showed a statistically significant improvement in both the rate of mycologic cure and the reduction of severity score.
Naftifine cream in the treatment of cutaneous candidiasis
Zaias N, Astorga E, Cordero CN, et al. Cutis 1988; 42: 238–40.
In a double-blind, parallel-group clinical trial, 60 patients with cutaneous candidiasis were randomly assigned to receive naftifine cream 1% or its vehicle twice a day for 3 weeks. Two weeks after the end of therapy, 77% of the naftifine-treated patients were mycologically cured (negative results on KOH preparations and culture) and had no clinically apparent disease, compared with only 3% of patients treated with vehicle alone.
A comparison of nystatin cream with nystatin/triamcinolone acetonide combination cream in the treatment of candidal inflammation of the flexures
Beveridge GW, Fairburn E, Finn OA, et al. Curr Med Res Opin 1977; 4: 584–7.
In a multicenter, double-blind trial, 31 patients with bilateral candidal lesions of the flexures were treated for 14 days with nystatin cream on one side and with a combination of nystatin and triamcinolone acetonide cream on the other side. Both treatments proved equally effective in terms of mycologic cure rate and clinical improvement. There was a weak trend by both patients and physicians to favor the combination preparation because symptoms resolved more rapidly.
Prospective aetiological study of diaper dermatitis in the elderly
Foureur N, Vanzo B, Meaume S, et al. Br J Dermatol 2006; 155: 941–6.
Of 46 patients, all over 85 years of age with dermatitis of the diaper area, 24 were identified as candidiasis. Of these, eight (33%) were cured after 1 month of topical bifonazole therapy, three (12.5%) improved, and 13 (54%) were cured after the addition of oral fluconazole 100 mg once daily for 1 month. Although topical antifungal drugs represent the first line of treatment for diaper dermatitis in the elderly, more than half the patients in this study required an oral antifungal to achieve a complete cure.
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