Cutaneous candidiasis

Cutaneous candidiasis is a superficial fungal infection of the skin caused predominantly by Candida albicans. It occurs when Candida — a normal commensal organism of skin and mucous membranes — overgrows in warm, moist, and occluded areas of the body.

The infection mainly affects intertriginous areas (skin folds) and is strongly associated with conditions that reduce host immunity or increase moisture.

Predisposing / Risk Factors

Host Factors

• Diabetes mellitus

• HIV/AIDS and other immunosuppression

• Pregnancy

• Obesity

• Infancy and old age

• Hyperhidrosis (excess sweating)

• Malnutrition

Drug-Related

• Prolonged antibiotic use

• Corticosteroid therapy

• Chemotherapy

• Oral contraceptive pills

• Immunosuppressive therapy

Local Factors

• Occlusive clothing

• Poor hygiene

• Prolonged wetness (diapers, gloves, boots)

• Frequent water exposure (dishwashers, cleaners)

• Friction in skin folds

Pathophysiology

Candida normally colonizes skin without causing disease.

In favorable conditions:

1. Moisture + maceration damages stratum corneum

2. Candida converts to invasive hyphal form

3. Invades superficial epidermis

4. Causes inflammation and pustule formation

The hallmark feature: satellite lesions around a primary erythematous plaque

Common Sites of Infection

• Groin (intertrigo)

• Axillae

• Inframammary folds

• Abdominal folds

• Perineum

• Diaper area (diaper dermatitis)

• Finger web spaces

• Around nails (paronychia)

• Under occlusive dressings

Clinical Presentation

A. Intertrigo (Most Common)

• Bright red erythematous moist patches

• Maceration

• Burning sensation

• Itching

• Satellite pustules/papules around edges

• Foul odor in severe cases

B. Diaper Candidiasis

• Beefy red rash

• Involves skin folds (distinguishes from irritant diaper rash)

• Satellite pustules

• Infant irritability

C. Candidal Paronychia

• Painful swollen nail folds

• Pus discharge

• Nail dystrophy

• Worse with frequent water exposure

D. Chronic Mucocutaneous Candidiasis (rare)

• Persistent widespread infection

• Often immunological disorder

Diagnostic Criteria

Diagnosis is clinical when the following are present:

• Moist erythematous plaques in skin folds

• Satellite pustules

• Maceration

• Risk factors (diabetes, moisture, antibiotics)

Investigations

Usually not required for classic presentation.

Differential Diagnosis

• Dermatophyte infection (tinea cruris/interdigital)

• Erythrasma

• Seborrheic dermatitis

• Psoriasis (inverse)

• Contact dermatitis

• Bacterial intertrigo

Key distinguishing feature: satellite pustules in candidiasis

Treatment

A. Non-Pharmacological Treatment

Essential for cure — medications alone often fail if moisture persists.

• Keep affected areas dry

• Wear loose cotton clothing

• Reduce friction in folds

• Frequent diaper changes in infants

• Weight reduction (obese patients)

• Dry skin folds after bathing

• Avoid prolonged wet exposure

• Use absorbent powders (zinc oxide/talc where appropriate)

• Control diabetes

B. Pharmacological Treatment

First-Line Topical Antifungals (14 days minimum)

Clotrimazole 1% creamApply every 12 hours for 2 weeks

OR

Miconazole 2% creamApply every 12 hours for 2 weeks

Alternative Topical Options

• Nystatin cream

• Ketoconazole cream

• Econazole cream

Continue therapy 7 days after lesion resolution.

Severe / Extensive Disease

Systemic therapy required:

Fluconazole oral(especially in recurrent or diabetic patients)

Paronychia Management

• Avoid water exposure

• Antifungal cream

• Occasionally mild topical steroid + antifungal combination

Complications

• Secondary bacterial infection

• Chronic recurrent intertrigo

• Nail dystrophy

• Spread to mucosal candidiasis

• Systemic candidiasis (rare, immunocompromised)

Prevention

• Maintain skin dryness

• Good hygiene

• Loose breathable clothing

• Control diabetes

• Avoid unnecessary antibiotics

• Dry skin folds after bathing

• Frequent diaper changes

• Use protective barrier creams in infants

• Proper hand drying for workers in wet environments

Prognosis

• Excellent with proper hygiene and antifungals

• Recurrence common if moisture persists

• Chronic in diabetics and immunocompromised