History
Candidal vulvovaginitis
This common condition in women presents with itching, soreness, and a thick creamy white discharge (see the images below). Although most candidal infections occur more frequently with advancing age, vulvovaginitis is unusual in older women. It is most prevalent in women aged 25-34 years, and, based on survey data, globally nearly 75% of women experience vulvovaginitis at least once. [36] 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.
Vaginal candidiasis. Erythema, edema, and cheesy white discharge. Courtesy of Kenneth Greer, MD.
Vulvar candidiasis. Bright erythema with scaling, fissuring, and satellite papules. Courtesy of Kenneth Greer, MD.
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. [37]
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 the image below). Exacerbations following intercourse are common. Candidal balanitis may be associated with diabetes mellitus and an lack of circumcision in males. [38, 39]
Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis.
Congenital candidiasis
Congenital candidiasis [40, 41] is rare, with 70 cases reported during the 1990s. It may be acquired by the infant in utero or during delivery. Presumably, congenital candidiasis is an ascending intrauterine infection with cutaneous or systemic manifestations generally within 12 hours after birth (see image below). Although the systemic form typically is fatal, congenital cutaneous infections usually have a more benign course unless untreated. Prematurity and the presence of an intrauterine foreign body (intrauterine device) are associated with this condition. Some infants have respiratory distress and pneumonia secondary to in utero aspiration of infected amniotic fluid.
Discrete superficial pustules developed within hours of birth on the hand of an otherwise healthy newborn. A potassium hydroxide preparation revealed spores and pseudomycelium, and culture demonstrated the presence of Candida albicans.
Candidal diaper dermatitis [42]
Infants with oropharyngeal candidiasis invariably harbor C albicans in the intestine and feces (85-90%). Colonized 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 candidal diaper dermatitis include local irritation of the skin by friction; ammonia from bacterial breakdown of urea, intestinal enzymes, and stool; detergents; and disinfectants.
Oral candidiasis
Also known as oral thrush, this is considered as 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.
Oropharyngeal candidiasis in the neonate, commonly called oral thrush, is often acquired from the infected maternal mucosa during passage of the infant through the birth canal. Oropharyngeal candidiasis is 35 times more common in neonates of infected mothers compared with uninfected mothers and 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.
Use of broad-spectrum antibiotics and inhaled corticosteroids, diminished cell-mediated immunity, diabetes mellitus, dentures, and xerostomia are all risk factors for oral candidiasis in adults.
See the image below.
White plaques are present on the buccal mucosa and the undersurface of the tongue and represent thrush. When wiped off, the plaques leave red erosive areas.
Xerostomia may result from aging, medication, or conditions like Sjögren syndrome. A decrease in salivary production decreases both the amount of available mucosal secretory antibody (IgA) and the natural cleansing action provided by saliva.
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. [43]
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 smoking. [44]
Intertrigo
Most cases of cutaneous candidiasis 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 the image below).
Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus result in a form of intertrigo.
Decubital candidiasis
Decubital candidiasis is a particular form of cutaneous candidiasis that occurs on the skin of chronically bedridden patients. [45]
Paronychia
Candida occasionally causes infection in the periungual area and underneath the nailbed (see the image below). 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. Disease is more common in people who frequently submerge their hands in water.
A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge.
Candidiasis and HIV
Many 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, [46] in 2007, reported on a case of disseminated candidiasis as an initial presentation of AIDS. Such cases often manifest with purpuric eruptions.
Other
Other rare presentations include ecthyma gangrenosum–like lesions in a neonate, [47] deep-seated subcutaneous ulcer, [48] interdigital ulcer, [49] and generalized cutaneous candidiasis complicating Darier disease. [50]
Physical Examination
Candidal vulvovaginitis
Clinical examination reveals erythema of the vaginal mucosa and vulvar 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 candidiasis.
Congenital candidiasis
Cutaneous congenital candidiasis typically manifests as an erythematous eruption of macules, papules and superficial pustules on the trunk and extremities, which resolves with extensive desquamation (see image below). The presence of white microabscesses on the placenta and umbilical cord of an infant with such an eruption suggests the diagnosis of cutaneous congenital candidiasis. It is always secondary to candidal chorioamnionitis, but it may pass unrecognized.
Fine superficial pustules on an erythematous patchy base are suggestive of candidosis.
Candidal diaper dermatitis
Candidal diaper dermatitis 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. Scaly papules merge to form well-defined, weeping, and 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 and represent the primary lesions.
Rarer and severe forms of candidal diaper dermatitis include granuloma gluteale infantum and Jacquet erosive diaper dermatitis. Granuloma gluteale infantum can be a complication of diaper dermatitis and presents as erythematous-to-purplish nodules and plaques in the anogenital region of infants. [51] In addition to candidal diaper dermatitis, other risk factors that indicate a predisposition to granuloma gluteale infantum are restrictive synthetic pants and topical corticosteroid use. Jacquet erosive diaper dermatitis is an uncommon variant of diaper dermatitis often seen in occluded skin in lengthy contact with urine or feces. [52] It presents on the genital and perianal skin as superficial ulcerations or pustules. [52]
Oral candidiasis
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.
The most common clinical appearance of oropharyngeal candidiasis (pseudomembranous candidiasis or oral thrush) in the adult population is white plaques on the buccal, palatal, or oropharyngeal mucosa overlying areas of mucosal erythema. Typically, the lesions are adherent, which, when removed, may demonstrate areas with tiny ulcerations. Sometimes, oral candidiasis manifests as diffuse erythema. A variant of oral candidiasis, median rheumatoid glossitis, presents as a discrete cherry-red patch on the posterior tongue. In addition, some patients may develop soreness and cracks at the lateral angles of the mouth called angular cheilitis (see image below). Denture stomatitis [17] presents as chronic mucosal erythema typically beneath the site of a denture.
Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals.
Intertrigo
Candidal intertrigo typically presents as an intensely pruritic, bright-pink, macerated rash with satellite papules and pustules. Erosio interdigitalis blastomycetica (interdigital candidiasis) manifests as hyperhidrosis and maceration and favors the skin between the third and fourth fingers.
Candidal paronychia
The proximal nailfold becomes chronically erythematous and swollen, with loss of the cuticle, nail dystrophy, and onycholysis (see the image below). This can usually be distinguished clinically from acute paronychia, which is caused by Staphylococcus aureus and presents with proximal abscess formation. This can be secondary to bacterial infection with Pseudomonas, which displays a green discoloration under the nail. A potassium hydroxide (KOH) preparation is helpful and is likely to show yeast organisms.
Chronic paronychia. Edema and erythema of the nailfolds with loss of the cuticle; note greenish discoloration of nails from likely pseudomonal coinfection. Courtesy of Kenneth Greer, MD.
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Vaginal candidiasis. Erythema, edema, and cheesy white discharge. Courtesy of Kenneth Greer, MD.
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Vulvar candidiasis. Bright erythema with scaling, fissuring, and satellite papules. Courtesy of Kenneth Greer, MD.
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Discrete superficial pustules developed within hours of birth on the hand of an otherwise healthy newborn. A potassium hydroxide preparation revealed spores and pseudomycelium, and culture demonstrated the presence of Candida albicans.
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Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis.
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White plaques are present on the buccal mucosa and the undersurface of the tongue and represent thrush. When wiped off, the plaques leave red erosive areas.
-
Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus result in a form of intertrigo.
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A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge.
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Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals.
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Fine superficial pustules on an erythematous patchy base are suggestive of candidosis.
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Chronic paronychia. Edema and erythema of the nailfolds with loss of the cuticle; note greenish discoloration of nails from likely pseudomonal coinfection. Courtesy of Kenneth Greer, MD.
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Candidiasis. Courtesy of Hon Pak, MD.
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Erythema, maceration, and satellite papules seen in candidal intertrigo under the breast. Courtesy of Kenneth Greer, MD.
