eMedicine Specialties > Dermatology > Fungal Infections

Candidiasis, Cutaneous

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): Matthew C Lambiase, DO, Staff Physician, Department of Dermatology, Brooke Army Medical Center; Daniel S Lehman, MD, Fellow in Minimally Invasive Urology/Oncology, Department of Urology, Columbia University Medical Center; Jessica M Allan, MD, Consulting Staff, Private Practice
Contributor Information and Disclosures

Updated: Mar 26, 2008

Introduction

Background

Yeasts are unicellular fungi that typically reproduce by budding, a process that entails a progeny pinching off of the mother cell. Candidosis is an infection caused by the yeast Candida albicans or other Candida species. 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.

The eMedicine articles Candidiasis, Mucosal and Candidiasis may be of interest.

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, Candida 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.

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 study³ 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, Kr ã nke et al⁴ 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 al⁵ 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, Nishimoto⁶ 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.

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.

Clinical

History

• Candidal vulvovaginitis: This common condition in women presents with itching, soreness, and a thick creamy white discharge (see Media File 1).

• Although most candidal infections occur more frequently with advancing age, vulvovaginitis is unusual in older women. In the absence of estrogen stimulation, the vaginal mucosa becomes thin and atrophic, producing less glycogen. Candidal colonization of vaginal mucosa is estrogen dependent and subsequently decreases sharply after menopause (see Media File 2).

• In contrast, the likelihood of colonization increases during pregnancy (25-33%). The widespread use of hormone replacement for reduction of osteoporosis and heart disease may cause an increasing trend in candidal vulvovaginitis among older women. Cutaneous hypersensitivity to C albicans has been reported in persons with idiopathic vulvodynia.⁷
• Candidal balanitis: Signs and symptoms of this candidal infection vary but may include tiny papules, pustules, vesicles, or persistent ulcerations on the glans penis (see Media File 3). Exacerbations following intercourse are common.

• Congenital candidosis^8,9 : This rarely reported candidal infection (70 cases during the 1990s) may be acquired by the infant in utero or during delivery. Presumably, congenital candidosis is an ascending intrauterine infection with cutaneous or systemic manifestations that typically present within 12 hours after birth. Although the congenital systemic form typically is fatal, congenital cutaneous infections usually have a more benign course. Prematurity and the presence of an intrauterine foreign body (intrauterine device) are associated with this condition. Untreated, infants are at higher risk for systemic infection, which is associated with a high mortality rate (70%). Some infants have respiratory distress and pneumonia secondary to in utero aspiration of infected amniotic fluid.
• Oropharyngeal candidiasis (OPC): This form is known more commonly as oral thrush and is considered by many to be a minor problem of little significance that may clear spontaneously. However, without appropriate treatment this can lead to a chronic condition that can result in discomfort and anorexia. Rarely, oropharyngeal infection leads to systemic candidiasis.
  • OPC in the neonate most commonly is acquired from the infected maternal mucosa during passage of the infant through the birth canal. OPC is 35 times more common in neonates of infected mothers compared to uninfected mothers.
  • OPC is the most common type of clinical presentation in infants and children. Immaturity of host defenses and incomplete establishment of the normal orointestinal flora are likely reasons why C albicans often acts as a pathogen in the neonate compared to a child aged several months who is not nearly as susceptible. Beyond the neonatal age, C albicans is considered a normal constituent of the oral and intestinal florae.
  • Candidosis of the nipple in the nursing mother is associated with infantile OPC. Nipple candidosis almost always is bilateral, with the nipples appearing bright red and inflamed, with the look and feel of being sunburned or on fire. Unlike a painful-with-nursing cut or abrasion from local trauma by the infant (incorrect latch-on), nipple candidosis hurts between feedings. Merely having the clothing brush against the nipples is painful.
• Candidal diaper dermatitis (CDD): Infants with OPC invariably harbor C albicans in the intestine and feces (85-90%). In most patients, CCD is the result of progressive colonization from oral and gastrointestinal candidiasis. Infected stools represent the most important focus for cutaneous infection. Moist macerated skin is particularly susceptible to invasion by C albicans. Additional factors that predispose infants to CDD include local irritation of the skin by friction; ammonia from bacterial breakdown of urea, intestinal enzymes, and stool; detergents; and disinfectants.
• Oral candidiasis in adults: Use of broad-spectrum antibiotics and inhaled corticosteroids, diminished cell-mediated immunity, and xerostomia are all risk factors for candidiasis (see Media File 4).

• Xerostomia may be either primary resulting from the natural aging process or secondary resulting from the anticholinergic effect of certain drugs including psychoactive drugs such as phenothiazines and tricyclic antidepressants. A decrease in salivary production decreases both the amount of available mucosal secretory antibody (immunoglobulin A [IgA]) and the natural cleansing action provided by saliva.
• In older adults, the development of oral thrush in the absence of a known etiology should raise the clinician's index of suspicion for an underlying cause of immunosuppression, such as malignancy or AIDS.
• With denture stomatitis, the areas of erythema may be painful and may affect up to 65% of patients who wear dentures, especially those who wear full sets. Despite popular belief, denture stomatitis is not associated with smokers or patients who are immunosuppressed.
• Intertrigo: Most cases of cutaneous candidosis occur in skin folds where occlusion (by clothing or shoes) produces abnormally moist conditions. Sites such as the perineum, mouth, and anus, in which Candida organisms normally may be carried, are at further risk of infection. Candidal infection of the skin under the breasts or pannus occurs when those areas become macerated (see Media File 5).

• Decubital candidosis: This is a particular form of cutaneous candidosis that occurs on the dorsal skin of chronically bedridden patients.¹⁰
• Paronychia: Candida organisms occasionally cause infection in the periungual area and underneath the nailbed (see Media File 6). Candida species (not always C albicans) can be isolated from most patients with chronic paronychia. The yeast is believed to play an etiologic role in this condition, but bacteria also may act as co-pathogens. Immediate contact dermatitis to food allergens may play a role in the pathogenesis of the condition as well. Progression to total nail dystrophy has been associated specifically with C albicans and usually has been limited to women with 2 important predisposing conditions, ie, Cushing syndrome and Raynaud disease. Disease is more common in people who frequently submerge their hands in water and usually is not associated with the elderly population. One important exception to this generalization is the population of patients with diabetes.

• Candidosis and HIV: Epidemiologic studies indicate that a very high percentage of patients infected with HIV contract some type of skin disorder during the course of the disease. More specifically, most patients with HIV infection have some form of candidal infection during the illness. Recurrent episodes of oral candidiasis typically occur in patients in whom CD4 counts are less than 300/µL, an important marker of disease progression. Additionally, Yanagisawa et al,¹¹ in 2007, reported on a case of disseminated candidiasis as an initial presentation of AIDS. Such cases often manifest with purpuric eruptions.
• Chronic mucocutaneous candidiasis: See Candidiasis, Chronic Mucocutaneous for discussion of that form of candidiasis.
• Breast pain: Andrews et al¹² studied 98 breastfeeding women, 20 who reported breastfeeding associated pain and 78 who were asymptomatic. Cultures were obtained from breast milk, areolae, and the infants' oropharynx. Six of the 20 symptomatic women returned breast milk cultures positive for yeast, compared with 6 of 78 controls (11 of 12 samples showed C albicans). The researchers suggested that Candida might play an etiologic role in breastfeeding-associated pain.
• Ecthyma gangrenosum: In 2007, Agarwal et al¹³ reported on a solitary ecthyma gangrenosum–like lesion that resulted from C albicans infection in a neonate.
• Ulcers: Xi et al,¹⁴ in 2007, reported a 51-year-old Cantonese woman who had a 1-year history of a large, deep-seated subcutaneous ulcer on her right shoulder for more than a year whose discharge showed C albicans and C parapsilosis. The researchers isolated C parapsilosis from the biopsy specimen.

Physical

• Candidal vulvovaginitis: Clinical examination reveals erythema of the vaginal mucosa and vulval skin with curdy white flecks within the discharge. Erythema may spread to include the perineum and groin, with satellite pustules. Alternatively, the vaginal mucosa may appear red and glazed. A patient presenting with symptoms of vulvovaginitis with identification of yeasts in the vaginal discharge has a diagnosis of candidosis.
• Congenital candidosis: In 2004, Diana et al¹⁵ reported that cutaneous congenital candidiasis (CCC) is a rare disease of term or premature infants. It typically manifests as an erythematous maculopapular eruption affecting the trunk and extremities; it resolves after extensive desquamation. Pustules and vesicles usually are superficial and resolve spontaneously or with topical treatment (see Media File 8). The presence of white microabscesses on the placenta and umbilical cord of an infant with such an eruption must suggest the diagnosis of CCC. It is always secondary to candidal chorioamnionitis, but it may pass unrecognized.

• OPC in the infant: Lesions become visible as pearly white patches on the mucosal surfaces. Buccal epithelium, gums, and the palate commonly are involved with extension to the tongue, pharynx, or esophagus in more severe cases. If the lesions are scraped away, an erythematous base is exposed. Lesions may progress to symptomatic erosion and ulceration.
• Candidal diaper dermatitis: The eruption of CDD usually starts in the perianal area, spreading to involve the perineum and, in severe cases, the upper thighs, lower abdomen, and lower back. Maceration of the anal mucosa and the perianal skin often is the first clinical manifestation. The typical eruption begins with scaly papules that merge to form well-defined, weeping, eroded lesions with a scalloped border. A collar of overhanging scales and an erythematous base may be demonstrated. Satellite flaccid vesicopustules around the primary intertriginous plaque also are characteristic of CDD and represent the primary lesions. Candidiasis may be a presenting feature of diabetic ketoacidosis.¹⁶
• Oral candidiasis in elderly persons: The most common clinical appearance of OPC (pseudomembranous candidosis or oral thrush) in the adult population occurs as white plaques that are present on the buccal, palatal, or oropharyngeal mucosa overlying areas of mucosal erythema. Typically, the lesions are removed easily and may demonstrate areas with tiny ulcerations (see Media File 7). In addition, some patients may develop soreness and cracks at the lateral angles of the mouth (angular cheilitis). Denture stomatitis presents as chronic mucosal erythema typically beneath the site of a denture.

• Intertrigo: Intertrigo typically presents with erythema, cracking, and maceration with soreness and pruritic symptoms. Lesions typically have an irregular margin with surrounding satellite papules and pustules. Web spaces of affected fingers or toes are macerated and have the appearance of soft white skin, which is a condition termed erosio interdigitalis blastomycetica (interdigital candidosis).
• Paronychia: The nailfold becomes erythematous, swollen, and tender, with an occasional discharge. Loss of the cuticle occurs, along with nail dystrophy and onycholysis with discoloration around the lateral nailfold (see Media File 9). A greenish color with hyponychial fluid accumulation may occur that results entirely from Candida, and not Pseudomonas, infection. A potassium hydroxide (KOH) preparation is helpful and is likely to show yeast organisms.

Causes

• Host factors that predispose patients to infections are numerous. Local factors such as tissue damage resulting from trauma, xerostomia, radiation-induced mucositis, ulcerations, skin maceration, or occlusion enhances adhesion and predisposes patients to increased infection rates.
• Endocrine diseases such as diabetes mellitus, Cushing syndrome, hypoparathyroidism, hypothyroidism, and polyendocrinopathy are associated with increased susceptibility to infection. The mechanism by which diabetes mellitus is believed to raise infection rates is through increased tissue glucose, altered yeast adhesion, and decreased phagocytosis.
• Nutritional deficiencies may alter host defense mechanisms or epithelial barrier integrity, allowing increased adherence or penetration. Iron deficiency anemia and deficiencies including vitamins B1, B2, B6, C, and folic acid are associated with heightened infection rates.
• T-lymphocyte–mediated immunity plays an important immunologic role against infection through phagocytosis and killing by polymorphonuclear cells and macrophages. Individuals with deficient T-lymphocyte function, such as patients with AIDS, appear to be particularly vulnerable to mucosal or cutaneous candidiasis but not to systemic infection. Patients with primary immune deficiencies, such as lymphocytic abnormalities, phagocytic dysfunction, IgA deficiency, viral-induced immune paralysis, and severe congenital immunodeficiencies, often are affected by OPC and other fungal mycoses.

• Search for CME/CE on This Topic »

• Candidiasis (Infectious Diseases)
• Candidiasis (Pediatrics: General Medicine)
• Cutaneous Manifestations of HIV Disease (Dermatology)
• Noncandidal Fungal Infections of the Mouth (Dermatology)

• Yeast Infection Overview
• Yeast Infection Treatment
• Yeast Infection Causes
• Yeast and Fungal Infections Center
• Yeast Infection Symptoms
• Children’s Health Center
• Skin, Hair, and Nails Center
• Yeast Infection Diaper Rash
• Yeast Infection Skin Rash

• Homeopathy No Match for Itraconazole in Candidiasis
• Monthly Cycle–Dependent Itraconazole May Be Effective for Recurrent Vulvovaginal Candidiasis
• Extensive Limb Involvement a Poor Prognostic Indicator in Cutaneous Lymphoma

• British HIV Association Guidelines for HIV-associated Malignancies 2008
• Dysphagia and Other Manifestations of Oesophageal Involvement in the Musculoskeletal Diseases
• Which Factors Predict Hospital-Acquired Late-Onset Neonatal Sepsis?

• Melanoma Resource Center
• Non-Hodgkin's Lymphoma Resource Center