Approach Considerations
While topical antifungal drugs are used most frequently in the treatment of cutaneous C albicans infection, there is concern about rising resistance to these therapies. In particular, reports of Candida strains displaying resistance to azoles and echinocandins have increased in recent years and present a concerning development in the management of invasive candidiasis. [59] Furthermore, the rise of C auris, a pathogenic strain of Candida exhibiting antifungal resistance, is a concerning development and is often found in nosocomial settings. The increasing prevalence of this species is thought to be due to the use of prophylactic systemic antifungal agents such as fluconazole. [60] A 2020 report from the US Centers for Disease Control and Prevention described three chronically ill people in New York who were identified as having pan-resistant C auris infection. [61] The report stated that the pan-resistant C auris infection developed after the patients had received antifungal medications, including echinocandins, a class of drugs that targets the fungal cell wall. As a result, other treatment options are being considered, including antimicrobial peptides, blue/ultraviolet light, and probiotics. [62, 63, 64, 65]
Medical Care
Candidal vulvovaginitis
Topical antifungal agents, including nystatin, miconazole nitrate (Micatin, Monistat-Derm), or clotrimazole (Lotrimin, Mycelex) creams, are generally 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.
Candidal balanitis
Topical therapy is sufficient in most patients. Asymptomatic sexual partners should be evaluated and treated if they are affected. If persistent lesions spread beyond the genitalia, diabetes should be considered.
Congenital candidiasis
Topical preparations usually are effective unless the infection is disseminated, in which case systemic medication is needed. Most patients can be treated with nystatin oral suspension. Usual treatment is 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/day.
Candidal diaper dermatitis
Treatment for candidal diaper dermatitis 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 talc-free baby powders and zinc oxide paste are adequate preventive measures. For topical therapy of candidal diaper dermatitis, nystatin, amphotericin B, miconazole, and clotrimazole are effective and almost equivalent in efficacy. For more severe forms of diaper dermatitis, control of underlying causative factors, especially diarrhea, is necessary.
Oral candidiasis
Most patients can be treated with nystatin oral suspension. Usual treatment is 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/day.
Treatment of adults with a topical agent such as nystatin (1:100,000 U/mL, 5 mL oral rinse and swallow four times daily) or clotrimazole troches (10 mg 5 times/day) usually is effective. In most patients, the duration of antifungal therapy should be at least twice as long as the termination of clinical signs and symptoms of candidiasis. Oral fluconazole, 100 mg once daily for 2 weeks, can be used 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.
Candidal intertrigo
Treatment is targeted at keeping the skin dry, with the addition of topical nystatin powder, clotrimazole, or miconazole twice daily, often in conjunction with a mild topical corticosteroid if needed for itching. 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).
Paronychia
Treatment with topical agents may not be effective but can be attempted for chronic candidal paronychia. [66] Antifungal solutions are preferred over creams to allow drying. Exacerbating factors such as excessive exposure to moisture should be discontinued. Oral therapy itraconazole, fluconazole, or terbinafine may be used.
Candidiasis and HIV
Topical therapy with agents such as nystatin and clotrimazole are the mainstay of treatment. Treatment with topical therapies may be effective in the early stages of HIV infection. 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 may promote the development of drug-resistant organisms.
Guidelines
Related clinical guidelines have been released by the Infectious Diseases Society of America. [67] See Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
Prevention
Owing to rising resistance in numerous antifungal drugs and the existence of undesirable adverse effects, as well as a general desire to avoid disease, it is preferable to prevent rather than treat Candida infections. The largest factor in preventing cutaneous Candida infection is removing moisture from the skin. [68] Accordingly, skin should be kept dry through means such as the use of breathable materials when indicated and possible. For example, in a clinical trial with infants (age 3-15 months), the use of a breathable diaper as opposed to a traditional diaper diminished C albicans colony count by nearly two thirds. [68]
Additionally, as demonstrated in infants, the use antibiotics increases the risk of Candida infection, a phenomenon that the authors attribute to the change in the gut microbiome, and judicious antibiotic use could lessen the likelihood of infection. [69]
-
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.
-
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.
-
Dry, red, superficially scaly, pruritic macules and patches on the penis represent candidal balanitis.
-
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.
-
A nailfold with candidal infection becomes erythematous, swollen, and tender with an occasional discharge.
-
Soreness and cracks at the lateral angles of the mouth (angular cheilitis) is a frequent expression of candidosis in elderly individuals.
-
Fine superficial pustules on an erythematous patchy base are suggestive of candidosis.
-
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.
-
Candidiasis. Courtesy of Hon Pak, MD.
-
Erythema, maceration, and satellite papules seen in candidal intertrigo under the breast. Courtesy of Kenneth Greer, MD.
