Cutaneous Candidiasis Clinical Presentation

Updated: May 22, 2018
  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

Candidal vulvovaginitis

This common condition in women presents with itching, soreness, and a thick creamy white discharge (see the image below).

A moist, erosive, pruritic patch of the perianal s A moist, erosive, pruritic patch of the perianal skin and perineum (with satellite pustule formation) is demonstrated in this woman with extensive candidosis.

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 the image below).

Discrete superficial pustules developed within hou 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.

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. [20]

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.

Dry, red, superficially scaly, pruritic macules an Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis.

Congenital candidosis  [21, 22]

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  [23]

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.

Oropharyngeal candidiasis in the neonate most commonly is 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 to uninfected mothers.

Oropharyngeal candidiasis 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 oropharyngeal candidiasis. 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  [23]

Infants with oropharyngeal candidiasis invariably harbor C albicans in the intestine and feces (85-90%). In most patients, candidal diaper dermatitis 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 candidal diaper dermatitis include local irritation of the skin by friction; ammonia from bacterial breakdown of urea, intestinal enzymes, and stool; detergents; and disinfectants.

Diaper dermatitis candidiasis can result in an a generalized eruption known as an Id reaction, also known as autosensitization or an autoeczematization reaction. [24]

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 the image below).

White plaques are present on the buccal mucosa and 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 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. Superficial mycoses may be the presenting sign in immunodepressed patients (especially AIDS). [25]

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 the image below).

Erythema, maceration, and satellite pustules in th Erythema, maceration, and satellite pustules in the axilla, accompanied by soreness and pruritus result in a form of intertrigo.

Decubital candidosis

This is a particular form of cutaneous candidosis that occurs on the dorsal skin of chronically bedridden patients. [26]

Paronychia

Candida organisms occasionally cause 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. 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.

A nailfold with candidal infection becomes erythem A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge

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. [27, 28, 29] 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, [30] in 2007, reported on a case of disseminated candidiasis as an initial presentation of AIDS. Such cases often manifest with purpuric eruptions.

Breast pain

Andrews et al [31] 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 al [32] reported on a solitary ecthyma gangrenosum–like lesion that resulted from C albicans infection in a neonate.

Ulcers

Xi et al, [33] 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.

Cutaneous candidiasis has manifested as an interdigital ulcer. [34]

Other

Cutaneous candidiasis was noted to occur under a ruby ring in a patient who was immunocompromised. [35]

Generalized cutaneous candidiasis can complicate Darier disease. [36]

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Physical Examination

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 al [37] reported that cutaneous congenital candidiasis 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 the image below). The presence of white microabscesses on the placenta and umbilical cord of an infant with such an eruption must suggest the diagnosis of cutaneous congenital candidiasis. It is always secondary to candidal chorioamnionitis, but it may pass unrecognized.

Fine superficial pustules on an erythematous patch Fine superficial pustules on an erythematous patchy base are suggestive of candidosis.

Oropharyngeal 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.

Candidal diaper dermatitis

The eruption of 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. 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 candidal diaper dermatitis and represent the primary lesions. Candidiasis may be a presenting feature of diabetic ketoacidosis. [38]

Oral candidiasis in elderly persons

The most common clinical appearance of oropharyngeal candidiasis (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 the image below). 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.

Soreness and cracks at the lateral angles of the m Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals.

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 the image below). 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.

Candida infection should be in the differential di Candida infection should be in the differential diagnosis when one or more nails become discolored, has subungual discoloration, nailplate separation from the nailbed, and lack evidence of a dermatophyte.
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