Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 18/03/2015
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Caroline Halverstam and Steven R. Cohen
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Cutaneous candidiasis is typically caused by Candida albicans, which exists as normal flora of human skin as well as in the gastrointestinal and genitourinary systems. Overgrowth of Candida species is suppressed by normal bacterial flora. Other Candida species occasionally cause mucocutaneous infections, the second most common being Candida tropicalis. Under certain conditions, these Candida species overgrow and become pathogens. Warmth and moisture of the intertriginous skin (axilla, inguinal folds, abdominal creases, inframammary creases), an increased skin pH, and the administration of antibiotics can disrupt the normal bacterial flora, allowing Candida to proliferate. Clinically, candidiasis presents as scaly erythematous patches with satellite papules and pustules. The diagnosis is made either microscopically, with a potassium hydroxide (KOH) preparation revealing spores and pseudohyphae, or by culture.
Topical antifungal agents include, but are not limited to, polyenes, azoles, allylamines, and ciclopirox olamines. Most studies required therapy twice daily for 4 weeks to ensure complete clearance in all patients. Notably, microscopic cure was often present before complete clinical clearance.
Topical corticosteroids are a source of controversy. Although the addition of corticosteroids to local antifungal therapy may reduce local inflammation in acute candidiasis, their use should be limited to 1 or 2 days because of their immunosuppressant properties.
Systemic therapy may be appropriate for cutaneous infections in immunosuppressed patients, in the setting of extensive disease not responding to topical therapy, or in patients non-compliant with topical therapy. Fluconazole 150 mg weekly appears to be as efficacious as fluconazole 50 mg daily or ketoconazole 200 mg daily. As in topical therapy, microscopic cure often precedes complete clinical clearance.
KOH
Culture
Diagnosis of superficial mycoses by direct microscopy: a statistical evaluation.
Mohanty JC, Mohanty SK, Sahoo RC, Sahoo A, Prahara. Indian J Dermatol Venereol Leprol 1999; 65: 72–4.
Scrapings and cultures were taken from 250 patients with superficial mycotic infections including 18 cases of candidiasis. Scrapings were cultured and examined by direct microscopy in 10% KOH solution . Eleven of the candidiasis cases showed pseudohyphae and blastospores on microscopic examination with KOH solution. Nine of the 18 cases of candidiasis had a positive culture. The overall sensitivity of a KOH test to detect any of the above mycoses was 89%, and was found to be as good at detecting mycoses as culture.
A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans.
Gallup E, Plott T. J Drugs Dermatol 2005; 4: 29–34.
A multicenter, open-label study which included 44 male and female subjects aged 6–29 months with diaper dermatitis due to C. albicans. The study medication was applied topically to the affected area twice daily for 1 week. Subjects were clinically evaluated at baseline and at days 3, 7, and 14. The results showed a statistically significant improvement in both the rate of mycological cure and the reduction of severity score at each time point compared to baseline.
Topical treatment of dermatophytosis and cutaneous candidiasis with flutrimazole 1% cream: double-blind randomized comparative trial with ketoconazole 2% cream.
Del Palacio A, Cuetara S, Perez A, Garau M, Calvo T, Sánchez-Alor G. Mycoses 1999; 42: 649–55.
A double-blind, randomized study in which the efficacy and tolerance of flutrimazole 1% cream was compared with ketoconazole 2% cream, applied once daily for 4 weeks, in 60 patients with culture-proven dermatophytosis (47 patients) or cutaneous candidiasis (13 patients). The results of this study showed that flutrimazole 1% cream is as safe and effective as ketoconazole 2% cream for Candida and dermatophyte skin infections.
Naftifine cream in the treatment of cutaneous candidiasis.
Zaias N, Astorga E, Cordero CN, Day RM, de Espinoza ZD, DeGryse R, et al. Cutis 1988; 42: 238–40.
In a double-blind, parallel-group clinical trial, 60 patients with cutaneous candidiasis were randomly assigned to receive naftifine cream 1% or its vehicle twice a day for 3 weeks. Two weeks after the end of therapy, 77% of the naftifine-treated patients were mycologically cured (negative results on KOH preparations and culture) and had no clinically apparent disease, compared to only 3% of patients treated with vehicle alone.
A comparison of nystatin cream with nystatin/triamcinolone acetonide combination cream in the treatment of candidal inflammation of the flexures.
Beveridge GW, Fairburn E, Finn OA, Scott OL, Stewart TW, Summerly R. Curr Med Res Opin 1977; 4: 584–7.
In a multicenter double-blind trial, 31 patients with bilateral candidal lesions of the flexures were treated for 14 days with nystatin cream on one side and with a combination of nystatin and triamcinolone acetonide cream on the other side. Both treatments proved equally effective in terms of mycological cure rate and clinical improvement. There was a weak trend by both patients and physicians to favor the combination preparation because symptoms resolved more rapidly.
Prospective aetiological study of diaper dermatitis in the elderly.
Foureur N, Vanzo B, Meaume S, Senet P. Br J Dermatol 2006; 155: 941–6.
Of 46 patients, all over 85 years of age with dermatitis of the diaper area, 24 were identified as candidiasis. Of these, eight (33%) were cured after 1 month of topical bifonazole therapy, three (12.5%) improved, and 13 (54%) were cured after the addition of oral fluconazole 100 mg once daily for 1 month. Although topical antifungal drugs represent the first line of treatment for diaper dermatitis in the elderly, more than half the patients in this study required an oral antifungal to achieve a complete cure.
Fluconazole versus ketoconazole in the treatment of dermatophytoses and cutaneous candidiasis.
Stengel F, Robles-Soto M, Galimberti R, Suchil P. Int J Dermatol 1994; 33: 726–9.
Patients were treated with either fluconazole 150 mg once weekly plus daily placebo, or ketoconazole 200 mg once daily plus weekly placebo for 2 to 6 weeks. Candida
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
Topical antifungal
Topical antifungal combined with topical corticosteroids
Systemic azoles
