Cutaneous Candidiasis
- Author: Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: William D James, MD more...
Background
Cutaneous candidiasis and other forms of candidosis are infections caused by the yeast Candida albicans or other Candida species. Yeasts are unicellular fungi that typically reproduce by budding, a process that entails a progeny pinching off of the mother cell. C albicans, the principal infectious agent in human infection, is an oval yeast 2-6 µm in diameter. C albicans (as well as most medically significant fungi) has the ability to exist in both hyphal and yeast forms (termed dimorphism). If pinched cells do not separate, a chain of cells is produced and is termed pseudohyphae.
Superficial infections of skin and mucous membranes are the most common types of candidal infections of the skin. Common types of candidal skin infection include intertrigo, diaper dermatitis, erosio interdigitalis blastomycetica, perianal dermatitis, and candidal balanitis. In certain subpopulations, candidal infection of the skin has increased in prevalence in recent years, principally because of the increased numbers of patients who are immunocompromised.
Esophagitis, septicemia, endocarditis, peritonitis, and urinary tract infections are less frequent types of candidosis. Although C albicans is the most common cause of human infection, the genus Candida includes more than 150 species. Candida tropicalis, Candida parapsilosis, Candida guilliermondi, Candida krusei, Candida kefyr, Candida zeylanoides, and Candida glabrata (formerly Torulopsis glabrata) are less common causes of human disease.
Humans carry yeast fungi, including candidal species, throughout the gastrointestinal tract (mouth through anus) as part of the normal commensal flora. The vagina also commonly is colonized by yeast (13% of women), most commonly by C albicans and C glabrata. The commensal oral isolation of candidal species ranges from 30-60% in healthy adults. Note that Candida species are not part of the normal flora of the skin; however, they may colonize fingers or body folds transiently.
Also see the eMedicine articles Candidiasis, Mucosal and Candidiasis.
Pathophysiology
Most candidal species are known to produce virulence factors including protease factors. Those strains lacking virulence factors have been shown to be less pathogenic. The ability of yeast forms to adhere to the underlying epithelium is an important step in the production of hyphae and tissue penetration. Removal of bacteria from the skin, mouth, and gastrointestinal tract by exposing to tissue with its endogenous flora results in inhibition of endogenous microflora, providing reduced environmental and nutritional competition that favors the growth of candidal organisms.
Additional research has been performed on the cytokines and interleukins that candidal organisms affect in keratinocytes. In keratinocytes, C albicans phospholipomannan triggers an inflammatory response through toll-like receptor 2.[1] C albicans aborts the expression of interferon-gamma–inducible protein-10 in human keratinocytes.[2] These factors probably explain how candidal infections occur in the skin, which has innate defenses against candidal organisms.
Epidemiology
Frequency
United States
Candida species are a common cause of intertrigo in both elderly and diabetic patients. Candida species currently are the fourth leading cause of bloodstream infections in the United States, with occurrence at a disproportionately high rate in persons aged 65 years and older.
International
A German study[3] investigated the different causes of diaper dermatitis in 46 men and women at a median age of 85 years. In 38 patients, a cause was established; specifically, 63% had candidiasis, 16% had irritant dermatitis, 11% had eczema, and 11% had psoriasis. Of these patients, 37 were treated and 73% were cured after 8 weeks of treatment.
In Germany, Krãnke et al[4] studied 126 patients with a presumptive diagnosis of anal eczema (age range, 7-82 y), and most patients were male (57.1% male, 42.9% female). The clinical diagnosis was intertrigo/candidiasis in 42.9% of patients.
In Argentina, Nardin et al[5] analyzed 2073 samples of skin, hair, nails, and oral mucous membranes obtained from 1817 patients who attended the Microbiology Branch of the Central Laboratory at Dr. J.M. Cullen Hospital from September 1999 to September 2003. The samples were examined and identified according to localization and the type of lesion. Of the total samples, 55.67% were positive; 63% were recovered from females and 37% were recovered from males. C albicans was the prevalent yeast species.
In Japan, Nishimoto[6] noted that cutaneous candidiasis was seen in 755 (1%) of 72,660 outpatients. Intertrigo (347 cases) was the most common clinical manifestation of cutaneous candidiasis, erosio interdigitalis occurred in 103 cases, and diaper candidiasis was noted in 102 cases.
A Spanish study of 3,097 inpatient cases noted that cutaneous candidiasis accounted for 7.1% of consultations.[7]
Mortality/Morbidity
Superficial candidal infections cause significant morbidity in older adults, which becomes a particular problem with the use of certain types of medication, poor self-care, and decreased salivary flow. Age alone is not sufficient for the development of candidal infection; however, increased morbidity is associated with both superficial and invasive forms of disease. This is a result of an increased risk in patients of developing an underlying immunosuppressed state, such as malignancy.
Age
Neonatal cutaneous and systemic candidiasis have become increasingly prevalent in neonatal intensive care nurseries. Postnatal acquisition has been attributed to increased survival rates of low birth weight babies in association with an increased number of invasive procedures and widespread use of broad-spectrum antibiotics. Neonatal candidiasis presents 3-7 days after birth with oral thrush and diaper dermatitis. This has been attributed to mucosal contact with the organism during labor and delivery.
The number of candidal infections has risen dramatically in recent years, mirroring the increasing number of patients who are immunocompromised. Specifically, increased age appears to be associated with increased morbidity and mortality. Older adults are more likely to be exposed to situations that increase the risk of invasive candidiasis, including treatment with broad-spectrum antibiotics, hyperalimentation, and increased contact with invasive monitoring devices in an intensive care unit. Superficial candidal infections, although typically believed to be benign, cause significant morbidity in the elderly population.
Candidal infections are exacerbated by certain types of medication (eg, antibiotics), poor self-care, and decreased salivary flow, all of which often are associated with aging. In addition, treatment with cytotoxic agents (eg, methotrexate, cyclophosphamide) for dermatologic and rheumatic conditions or aggressive chemotherapy for malignancy in elderly patients puts them at higher risk.
Li M, Chen Q, Shen Y, Liu W. Candida albicans phospholipomannan triggers inflammatory responses of human keratinocytes through Toll-like receptor 2. Exp Dermatol. Jul 2009;18(7):603-10. [Medline].
Shiraki Y, Ishibashi Y, Hiruma M, Nishikawa A, Ikeda S. Candida albicans abrogates the expression of interferon-gamma-inducible protein-10 in human keratinocytes. FEMS Immunol Med Microbiol. Oct 2008;54(1):122-8. [Medline].
Foureur N, Vanzo B, Meaume S, Senet P. Prospective aetiological study of diaper dermatitis in the elderly. Br J Dermatol. Nov 2006;155(5):941-6. [Medline].
Kränke B, Trummer M, Brabek E, Komericki P, Turek TD, Aberer W. Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients. Wien Klin Wochenschr. Mar 2006;118(3-4):90-4. [Medline].
Nardin ME, Pelegri DG, Manias VG, Méndez Ede L. [Etiological agents of dermatomycoses isolated in a hospital of Santa Fe City, Argentina]. Rev Argent Microbiol. Jan-Mar 2006;38(1):25-7. [Medline].
Nishimoto K. [An epidemiological survey of dermatomycoses in Japan, 2002]. Nippon Ishinkin Gakkai Zasshi. 2006;47(2):103-11. [Medline].
Peñate Y, Guillermo N, Melwani P, Martel R, Borrego L. Dermatologists in hospital wards: an 8-year study of dermatology consultations. Dermatology. 2009;219(3):225-31. [Medline].
Ramirez De Knott HM, McCormick TS, Do SO, et al. Cutaneous hypersensitivity to Candida albicans in idiopathic vulvodynia. Contact Dermatitis. Oct 2005;53(4):214-8. [Medline].
Gibney MD, Siegfried EC. Cutaneous congenital candidiasis: a case report. Pediatr Dermatol. Dec 1995;12(4):359-63. [Medline].
Raval DS, Barton LL, Hansen RC, Kling PJ. Congenital cutaneous candidiasis: case report and review. Pediatr Dermatol. Dec 1995;12(4):355-8. [Medline].
Hoppe JE. Treatment of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants: review and reappraisal. Pediatr Infect Dis J. Sep 1997;16(9):885-94. [Medline].
Ramos-E-Silva M, Lima CM, Schechtman RC, Trope BM, Carneiro S. Superficial mycoses in immunodepressed patients (AIDS). Clin Dermatol [serial online]. 2010 Mar 4;28(2);217-25. [Medline]. Available at http://www.ncbi.nlm.nih.gov/pubmed/20347666.
Nico MM, Rivitti EA. 'Decubital candidosis': a study of 26 cases. J Eur Acad Dermatol Venereol. May 2005;19(3):296-300. [Medline].
Aly R, Berger T. Common superficial fungal infections in patients with AIDS. Clin Infect Dis. May 1996;22 Suppl 2:S128-32. [Medline].
Marquart KH. Electron microscopy reveals fungal cells within tumor tissue from two African patients with AIDS-associated Kaposi sarcoma. Ultrastruct Pathol. May-Jun 2006;30(3):187-92. [Medline].
Wang SM, Yang YJ, Chen JS, Lin HC, Chi CY, Liu CC. Invasive fungal infections in pediatric patients with leukemia: emphasis on pulmonary and dermatological manifestations. Acta Paediatr Taiwan. May-Jun 2005;46(3):149-55. [Medline].
Yanagisawa N, Suganuma A, Takeshita N, et al. [A case of disseminated candidiasis as an initial presentation of AIDS]. Kansenshogaku Zasshi. Jul 2007;81(4):459-62. [Medline].
Andrews JI, Fleener DK, Messer SA, Hansen WF, Pfaller MA, Diekema DJ. The yeast connection: is Candida linked to breastfeeding associated pain?. Am J Obstet Gynecol. Oct 2007;197(4):424.e1-4. [Medline].
Agarwal S, Sharma M, Mehndirata V. Solitary ecthyma gangrenosum (EG)-like lesion consequent to Candida albicans in a neonate. Indian J Pediatr. Jun 2007;74(6):582-4. [Medline].
Xi L, Li X, Zhang J, Lu C, Xie T, Yin R. Good response in a patient with deep-seated subcutaneous ulcer due to Candida species. Mycopathologia. Aug 2007;164(2):77-80. [Medline].
Luo DQ, Yang W, Wu LC, Liu JH, Chen WN. Interdigital ulcer: an unusual presentation of Candida infection. Mycoses. May 25 2011;[Medline].
Geddes ER, Polder K, Cutlan JE, Torres-Cabala CA, Hymes SR. Ulcerated plaque under a ruby ring in an immunosuppressed patient. Dermatol Online J. Aug 15 2010;16(8):4. [Medline].
Diana A, Epiney M, Ecoffey M, Pfister RE. "White dots on the placenta and red dots on the baby": congential cutaneous candidiasis--a rare disease of the neonate. Acta Paediatr. Jul 2004;93(7):996-9. [Medline].
Williams MD, Sallee D, Robinson M. Diabetic ketoacidosis in toddler with a diaper rash. Am J Emerg Med. Sep 2008;26(7):834.e1-2. [Medline].
Lim CS, Lim SL. New contrast stain for the rapid diagnosis of dermatophytic and candidal dermatomycoses. Arch Dermatol. Sep 2008;144(9):1228-9. [Medline].
Sundaram SV, Srinivas CR, Thirumurthy M. Candidal intertrigo: treatment with filter paper soaked in Castellani's paint. Indian J Dermatol Venereol Leprol. Sep-Oct 2006;72(5):386-7. [Medline].
Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. Mar 1 2009;48(5):503-35. [Medline].
Duong T, Ingen-Housz-Oro S, Gaulier A, Petit A, Dubertret L, Sigal-Grinberg M. [Extensive cutaneous candidiasis revealing cutaneous T-cell lymphoma: 2 cases]. Ann Dermatol Venereol. Jun-Jul 2006;133(6-7):566-70. [Medline].
Aridogan IA, Ilkit M, Izol V, Ates A. Malassezia and Candida colonisation on glans penis of circumcised men. Mycoses. Sep 2005;48(5):352-6. [Medline].
Elewski BE. Cutaneous mycoses in children. Br J Dermatol. Jun 1996;134 Suppl 46:7-11: discussion 37-8. [Medline].
Fotos PG, Lilly JP. Clinical management of oral and perioral candidosis. Dermatol Clin. Apr 1996;14(2):273-80. [Medline].
Gilbert DN, Moellering RC, Merle AS. Sanford Guide to Antimicrobial Therapy. 35th ed. 2005.
Hay RJ. Yeast infections. Dermatol Clin. Jan 1996;14(1):113-24. [Medline].
Hedderwick S, Kauffman CA. Opportunistic fungal infections: superficial and systemic candidiasis. Geriatrics. Oct 1997;52(10):50-4, 59. [Medline].
Rang HP, Dale MM, et al. Pharmacology. 689-90. New York, NY: Churchill Livingstone; 1995:756-60.
Seebacher C, Abeck D, Brasch J, et al. [Candidiasis of the skin]. J Dtsch Dermatol Ges. Jul 2006;4(7):591-6. [Medline].
Smolinski KN, Shah SS, Honig PJ, Yan AC. Neonatal cutaneous fungal infections. Curr Opin Pediatr. Aug 2005;17(4):486-93. [Medline].
Takechi M. Minimum effective dosage in the treatment of chronic atopic dermatitis with itraconazole. J Int Med Res. May-Jun 2005;33(3):273-83. [Medline].
Warren NG. Taxonomy and introduction. Dermatol Clin. Jan 1996;14(1):1-7. [Medline].

