This report reflectsthe best data available at the time the report was prepared, butcaution should be exercised in interpreting the data; the resultsof future studies may require alteration of the conclusions orrecommendations set forth in this report.

Reprint requests: American Academy ofDermatology, P.O. Box 4014,
Schaumburg, IL 60168-4014.
J AM ACAD DERMATOL 1996;34:110-5.
Copyright 1996 by the American Academy of Dermatology, Inc.

Guidelines of care for superficial mycoticinfections of the skin: Mucocutaneous candidiasis

Guidelines/OutcomesCommittee on: Lynn A. Drake, MD, Chairman, Scott M. Dinehart,MD, Evan R. Farmer, MD, Robert W. Goltz, MD, Gloria F. Graham,MD, Maria K. Hordinsky, MD, Charles W. Lewis, MD, David M. Pariser, MD, John W.Skouge, MD, Stephen B. Webster, MD, Duane C.Whitaker, MD, Barbara Butler, CPA-SDR Consultant, and Barbara J.Lowery, MPH

Task Force:Boni E. Elewski, MD, Chairman, Mervyn L. Elgart, MD, Paul H.Jacobs, MD, Jack L. Lesher, Jr., MD, and Richard K. Scher, MD

I. Introduction

The American Academy of Dermatology’s Guidelines/Outcomes Committee is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration.

II. Definition

"Guidelines of Care for Superficial Mycotic Infections of the Skin: Mucocutaneous Candidiasis" is one of six documents addressing superficial mycoses. Companion documents in this series include:
Guidelines of Care for Superficial Mycotic Infections of the Skin: Tinea Corporis, Tinea Cruris, Tinea Faciei, Tinea Manuum, and Tinea Pedis
Guidelines of Care for Superficial Mycotic Infections of the Skin: Tinea Capitis and Tinea Barbae
Guidelines of Care for Superficial Mycotic Infections of the Skin: Onychomycosis
Guidelines of Care for Superficial Mycotic Infections of the Skin: Pityriasis Versicolor
Guidelines of Care for Superficial Mycotic Infections of the Skin: Piedra

Mucocutaneous candidiasis is a mycotic infection of the skin and mucous membranes usually caused by the yeast, Candida albicans. However, other Candida species are occasionally responsible. Caution must be exercised when interpreting non C. albicans species. The standard terminology used in this document is cutaneous candidiasis; oral candidiasis (thrush); genital candidiasis; nail unit candidiasis; and chronic mucocutaneous candidiasis (CMCC) (Table I).

III. Rationale

A. Scope

Mucocutaneous candidiasis is a common disorder that affects all age groups, with no sex, race, or ethnic predilection. Mucocutaneous candidiasis is more common in persons who wear dentures, have diabetes mellitus, and in those immunocompromised by disease or by therapy. Most patients have disease limited to the cutaneous surfaces, especially areas of skin folds. However, immunocompromised persons may develop extensive cutaneous involvement. In some patients a serious, even life-threatening, systemic infection may develop. Systemic candidiasis is not addressed in this document.
Mucous membrane involvement may be a marker for an immunocompromised state. The presence of oral candidiasis, especially in adults, may be an initial manifestation of diabetes mellitus, leukemia, lymphoma, malignancy, neutropenia, and HIV infection. Genital candidiasis may affect the vulva and vaginal area, as well as the perineal and crural folds, causing candidal intertrigo. Candidiasis may also affect the nail unit, particularly the nail plate and paronychial area.

B. Issue

Candida yeasts are part of the normal flora of the skin, mouth, intestinal tract, and vagina. Multiple intrinsic and extrinsic factors contribute to the development of clinical infection, called candidiasis. Candidiasis is endemic, and when host conditions are favorable, there may be person-to-person transmission. Although numerous systemic and topical therapies are available, unless predisposing factors are corrected, relapses and recurrences are common. Untreated, mucocutaneous candidiasis may become chronic and cause significant disability. Some cases may resolve spontaneously, or on removal of predisposing factors, such as return to an immunocompetent state or discontinuation of antibiotic therapy. However, recurrences are common.
Risk factors for mucocutaneous candidiasis may include:

1. Cutaneous candidiasis

a. Diabetes mellitus

b. Tropical environment

c. Obesity

d. Use of systemic corticosteroids or antibiotic therapy

e. Neutropenia

f. HIV infection

g. Other immunocompromised states

h. Occlusion (e.g., diapers, casts, dressings)

i. Diseases which disturb the integument (e.g., psoriasis, contact dermatitis)

j. Other

2. Oral candidiasis

alloggio in albergo economico Stavangera. Use of broad-spectrum antibiotics; systemic, topical, and inhalational corticosteroids; and cytotoxic drugs

b. Radiation therapy

c. HIV infection

d. Other immunocompromised states

e. Age (i.e., infants and elderly)

f. Occlusion (e.g., dentures)

g. Other

3. Genital candidiasis

a. Women

1) Use of broad-spectrum antibiotics and oral contraceptives

2) Pregnancy

3) Low vaginal pH

4) Diabetes mellitus

5) HIV infection

6) Other immunocompromised states

7) Poor hygiene

8) Infected sexual partner

9) Other

b. Men

1) Uncircumcised penis

2) Maceration

3) Incontinence

4) Diabetes mellitus

5) HIV infection

6) Other immunocompromised states

7) Poor hygiene

8) Infected sexual partner

9) Other

c. Infants and children

1) Occlusion (e.g., diapers)

2) HIV infection

3) Other immunocompromised states

4) Other

4. Nail unit candidiasis

a. Prolonged exposure to water

1) Dish washers

2) Bartenders

3) Beauticians

4) Health care providers

5) Other

b. Occlusion

1) Artificial nails

2) Prolonged use of gloves

3) Other

c. Trauma to the nailfolds and cuticles

1) Nail biting

2) Manicure

3) Occupationally caused

4) Other

d. Other

5. Chronic mucocutaneous candidiasis (CMCC)

CMCC occurs as a autosomal recessive trait that appears in childhood and has several recognized clinical presentations. Despite the widespread or generalized skin and mucosal involvement with Candida, patients rarely have systemic or disseminated disease. Associated findings include alopecia, vitiligo, malabsorption disorders, and endocrine dysfunction. Infection with other microorganisms including Staphylococcus, Streptococcus, and Haemophilus species are quite common in these syndromes.

6. Other

IV. Diagnosticcriteria

A. Clinical

1. History may include

a. General medical history, especially but not limited to:

1) History of weight loss or weight gain

2) Endocrine - diabetes mellitus

3) Risk factors for HIV disease

4) Presence of other risk factors (See III.B.)

5) Use of systemic medications

6) Other

b. Sexual practices

c. Recurrent infections

d. Duration of condition

e. Current treatment(s) topical and systemic of

1) Mucocutaneous candidiasis

2) Other disease

f. Past treatment(s) topical and systemic of

1) Mucocutaneous candidiasis

2) Other disease

g. Family history of diabetes mellitus and/or mucocutaneous candidiasis

h. Occupation

i. Dermatophytic infection, particularly tinea pedis, tinea cruris

j. Drug allergies

k. Other

2. Physical examination may include

a. General physical examination as indicated

b. Examination of the involved area, but special attention may be directed to

1) Skin folds

2) Diaper area

3) Corners of mouth and mucous membranes (e.g., perlche)

4) Interdigital spaces

5) Scrotum, glans penis and foreskin, crural folds, gluteal area

6) Perianal area

7) Vagina, vulva

8) Axillae

9) Nail unit

10) Other

c. Extent of involvement

d. Clinical appearance (Table I)

ERROR MSGe. Associated findings

1) Secondary bacterial infection

2) Postinflammatory hyperpigmentation and hypopigmentation

3) Onychodystrophy and onycholysis

4) Excoriations

5) Other

f. Other

Table I.Location and presentation of mucocutaneous candidiasis infection

B. Diagnostic tests

After review of the patient history and physical examination, the diagnosis can often be established. Laboratory tests may confirm the diagnosis of mucocutaneous candidiasis. This verification is especially important when the use of systemic therapy is anticipated. Simple, inexpensive tests that can be performed in the physician’s office at the time of the patient visit may yield immediate results. Such tests include but are not limited to:

1. Potassium hydroxide preparation (KOH)

Material is obtained from the site of infection. If the lesion is a pustule, the purulent material can be used for the specimen. In cases of cutaneous involvement, the specimen can be obtained from the edge of a lesion. The material is placed on a glass slide and 10% to 20% KOH is added with or without dimethyl sulfoxide. A fungal stain, such as Chlorazol Black E, or Parker’s blue black ink may be used to highlight the pseudohyphae. The presence of pseudohyphae and yeast forms confirm infection.

2. Other stains

Other stains may also be used to identify the yeast forms or pseudohyphae of Candida. These stains include, but are not limited to

Funchal cheap hotelsa. Gram stain

b. Polychromatic multiple stain (PMS)

c. Other

3. Fungal culture

Candida species are yeasts rather than molds and therefore, grow as yeast colonies on Sabouraud’s glucose agar. The addition of cycloheximide to Sabouraud’s agar may inhibit many species of Candida and other saprophytes. However, C. Albicans will grow on media containing cycloheximide. Examples of such media include Mycosel, Mycobiotic, and dermatophyte test medium. Although C. albicans will grow on dermatophyte test media, the agar will not exhibit a red color change as occurs with dermatophyte growth if read at the appropriate time interval, as indicated by the manufacturer’s instructions.

4. Studies for differential diagnosis may include

a. Bacterial culture to evaluate for secondary infection

b. zanck smear or viral cultures to evaluate for herpes virus infection

c. Wood’s light examination to evaluate for erythrasma, especially in intertriginous areas

d. Skin biopsy to differentiate candidiasis from other dermatoses

e. Other

5. Laboratory tests to evaluate risk factors, if applicable, may include:

a. Endocrine tests

1) Blood glucose level

2) Thyroid function studies

3) Other

b. Complete blood cell count

c. HIV

d. Other

C. Inappropriate diagnostic tests

1. Routine allergy testing

2. Hair analysis

3. Other

D. Exceptions

Not applicable

E. Evolving diagnostic tests

Not applicable

V. Recommendations

A. Treatment

1. Medical (Table II)

a. Alteration or improvement of cutaneous environment

1) Avoid occlusion

2) Promote dryness

3) Promote good hygiene

4) Other

b. Cutaneous, genital, and nail unit candidiasis

1) Topical antifungal products include, but are not limited to

a) Imidazole/triazoles

(1) Clotrimazole

(2) Econazole

(3) Ketoconazole

(4) Miconazole

(5) Oxiconazole

(6) Sulconazole

(7) Terconazole (vaginal candidiasis only)

(8) Other

b) Ciclopirox olamine

c) Polyene antibiotics

(1) Nystatin

(2) Topical amphotericin B lotion

(3) Other

d) Topical corticosteroids may be used sparingly for short periods in conjunction with topical and/or systemic antifungals to reduce the inflammatory component.

e) Other topical agents

(1) Drying agents

(2) Powders

(3) Gentian violet

(4) Castellani’s paint

(5) Potassium permanganate compresses

(6) Iodochlorhydroxyquin

(7) Other

f) Evolving

(1) Naftifine

(2) Terbinafine

(3) Other

2) Systemic therapy

Occasionally indicated, especially in widespread disease, recalcitrant disease, and immunocompromised patients

a) Fluconazole

b) Ketoconazole

c) Evolving oral antifungals

(1) Terbinafine (cutaneous candidiasis only)

(2) Itraconazole

(3) Other

d) Other

c. Oral or esophageal candidiasis

1) Topical antifungal products include, but are not limited to

a) Clotrimazole troches

b) Nystatin suspensions

c) Other

2) Systemic therapy

a) Fluconazole

b) Ketoconazole

c) Evolving oral antifungals

(1) Itraconazole

(2) Other

d) Other

d. Chronic mucocutaneous candidiasis

Although topical agents may be useful as adjunctive therapy, this disease is most commonly treated with systemic agents.

1) Systemic therapy may include the following:

a) Ketoconazole

b) Fluconazole

c) Other

2) Evolving systemic therapy

a) Terbinafine

b) Itraconazole

c) Other

e. Other

Treatment of gastrointestinal tract colonization with agents such as oral nystatin may be helpful in preventing recurrences and as an adjunct to other treatment.

2. Surgical

Not applicable

3. Other

a. Treatment of sexual partner(s)

Because genital infections may be sexually transmitted, partners should be examined and treated appropriately.

b. Other

B. Miscellaneous

1. Follow-up

Follow-up examinations may be indicated, depending on extent, severity, and tolerance to medications, as well as the need to augment or alternate treatment based on clinical response. Intervals between visits will vary, depending on, but not limited to the severity of the problem and the intensity of the treatment.

2. Monitoring of patients receiving systemic therapy

Periodic monitoring of hepatic, renal, and hematopoietic function may be indicated in patients treated with systemic antifungals.

3. Drug interactions

Oral antifungals have the potential for significant drug interactions and toxicities. The package insert and the Physicians’ Desk Reference (PDR) should be consulted.

4. Contraindications and precautions for use of systemic antifungal therapy

a. Hypersensitivity to medication

b. Precautions (see package insert and the PDR)

c. Other

Table II. Medications for candidiasis

NOTES: Consult Physicians’Desk Reference or package insert. X, Indication; 1, topicalcorticosteroids may be used sparingly for short periods inconjunction with topical or systemic antifungals to reduce theinflammatory component; 2, oral antifungals may be indicated tosevere disease, recalcitrant disease, and in immunocompromisedpatients; 3, evolving oral therapy; 4, troches.

VI. Supportingevidence

See Bibliography (Appendix)

VI. Disclaimer

Adherence to these guidelines will not ensure successful treatment in every situation. Further, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U. S. Food and Drug Administration.

Appendix. Bibliography
Bickers DR. Antifungal therapy: potential interactions with otherclasses of drugs. J AM ACAD DERMATOL 1994;32:S87-S90.
Bodey GP. Candidiasis in cancer patients. Am J Med1984;77(4D):13-9.
Bodey GP, Samonis G, Rolston K. Prophylaxis of candidiasis incancer patients. Semin Oncol 1990;17:24-8.
Brodell RT, Elewski BE. Clinical pearl: systemic antifungal drugsand drug interactions. J AM ACAD DERMATOL 1995;33:259-60.
Burke WA. Use of itraconazole in a patient with chronicmucocutaneous candidiasis. J AM ACAD DERMATOL 1989;21:1309-10.
Coldiron BM, Manders SM. Persistent Candida intertrigotreated with fluconazole. Arch Dermatol 1991;127:165-6.
Greenspan D. Treatment of oropharyngeal candidiasis inHIV-positive patients. J AM ACAD DERMATOL 1994;31:S51-S5.
Hay RJ. Antifungal drugs on the horizon. J AM ACAD DERMATOL1994;31:S82-S5.
Hay RJ. Antifungal therapy of yeast infections. J AM ACADDERMATOL 1994;31:S6-S9.
Kalb RE, Grossman ME. Ectodermal defects and chronicmucocutaneous candidiasis in idiopathic hypoparathyroidism. J AMACAD DERMATOL 1986;15:353-6.
Kirkpatrick CH. Chronic mucocutaneous candidiasis. J AM ACADDERMATOL 1994;31:S14-S7.Kirkpatrick CH, Sohnle PG. ChronicMucocutaneous candidiasis. In: Safai B, Good RA, eds. Immunodermatology. New York: Plenum Medical, 1982:495-514.
Lesher JL Jr, Smith JG Jr. Antifungal agents in dermatology. J AMACAD DERMATOL 1987;17:383-94.
Klein RS, Harris CA, Small CB, et al. Oral candidiasis in highrisk patients as the initial manifestation of the acquiredimmunodeficiency syndrome. N Engl J Med 1984;311:354-8.
Physician’s Desk Reference. Montvale, NJ: Medical Economics,1995.
Sobel JD. Controversial aspects in the management of vulvovaginal candidiasis. J AM ACAD DERMATOL 1994;31:S10-S3.
alberghi a BolognaWingard JR, Merz WG, Rinaldi MG, et al. Increase in Candidakrusei infection among patients with bone marrowtransplantation and neutropenia treated prophylactically with fluconazole. N Engl J Med 1991;325:1274-7.