CUTANEOUS CANDIDIASIS

First-line treatment of localized disease includes topi-cal formulations of imidazoles (ketoconazole, clotrim-azole,
miconazole, econazole) in various formulations, which may include creams or powders. Nystatin topical is also effective.
More severe cases typically require short courses of oral antifungals such as fluconazole 150 mg for several doses.

CHRONIC MUCOCUTANEOUS
CANDIDIASIS
Given the high likelihood of recurrence, prolonged courses of oral imidazoles or newer triazoles (including voriconazole and
posaconazole) are first-line treatment. Because of the development of resistance, echinocandins, liposomal amphotericin, or
flucytosine is sometimes required.

DISSEMINATED CANDIDIASIS
Treatment of patients with invasive candidiasis should be undertaken with the assistance of an infectious disease specialist.
Either an echinocandin (caspofungin, micafungin, or anidulafungin) or fluconazole is a firstline treatment recommended in
hemodynamically stable immunocompetent patients. Neutropenic patients should be started on empiric
echinocandin and switched to fluconazole once stable. Resistance to azoles and echinocandins is a potential concern,
particularly in non–Candida albicans species disease and in patients with prior exposure to these medications. Lipid
formulation amphotericin B is an alternative in situations of resistance to first-line agents. Followup blood cultures and
ophthalmologic examination are recommended for all patients with candidemia.
CUTANEOUS FINDINGS
Localized Candida infection in the skin classically presents as beefy-red patches and plaques with satellite papules and
pustules at the periphery (Fig. 161-1). Intertriginous areas, particularly the axillae, inframammary folds, groin folds, and
infrapannus area, are frequently affected, and maceration may be an additional feature in these sites
(Fig.161-2A,B). Candida also maybe implicated in miliaria arising on occluded skin surfaces, manifesting as small
monomorphous vesicles (Fig. 161-3). On oropharyngeal mucosal surfaces, background erythema with adherent whitish
material may be seen, as in the pseudomembranous form of oropharyngeal candidiasis (thrush) (Fig. 161-4A, D), however an
Erythematous form, characterized by a shiny depapillated lingual surface, as in median rhomboid glossitis, also occurs, and
may be seen in those who wear dentures (Fig.161-4B). Additionally, fissuring and crusting at the oral
Commissures may be seen in angular cheilitis (also known as perleche; Fig. 161-4C). In breastfeeding women, nipple
candidiasis may present with shiny erythema of the areola and nipple, which may be associated with flaking of the skin, and
thrush may concurrently be apparent in the infant’s mouth.On genital skin and mucosa, including the vulva, glans penis, and
prepuce, Candida may present with patchy erythema or erythematous plaques with associated itching and burning sensation.
In patients with vulvovaginitis, a thick, white, curdlike discharge is typical. Pustules are seen more frequently in balanitis
And balanoposthitis than in vulvitis (Fig.161-5). In the diaper area, the classic presentation is beefy-red erythematous
plaques with satellite papules and pustules (Fig. 161-2C). In the interdigital spaces, particularly the third webspace of the
hands, a macerated whitish plaque on erythematous back- ground (erosio interdigitalis blastomycetica) may be seen,
especially in patients with chronic exposure to moisture from wet work (Fig. 161-2D).

Figure 161-1 Typical morphology of cutaneous candidiasis

Demonstrating erythematous papules coalescing into plaques,
with satellite papules and vesiculopustules.

Figure 161-3 Miliaria caused by Candida seen on the

forehead of a diabetic patient who had applied a partially
occlusive dressing for headache symptoms.
Figure 161-2 Examples of Candida intertrigo. A, Erythematous papules becoming confluent over the inguinal area with
prominent satellite papules (with scrotal involvement, in contrast to tinea cruris). B, Erythematous plaques with erosion
and satellite papules. C, Diaper candidiasis demonstrated erythematous, partially eroded plaques, and satellite papules.
D, Erosio interdigitalis blastomycetica demonstrating an erythematous plaque with prominent maceration in the
interdigital webspace.