Hospital Medicine

Candidal skin infections

I. Introduction

Candida intertrigo is a superficial infection of the skin with Candida species. Candida albicans is the most commonly encountered pathogenic species but infections with other species can occur including C. galbrata, C. tropicalis, C. parapsilosis, and C. krusei.

Candida skin infections are commonly encountered in the inpatient setting. Infections typically arise in areas with persistent moisture. Areas commonly infected include skin folds of the breasts, pannus, axilla, groin, perineum, and genitals. Infections of the hands and periungal infections can arise in patients whose hands are in frequent contact with water or wear occlusive gloves for long periods.

Symptoms

Typically, patients report redness, itching, burning, and discomfort at the site of infection.

Exam Findings

In intertriginous infections, exam reveals symmetrical areas of erythematous, macerated skin along skin folds. Gray or whitish deposits may be seen overlying the inflamed skin. Infected skin may be demarcated by a scaly border along the periphery. Satellite pustules separate from the primary lesion can occur. Candida balanitis may present with persistent scaly patches and ulceration of the glans penis.

Prevalence/Occurrence

Candida species are a common cause of skin infections. A study by Peñate et al. published in Dermatology in 2009 found that cutaneous candidiasis was a commonly encountered inpatient dermatologic problem, accounting for 7.1% of dermatology consultation.

Risk Factors

While normal flora of the gastrointestinal tract, Candida is not considered normal flora of the skin. Predisposing factors to candidal skin infection include those that impact local tissue integrity, affect the normal flora of the skin, or impair the immune response to infection. Obesity and use of occlusive dressings increase the moisture content in susceptible areas promoting growth of Candida. Elderly and deconditioned patients are at risk for infection due to diaper use, inadequate self care, and poor nutritional status. Antibiotic use can alter the normal flora of the skin and allow for the growth of Candida. Similarly, conditions that impair the immune response can blunt the response to candidal infection. A variety of immunocompromised states can predispose to candida skin infection including diabetes, malignancy, certain therapies (chemotherapy, steroids, and immune modulating medications), radiation treatments, HIV/AIDs, and autoimmune disease. Patients in the inpatient setting are at particular risk for candidal skin infections given the likelihood of multiple predisposing conditions in the same patient.

Mortality/Morbidity

Candidal skin infections are typically easily treated with low morbidity. However, complications of candida can occur including bacterial superinfection of the skin.

Although rare, superficial candidal infections may progress to systemic infection. This is thought to arise because breakdown of skin integrity from infection allows for seeding of the blood with yeast.

Differential Diagnosis

Differential diagnosis includes infections and noninfectious skin conditions including tinea infections, bacterial cellutitis, scabies, atopic dermatitis, irritant or allergic contact dermatitis, psoriasis, herpes, seborrheic dermatitis, viral exanthema and drug reactions.

Diagnosis

The diagnosis of Candida skin infection is clinical. A characteristic rash in patients with predisposing factors is sufficient to make the diagnosis. Testing including microscopic examination and culture of skin scrapings may be used to confirm the diagnosis.

Tests not to get

Skin biopsy is not useful in diagnosing candidal skin infection as there are no classic histologic findings typical of intertrigo.

Testing

Diagnostic testing includes microscopic examination and culture of skin scrapings and swabs. Potassium hydroxide (KOH) preparations of skin scrapings are a simple and cost-effective method of detecting candida. KOH allows for visualization of the fungal elements of Candida including budding yeast and pseudohyphae. Stains that bind the fungal cell wall may enhance the visualization of fungal elements. Culture of skin swabs from the affected area may allow for identification of specific Candida species.

If suspected, bacterial culture can help identify a secondary bacterial infection.

Treatment

Initial management of suspected candida skin infections includes topical antifungals and interventions to reduce moisture and skin contact. Topical antifungals including imidazoles, terbinafine, and ciclopirox are considered first line pharmacologic agents. Topical antifungal agents should be applied twice daily to the affected area until resolution. A typical treatment course is 2-4 weeks. If the patient does not improve after a course of topical treatment, bacterial culture and sensitivity should be performed.

Adjunctive therapy can be considered to reduce the symptoms of candida skin infection. Topical corticosteroids used in conjunction with antifungal therapy may be helpful in addressing associated pruritus and pain. Low potency steroids are recommended and stronger steroids preparations including those that contain both an antifungal drug and topical corticosteroid should be avoided. Most topical antifungal agents have some anti-inflammatory properties. Ciclopirox also has activity against both gram-positive and gram-negative bacteria.

Systemic antifungals including fluconazole and itraconazole are effective treatments for candidal skin infections. The potential for side effects and presence of effective topical alternatives limits their utility in practice. While there are no clear guidelines for oral therapy for Candida intertrigo, it may be considered in patients with severe skin infection (multiple areas, significant maceration, significant exudates, and skin breakdown), recurrent or persistent infections, or multiple predisposing factors. Oral ketoconazole is effective for candidal skin infections but is not recommended due to risk of liver injury. A typical treatment course is 2-6 weeks or until signs and symptoms have resolved.

PE Guide

Symptoms and skin manifestations should respond to appropriate therapy. The diagnosis should be reconsidered in patient failing to respond to therapy. In this situation, microscopic examination and culture may assist in the diagnosis.

Chronic Treatment

Treatment of candidal skin infections is twofold: antifungal agents and addressing predisposing factors. Prolonged treatment may be necessary in patients with multiple predisposing factors.

Enhanced local skin care and efforts to minimize moisture and friction are an important consideration. Some advocate using absorptive powders and barrier creams however there is little evidence for a benefit of these treatments. In the inpatient setting, removing occlusive dressings and increased attention to local skin care is key to treatment of candidal skin infections.

Efforts to address underlying predisposing factors are important to promote resolution of infection. These may include improving glucose control in diabetics and maximizing nutritional status.

Common Pitfalls

One common pitfall encountered in treating patients with Candida skin infections is failure to improve local skin care. Low tech interventions such as minimizing the occlusive dressings, regular bathing, changing soiled diapers, and frequent repositioning may help promote resolution of the infection.

Complications

Candida skin infections are typically easily treated with low morbidity. Both recurrence and persistence of candida skin infections can occur. This is more often due to the persistence of predisposing factors in patients rather than true treatment failure.

Complications of Candida intertrigo can occur. Infection leads to local inflammation and damage of the protective skin barrier. As a result, bacterial superinfection can complicate a case of candida intertrigo. Superficial candida infections may progress to systemic infection. This is thought to arise because breakdown of skin integrity allows for seeding of the blood with yeast. Although rare, this is particularly worrisome given the morbidity associated with candidemia.

Discharge

Patients should be educated on local skin care to minimize moisture and friction. Obese patients should be counseled to lose weight. Patients should be advised to wear light, nonconstrictive, absorbent clothing.

Prevention

Preventative measures patients may take include efforts to reduce moisture and friction including keeping areas clean and dry and wearing absorbent, nonocclusive clothing. In the inpatient setting, interventions such as minimizing occlusive dressings, regular bathing, changing soiled diapers and frequent repositioning may help prevent Candida infection.

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