6-31: Mucocutaneous Candidiasis

Mucocutaneous candidiasis is a superficial fungal infection that may involve almost any cutaneous or mucous surface of the body. It is particularly likely to occur in diabetic patients, during pregnancy, in obese persons, and in the setting of immunosuppression. Systemic antibiotics, oral corticosteroids, hormone replacement therapy, and oral contraceptive agents may be contributory. Oral and interdigital candidiasis may be the first sign of HIV infection (see Chapter 31). Denture use predisposes the elderly to infection. Abnormalities in the IL-17, IL-22, mannose-binding lectin, and toll-like receptors have all been implicated in predisposing patients to Candida infection of the skin and mucous membranes.

A. Symptoms and Signs

Itching may be intense. Burning is reported, particularly around the vulva and anus. The lesions consist of superficially denuded, beefy-red areas in the depths of the body folds, such as in the groin and the intergluteal cleft, beneath the breasts, at the angles of the mouth(eFigure 6–62), in the webspaces of digits, and in the umbilicus. The peripheries of these denuded lesions are superficially undermined, and there may be satellite vesicopustules. Whitish, curd-like concretions may be present on mucosal lesions (Figure 6–22). Paronychia may occur.

B. Laboratory Findings

Clusters of budding yeast and pseudohyphae can be seen under high power (400×) when skin scales or curd-like lesions are mounted in 10% KOH (eFigure 6–25). Culture can confirm the diagnosis.

Intertrigo (eFigure 6–18), seborrheic dermatitis, tinea cruris, “inverse psoriasis,” (eFigure 6–31) and erythrasma involving the same areas may mimic mucocutaneous candidiasis (eFigure 6–32).

Systemic invasive candidiasis with candidemia may be seen with immunosuppression and in patients receiving broad-spectrum antibiotic and hypertonic glucose solutions, as in hyperalimentation. There may or may not be clinically evident mucocutaneous candidiasis.

A. General Measures

Affected parts should be kept dry and exposed to air as much as possible. Water immersion should be minimized and gloves should be worn for those with infected nails or digital skin. If possible, discontinue systemic antibiotics. For treatment of systemic invasive candidiasis, see Chapter 36.

B. Local Measures

1. Nails and paronychia

Apply clotrimazole solution 1% twice daily. Thymol 4% in ethanol applied once daily is an alternative.

2. Skin

Apply either nystatin ointment or clotrimazole cream 1%, with hydrocortisone cream 1%, twice daily. Gentian violet 0.5% solution is economical and highly effective in treating mucocutaneous candidiasis, but the purple discoloration may represent a cosmetic issue. Severe or widespread cutaneous disease responds to fluconazole, 100–200 mg orally daily, for 1 week.

3. Vulvar and anal mucous membranes

For vaginal candidiasis, single-dose fluconazole (150 mg orally) is effective. Intravaginal clotrimazole, miconazole, terconazole, or nystatin may also be used. Long-term suppressive therapy may be required for recurrent or “intractable” cases. Non-albicans candidal species may be identified by culture in some refractory cases and may respond to oral itraconazole, 200 mg twice daily for 2–4 weeks.

4. Balanitis

This is most frequent in uncircumcised men, and Candida usually plays a role. Topical nystatin ointment is the initial treatment if the lesions are mildly erythematous or superficially erosive. Soaking with dilute 5% aluminum acetate for 15 minutes twice daily may quickly relieve burning or itching. Chronicity and relapses, especially after sexual contact, suggest reinfection from a sexual partner who should be treated. Severe purulent balanitis is usually due to bacteria. If it is so severe that phimosis occurs, oral antibiotics—some with activity against anaerobes—are required; if rapid improvement does not occur, urologic consultation is indicated.

5. Mastitis

Lancinating breast pain and nipple dermatitis in breast-feeding women may be a manifestation of Candida colonization/infection of the breast ducts. Topical nystatin cream and clotrimazole 0.1% cream are safe during lactation. Topical gentian violet 0.5% daily for 7 days is also useful. Oral fluconazole, 200 mg daily for 2 weeks, can be dramatically effective and is also safe during lactation.

Cases of cutaneous candidiasis range from the easily cured to the intractable and prolonged.