• CKS found no trial evidence to guide advice for people with candida infection of the skin. The recommendations are therefore based on expert opinion in a guideline on the management of candidiasis [Pappas et al, 2004], and review articles [Evans and Gray, 2003; Laube, 2004].

Topical antifungal treatment

• There is a lack of evidence regarding the efficacy of treatments for candida infection of the skin [Evans and Gray, 2003]. However, CKS has recommended treatment with a topical imidazole cream based on expert opinion in a guideline on the management of candidiasis [Pappas et al, 2004], reviews [Evans and Gray, 2003; Laube, 2004; Pappas et al, 2004], and the British National Formulary (BNF) [BNF 56, 2008]. Ointments are not recommended because they can trap excess moisture [Evans and Gray, 2003].
• The topical formulations recommended in this topic are all licensed for this purpose. CKS found limited evidence of mycological cure with topical clotrimazole, econazole, and miconazole compared with placebo.
• The suggested duration of treatment (see Prescriptions) is based on the manufacturers' summaries of product characteristics (SPCs) [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2008a; ABPI Medicines Compendium, 2008b] and the BNF [BNF 56, 2008]. The BNF recommends continuing local antifungal treatment for 1–2 weeks after the disappearance of all signs of infection, to prevent relapse [BNF 56, 2008].
• Nystatin cream has also been widely used to treat candida infection of the skin, but it is no longer available, except in combination preparations. Evidence from one small study suggests it is effective in treating candida infection of the skin.

Topical corticosteroids

• CKS found two reviews which suggested the use of mildly potent topical corticosteroids to alleviate inflammation and pruritus, on the basis of expert opinion [American Academy of Dermatology, 1996; Laube, 2004].
• CKS found no evidence to indicate the duration of use of a topical corticosteroid so has based this recommendation on feedback from expert reviewers, bearing in mind the potential for adverse effects (e.g. skin thinning and striae) with prolonged use [McKay, 1988; American Academy of Dermatology, 1996].
• CKS found no evidence regarding combination products, but they have been included because they may be useful for certain people.

Systemic treatment

• A number of review articles discussed the place of systemic treatments, and consistently stated that they should not be routinely used, but suggested situations in which they may be appropriate. CKS has listed these criteria [Evans and Gray, 2003; Laube, 2004; Janniger et al, 2005].
• Fluconazole is licensed for candida infection of the skin and the dose and duration of treatment offered for adults (see Prescriptions) is based on the manufacturer's SPC and the BNF [ABPI Medicines Compendium, 2003; BNF 56, 2008]. CKS found no evidence for the use of oral fluconazole in children, and has not recommended its use for people less than 16 years of age because, if topical treatment is not effective, the infection is widespread, or the child is immunosuppressed; assessment in secondary care may be more appropriate.

Drugs not recommended

• CKS found no evidence for the use of topical terbinafine for candida infection of the skin and it is not recommended for use in children [ABPI Medicines Compendium, 2006]. Systemic treatment with terbinafine is not appropriate for refractory candidiasis and it is not licensed for this purpose [BNF 56, 2008].
• Griseofulvin and itraconazole are not licensed to treat candida infection of the skin [ABPI Medicines Compendium, 2008c; BNF 56, 2008].
• Oral ketoconazole can cause serious hepatotoxicity and the Medicines and Healthcare Products Regulatory Agency recommends it should only be used for cutaneous candidosis which cannot be treated topically, or in people intolerant of both fluconazole and itraconazole [MHRA, 2008]. CKS therefore does not recommend its use in primary care for candida infection of the skin.

Immunocompromised people

• A guideline for the management of skin and soft tissue infections states that in immunocompromised people, non-invasive infections can be effectively treated with improved skin care and a topical antifungal drug or a short course of fluconazole [Stevens et al, 2005]. CKS has therefore advised the same management approach for this group as the immunocompetent population.

• CKS found no guidelines on when to refer people with candida infection of the skin. Therefore the recommendations have been based on the following rationale:
• If management in primary care with a topical imidazole followed by oral fluconazole has not been successful, CKS advises referral to a dermatologist to ensure that the diagnosis is correct and for consideration of further treatment which is more appropriate to a secondary care setting.
• People with widespread infection or recurrent episodes may have underlying predisposing factors (e.g. immunocompromise) which require investigation, and may need further treatment only available in secondary care.