CKS found little published evidence regarding the treatment of candidal skin infections. However, imidazoles are widely considered to be effective.

Topical imidazoles

• There are only a few randomized controlled trials (RCTs) that have assessed the efficacy of topical imidazoles specifically for skin candidiasis. Most of these are very small, with high drop-out rates, and they did not all use mycological cure as the primary outcome.
• The pooled results from two randomized, double-blind, placebo-controlled trials (n = 1361) show that clotrimazole 1% cream and topical clotrimazole 1% solution are effective for the treatment of cutaneous candidiasis when compared with placebo [Spiekermann and Young, 1976].
• People with mycologically confirmed athlete's foot, ringworm of the body, fungal groin infection, pityriasis versicolor, and cutaneous candidiasis were randomized to receive one of four treatments (clotrimazole cream, placebo cream, clotrimazole solution, or placebo solution) for 4–6 weeks.
• For people with cutaneous candidiasis, significantly more people treated with clotrimazole solution or with clotrimazole cream had negative microscopy at 6 weeks, compared with people treated with the placebo vehicles (clotrimazole solution versus placebo, p < 0.001; clotrimazole cream versus placebo, p = 0.003).
• In a small double-blind RCT (n = 30), people with candidal skin infection were randomized to receive miconazole 2% lotion or placebo for 2 weeks [Cullin, 1977]. At week 2, mycological cure rates were 13/15 for miconazole and 1/15 for placebo. No p-values were reported.
• Another small RCT (n = 38) compared clotrimazole 1% cream with econazole 1% cream and placebo for the treatment of candidal intertrigo [Cullen et al, 1984]. After 21 days, overall cure rates (clinical and mycological) were 10/14 (71%) in the econazole group, 11/18 (61%) in the clotrimazole group, and 1/6 (17%) in the placebo group. However, these differences were not statistically significant.

Oral fluconazole

• One RCT (n = 391) compared oral fluconazole 150 mg once weekly for 2–4 weeks with clotrimazole 1% cream applied twice daily for 2–4 weeks [Crevits et al, 1998]. For people with candidal skin infection, mycological cure rates at the end of treatment were 100% for oral fluconazole and 71% for clotrimazole 1% cream.

Nystatin

• In a small single-blind RCT (n = 30), people were randomized to receive 5-fluorocytosine or nystatin cream for 2 weeks. At week 2, all 30 subjects were mycologically free of infection [Gisslen et al, 1974].