eMedicine Specialties > Dermatology > Fungal Infections
Candidiasis, Cutaneous: Treatment & Medication
Updated: Dec 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Candidal vulvovaginitis: Topical antifungal agents including miconazole nitrate (Micatin, Monistat-Derm) or clotrimazole (Lotrimin, Mycelex) creams 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 sufficient in most patients. Evaluate asymptomatic sexual partners and treat them if they are affected. If persistent lesions spread beyond the genitalia, consider the possibility of diabetes, and assess for the disease.
- Congenital candidosis: Topical preparations usually are effective. Some authors recommend the use of oral nystatin in conjunction with topical agents to lower the risk of systemic infection.
- OPC in the infant: Most patients can be treated with nystatin oral suspension. Treat for 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; dosage for infants is 1 mL (100,000 U) to each side of the mouth 4 times/d.
- Candidosis of the nipple: Treat nipple candidosis for 2 weeks using an antifungal cream after each feeding. The baby must be treated simultaneously with nystatin swabbed on all 4 gum lines and in the oral cavity, along with a few ingested drops, for 2 weeks. Babies may have no symptoms of OPC and still be reinfecting their mothers. Careful hygiene is also important. Frequent changing and washing of bras in boiling water (along with anything the baby puts in its mouth, eg, pacifiers) is necessary. Gentian violet is not used because it stains badly and may irritate the infant's mouth. If candidosis of the nipple goes untreated, it may extend, and oral treatment for the mother may be necessary. Cultures often are not pure and usually are not helpful.
- Candidal diaper dermatitis: Treatment for CDD includes practical measures that reduce the amount of 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. For topical therapy of CDD, nystatin, amphotericin B, miconazole, and clotrimazole are effective and almost equivalent in efficacy.
- Oral candidiasis in adults
- Treatment with a topical agent such as nystatin (1:100,000 U/mL, 5 mL oral rinse and swallow qid) or clotrimazole troches (10 mg 5 times/d) usually is effective. In most patients, extend the duration of antifungal therapy at least twice as long as the termination of clinical signs and symptoms of candidosis. Reserve oral fluconazole, 100 mg once daily for 2 weeks, for patients with more severe disease.
- With denture stomatitis, improved oral hygiene with removal of dentures at night, vigorous brushing to remove plaque, and disinfecting (swish and spit) with chlorhexidine gluconate (Peridex) usually is adequate treatment. Topical therapy with clotrimazole troches or nystatin may be used for lesions that do not respond to the above measures. For more resistant cases oral fluconazole, 100 mg/day for several weeks, in addition to the above measures, may prove effective.
- Intertrigo
- Treatment is targeted to keeping the skin dry, with the addition of topical nystatin powder, clotrimazole, or miconazole twice daily, often in conjunction with a midpotency corticosteroid. Patients with 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). Many anecdotally based remedies exist for intertrigo that have been used in dermatology offices for years with success. The remedies have focused on both drying the moist inflamed area and treating the candidosis. The treatments are adjusted based on whether the inflammation is acute (wet and red), subacute (red +/- maceration), or chronic (red and dry)
- For acute intertrigo, Domeboro solution, Castellani paint, or vinegar/water (1 tbsp vinegar per qt room-temperature water) may be applied twice per day for 5-10 minutes for 3-5 days as needed. Dry the area with a hair dryer (no heat). Apply a shake lotion twice per day (mixture: 40 g USP talc, 40 g zinc oxide, 10 g glycerin; mix into slurry or milkshake consistency, add distilled water up to 120 mL, dispense in 180-mL [6 oz] bottle). Place a large bath towel under breasts or in pendulous areas twice per day. Castellani paint (carbol fuchsin) is messy, but nightly painting may help when nothing else does. Some patients respond well to triamcinolone-nystatin cream.
- For subacute intertrigo, benzoyl peroxide wash may be used 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 (no refills for the latter).
- For chronic intertrigo, the zinc-talc shake lotion may be used once or twice daily, and the hydrocortisone cream/antifungal mixture may be applied at night. Local hyperhidrosis may be treated with antiperspirants (ie, Arrid Extra Dry Unscented, Dry Idea) on a long-term basis. These products, along with the more concentrated Drysol (aluminum chloride 20%), may sting macerated skin. Nystatin in talc (100,000 U/g or 15 g) may be applied twice per day for a few days, then tapered and replaced with unscented baby powder as a powder-approach alternative.
- Sundaram et al18 noted that candidal intertrigo can be treated with filter paper soaked in Castellani paint.
- Paronychia: Treatment with topical agents usually is 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 mo) or terbinafine (250 mg qd for 3 mo) is recommended.
- Candidosis and HIV: Topical therapy with agents such as nystatin and clotrimazole require a minimum of 20-30 minutes of drug contact with the oral mucosa. Treatment with topical therapies may be effective in the early stages of HIV infection, and it becomes less effective with disease progression. Oral treatment with a 2-week course of antifungal therapy (itraconazole, fluconazole, ketoconazole) is indicated in more refractory cases. In patients who are significantly immunocompromised, maintenance therapy on an intermittent (alternate days to twice weekly dosing of ketoconazole 200 mg or fluconazole 100 mg) or continuous basis may be required to provide symptomatic relief. In general, the goal is the cessation of therapy once clinical symptoms have subsided, since prolonged therapy increases the likelihood of the development of drug-resistant organisms.
- Infectious Diseases Society of America clinical guideline summary - Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.19
Medication
The azoles are a group of synthetic antimycotic agents with a broad spectrum of activity. The primary drugs available include ketoconazole, miconazole, fluconazole, itraconazole, and econazole. The mechanism of action of azoles is blocking the synthesis of ergosterol, the primary sterol in the fungal cell membrane. The depletion of ergosterol alters the fluidity of the cell membrane and alters the action of the membrane-associated enzymes. This results in inhibition of replication and inhibition of the transformation of candidal yeast forms into hyphae, which is the invasive and pathogenic form of the parasite.
Nystatin and amphotericin are polyenes, which are active against some fungi but have little action on mammalian cells and no action on bacteria. They bind to cell membranes and interfere with permeability and transport functions. These antibiotics act as ionophores and causes leakage of cations.
Terbinafine is an allylamine that is fungicidal for a wide range of skin pathogens. It inhibits squalene epoxidase, which is involved in the synthesis of ergosterol from squalene in the fungal cell wall. The accumulation of squalene within the cell is toxic to the organism.
A case of chronic mucocutaneous candidosis that was cured with micafungin has been reported.
Voriconazole is another third-line treatment.
Antifungal agents
Exert fungicidal effect by altering permeability of fungal cell membrane. Mechanism of action also may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide toxic to the fungal cell.
Nystatin (Mycostatin)
Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.
Treatment should continue until 48 h after disappearance of symptoms.
Adult
Thrush: (1:100,000 U/mL) 4-6 mL PO swish and swallow qid
Chronic intertrigo: Nystatin in talc, 100,000 U/g (15 g or 30 g) bid; taper as conditions improves; use unscented baby powder adjunctively
Tablets: Insert 1 tab intravaginally qhs for 14 d
adjunctively
Pediatric
Infants: 1 mL to gums and either side of mouth qid; few gtt ingested as part of treatment
Preterm infants: 0.5 mL to either side of mouth qid
Treat for 10-14 d or until 48-72 h after resolution of symptoms
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Virtually no adverse effects when used topically; may cause GI tract distress or diarrhea if taken in large doses PO; do not use to treat systemic mycoses
Miconazole (Micatin, Monistat-Derm, Monistat)
Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased causing nutrients to leak out, resulting in fungal-cell death.
Lotion is preferred in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.
Adult
Tablets: Insert 1 suppository intravaginally qhs for 7 d (100 mg) or 3 d (200 mg)
Intravaginal cream: Insert 1 applicator intravaginally qhs for 7 d
Topical: Apply 2% cream/powder/spray to affected areas bid for 7 d
Pediatric
Topical: Apply 2% cream/powder/spray to affected areas bid for 7 d
None reported
Documented hypersensitivity; first trimester of pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes; local reactions to 0.5-1.5% concentrations include dyspareunia, mild vaginal or vulvar erythema, burning, pruritus, urticaria, and rash
Clotrimazole (Lotrimin, Mycelex, Gyne-Lotrimin)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells. Reevaluate diagnosis if no clinical improvement after 4 wk.
Adult
Thrush: 10 mg troche dissolved 5 times/d for 14 d
Tablets: 100 mg: Insert 1 tab intravaginally qhs for 7 d
500 mg: Insert 1 tab intravaginally hs once
Intravaginal cream: Insert 1 applicator qhs for 7 d
Topical: Apply 1% cream, solution, or lotion to affected areas bid for 7 d
Pediatric
Topical: Apply 1% cream, solution, or lotion to affected areas bid for 7 d
None reported
Documented hypersensitivity; first trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external use only; avoid contact with eyes; discontinue if irritation or sensitivity develops; local reactions to 0.5-1.5% concentrations include dyspareunia, mild vaginal or vulvar erythema, burning, pruritus, urticaria, and rash
Fluconazole (Diflucan)
Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.
Adult
Thrush (non-AIDS related): 200 mg PO single dose or 100 mg/d for 5 d
Thrush (AIDS related): 200 mg PO first day, then 100 mg qd until improvement (3-4 d)
Continued suppressive treatment: 100 mg PO qwk
Intertrigo: 100 mg PO qd for 7-14 d
Vaginal: 150 mg PO single dose
Pediatric
3-6 mg/kg PO qd for 14-28 d or 6-12 mg/kg qd depending on severity of infection
Levels may increase with hydrochlorothiazides; fluconazole levels may decrease with chronic coadministration of rifampin; coadministration of fluconazole may decrease phenytoin clearance; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine concentrations may occur when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse effects include nausea, headache, skin rash, abdominal pain, vomiting, and diarrhea (16% overall rate of adverse effects); rare adverse effects include severe hepatotoxicity, exfoliative dermatitis, and anaphylaxis; monitor closely if rashes develop and discontinue if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS or malignancy and while taking multiple concomitant medications; not recommended in breastfeeding
Itraconazole (Sporanox)
Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Adult
Paronychia: 200 mg PO bid for first wk of month for 3 mo
Intertrigo: 100 mg PO qd for 1-2 wk
Pediatric
Not established; suggested dose of 100 mg/d PO for systemic fungal infections
Antacids may reduce absorption of itraconazole; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (lovastatin or simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce itraconazole levels (phenytoin metabolism may be altered)
Documented hypersensitivity; astemizole, oral triazolam, oral midazolam, and cisapride coadministration (results in increased serum levels that may lead to life-threatening arrhythmias)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic insufficiency; rare adverse effects include hepatitis, hypokalemia, hypertension, impotence, and allergic skin reactions
Terbinafine (Lamisil)
For treatment of paronychia; allylamine antifungal, which inhibits squalene epoxidase and decreases ergosterol synthesis, causing fungal-cell death.
Use medication until symptoms significantly improve.
Duration of treatment should be > 1 wk but not > 4 wk. May not be as effective for candidal infections as azole antifungals.
Adult
Paronychia: 250 mg PO qd for 12 wk
Pulse dosing: 500 mg PO qd for first wk of month for 2 mo (fingernails) or 4 mo (toenails)
Pediatric
Weight-based dosing (PO):
12-20 kg: 62.5 mg/d
20-40 kg: 125 mg/d
>40 kg: 250 mg/d
Treatment duration as in adults
May decrease cyclosporine effects; toxicity of terbinafine may increase with rifampin and cimetidine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Rare cases of symptomatic cholestatic hepatitis have been reported; discontinue if chemical irritation or signs of hepatobiliary dysfunction develop; joint and muscle pains, rash, and decreased WBC count can occur
More on Candidiasis, Cutaneous |
| Overview: Candidiasis, Cutaneous |
| Differential Diagnoses & Workup: Candidiasis, Cutaneous |
 Treatment & Medication: Candidiasis, Cutaneous |
| Follow-up: Candidiasis, Cutaneous |
| Multimedia: Candidiasis, Cutaneous |
| References |
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References
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Further Reading
Keywords
yeast, candidosis, vulvovaginitis, balanitis, intertrigo, paronychia, onychomycosis, erosio interdigitalis blastomycetica
