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Candida - skin - Management
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How should I diagnose skin candida infection?

  • The diagnosis of candida infection of the skin is usually made from characteristic features, and investigations are usually unnecessary:
    • Soreness and itching is usual.
    • Commonly affected areas include skin flexures (such as the groin, under the breasts, axillae, and perineal folds), interdigital web spaces, and the corners of the mouth.
    • Thin-walled pustules with a red base may be present. Scale can accumulate, producing a white-yellow, curd-like substance over the infected area.
    • In flexural areas (intertrigo) the skin fold is typically red and moist. As the condition develops, a typical fringed, irregular edge and pustular or papular satellite lesions may be present.
    • If the web spaces of the toes or fingers are involved, marked maceration with a thick, horny layer is usually prominent.

Basis for recommendation

What else might it be?

  • If typical features are not present, consider other diagnoses which may be mistaken for candida infection of the skin:

Basis for recommendation

When should I look for an underlying cause?

  • Look for an underlying cause if candida infection of the skin is widespread or recurrent (investigations may be required). Consider:
    • Use of systemic corticosteroids or antibiotic treatment.
    • Diseases in which the barrier function of the skin is disturbed (such as psoriasis and seborrhoeic eczema).
    • Immunocompromise (such as HIV infection, chemotherapy, immunosuppressive drugs).
    • Diabetes — see the CKS topic on Diabetes type 2.
    • Anaemia — see the CKS topic on Anaemia - iron deficiency.

Basis for recommendation

  • CKS found no evidence or guidelines on when to investigate for an underlying cause of candida infection of the skin, but has pragmatically suggested that this should be done if the infection is widespread or recurrent.
  • The recommendations on potential conditions to exclude have been extrapolated from the risk factors for developing candida infection of the skin. These were discussed in a guideline on the management of mucocutaneous candidiasis [American Academy of Dermatology, 1996] and a review [Evans and Gray, 2003], both based on expert opinion.

When should I swab?

  • Swabs are not routinely recommended. Take standard bacteriology swabs for microscopy and culture if:
    • The diagnosis is uncertain.
    • There is no improvement after initial treatment.
    • Secondary bacterial infection is suspected.
    • Systemic treatment is being considered.
    • The person is immunocompromised.

Basis for recommendation

  • CKS identified no guidelines or trials on when to swab; recommendations are based on expert opinion in reviews of the literature:
    • The culture of candida from an inflamed skin fold usually justifies starting anti-candida treatment [Hay and Moore, 2004].
    • If there is no improvement after treatment, bacterial culture and sensitivity tests should be performed [Janniger et al, 2005].
    • A skin swab is recommended if there is clinical suspicion of secondary bacterial infection [Laube, 2004].
    • Laboratory tests to confirm the diagnosis of mucocutaneous candidiasis are especially important when systemic treatment is planned [American Academy of Dermatology, 1996].
    • Drug-resistant strains of Candida albicans and related species have been reported, especially in immunosuppressed people and people managed with prophylactic antifungal preparations [Evans and Gray, 2003].

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