Candidiasis (or candidosis) refers to a diverse group of
infections caused by Candida albicans or by other
members of the genus Candida. These organisms
typically infect the skin, nails, mucous membranes, and
gastrointestinal tract, but they also may cause systemic
C. albicans is a dimorphic yeast that is responsible for 70
percent to 80 percent of all candidal infections, which
makes it the most common cause of superficial and
Epidemiologic studies indicate that the relative preva
lence of C. albicans in clinical isolates is declining, and
other species such as C. glabrata, C. tropicalis, C. krusei,
C. dubliniensis and C. parapsilosis are increasingly
encountered as pathogens.
The dif ferent species of Candida can be identified in the
laboratory by microscopic examination of yeast
Factors predisposing to candida infections
Mechanical factors- trauma, local occlusion,
moisture, maceration, dentures, obesity
Nutritional factors- avitaminosis, iron deficiency,
Physiologic alterations- extremes of age,
Systemic illnesses- Down syndrome, endocrine
diseases, malignancy, uremia, immunodeficiency
Iatrogenic causes- X-ray radiation, medications,
C. albicans is often found as a saprophyte and
colonizes the mucous membranes of warm blooded
In up to 50 per cent of normal individuals, the
oropharynx is colonized.
In addition, C. albicans exists as a commensal
organism in the vaginal mucosa of 20 percent to 25
per cent of asymptomatic, healthy women8 and up to
30 percent of pregnant women.
The cutaneous and mucosal manifestations of
candidiasis can be divided into several distinct
candidiasis or thrush is the
most common form of oral
Predisposing factors include
diabetes mellitus, systemic steroid
use, antibiotic use, pernicious
radiotherapy to head and neck, and
cell mediated immunodeficiency.
Up to one third of patients infected
with human immunodeficiency
virus develop oral candidiasis, and
over 90 percent of patients with
syndrome develop oral candidiasis
over the course of their disease.
Oral candidiasis appears as discrete white patches that may become
confluent on the buccal mucosa, tongue, palate, and gingivae.
This friable pseudomembrane resembles milk curds and consists of
desquamated epithelial cells, fun gal elements, inflammatory cells, fibrin,
and food debris.
Scraping the patches exposes a brightly erythematous surface underneath.
Microscopic examination of this material reveals masses of tangled
pseudohyphae and blastospores. In severe cases, the mucosal surface may
Acute atrophic candidiasis
commonly occurs after sloughing of
the thrush pseudomem brane.
This condition is associated with
broad spectrum antibiotic therapy,
glucocorticoid use, and human immu
nodeficiency virus infections.
The most common location is on the
dorsal surface of the tongue, where
there are patchy depapillated areas
with minimal pseudomembrane
There is both an asymptomatic and
symptomatic variant, the later of
which is characterized by burning or
Chronic atrophic candidiasis
(denture stomatitis) is a
common form of oral candidiasis
seen in 24 per- cent to 60 percent
of those wearing dentures.
Female patients are affected more
commonly than males.
Clinical findings of chronic
erythema and edema of the palatal
mucosa that contacts the dentures
as well as angular cheilitis are
Presumably, the chronic lowgrade
trauma and occlusion provided by
dentures predispose to candidal
colonization and subsequent
Candidal cheilosis (angular
‘‘perleche’’, is characterized by
maceration, and soreness at the
angles of the mouth.
This condition is commonly
encountered in habitual lip
lickers, usually in the young,
and in elderly patients with
sagging skin at the oral
Loss of dentition, poorly fitting
dentures, malocclusion, and
riboflavin deficiency may be
VAGINAL AND VULVOVAGINAL
Approximately three fourths of all
women will experi ence an episode of
vulvovaginal candidia sis (VVC) in
C. albicans causes 80 percent to 90
percent of cases of WC, and C.
glabrata is die next most common
Risk factors for VVC include diabetes
mellitus, steroid use, presence of an
intrauterine device, wearing of tight
fitting and synthetic clothing, and
immunosuppression. These factors
disrupt the vaginal lactobacilli that
nor mally inhibit overgrowth of
Patients generally present with a thick vaginal
discharge associated with burning, itching, and
Examination shows whitish plaques on the
vaginal wall with underlying ery thema and
surrounding edema that can extend to the labia
Recurrent VVC is defined as four or more
episodes per year. Recurrent VVC occurs in up
to 5 percent of women. Changes in the
hormonal environment, such as pregnancy and
the luteal phase of the menstrual cycle, can
induce a relapse of WC. Use of a genital
cleansing solution or douche is also associated
with recurrent candidiasis. The mechanism
may be an allergy or hypersensitivity
response that increases suscepti bility to
Candida. Frequent sexual intercourse may
predispose women to recurrent VVC.
CANDIDA OF MALE GENITALIA: BALANITIS
Candida cause 30 percent to 85
percent of infectious balanitis.
Factors predisposing to balanitis
include candidal vaginal infection in
sexual partners, diabetes mellitus,
and an uncircumcised state.
C. albicans balanitis presents as
small papules or frag ile
papulopustules on the glans or in
the coronal sulcus.These break to
leave superficial erythematous
erosions with a collarette of whitish
scale. Infection may spread to the
scrotum and inguinal areas.
Intertrigo is the most common
clinical presentation on glabrous
Usual locations for in- tertrigo
include the genitocrural, axillary,
gluteal, interdigital, and
inframammary areas and between
folds of skin on the abdominal wall.
Predisposing conditions include
obesity, wearing of occlusive
clothing, diabetes mellitus, and
Cutaneous candidiasis appears as pruritic,
erythematous, macerated skin in intertriginous areas
with satellite vesicopustules.
These pustules break open, leaving an erythematous
base with a collarette of easily detachable necrotic
Cutaneous candidal infection is diagnosed by the
typical appearance of skin lesions and the presence
of satellite vesi copustules.
The clinical diagnosis should be confirmed by KOH
examination and culture of skin scrapings.
Candidal diaper dermatitis
is caused by yeast colonization
from patients’ gastrointestinal
Chronic occlusion by wet
diapers furthers the infection.
Lesions appear first in the
perianal area and spread to the
perineum and inguinal creases,
which show pronounced
to interdigital candidal
infection of the hands
or feet; because of
usually affects the third
or fourth interspace.
often affects the back in
Lesions start as isolated
Candida also can colonize
and infect the skin around
wounds covered by occlusive
antibiotics also con tribute
to Candida wound
Candidal paronychia is
common in individuals whose
hands are habitually involved in
wet work (e.g., housekeep ers,
bakers, fishermen, bartenders).
Typ ically there is redness,
swelling, and ten derness of the
paronychial area with prominent
retraction of the cuticle to ward
the proximal nail fold.
Occasionally, pus can be
Secondary nail changes include
onycholysis and transverse
depressions of the nail plate
(Beau’s lines) with a brownish or
green discoloration along the
lateral bor ders.
should be differentiated
from bacterial paronychia
or paronychia associated
The incidence of disseminated
candidiasis is steadily rising as
patients are living longer.
The organisms responsible
include C. albicans, C. tropicalis,
C. glabrata, and C. parapsilasis.
These organisms may gain
hematogenous access from the
oropharynx or gastrointestinal
tract when the function of the
mucosal barrier rs
compromised (e.g., by mucosms
secondary to chemotherapy) or
intravenous catheters. Multiple
organs are involved.
Skin lesions occur in some patients with
disseminated infection. The recognition
of such lesions may be important in
early diagnosis, because antemortem
blood culture results are negative in a
high percentage of patents with autopsy
proven systemic candidiasis.
The characteristic skin lesions are
erythemamus papules with a
hemorrhagic or pustular center. The
eruption is located on the trunk and
extremities and has a varying number of
Associated findings include fever and
myalgias.Necrouccutaneous lesions also
have been encountered in these patients.
CHRONIC MUCOCUTANEOUS CANDIDIASIS
Chronic mucocutaneous candidiasis
(CMC) consists of several clinical
syndromes characterized by chronic,
treatment resistant, superficial candidal
infections of the skin, nails, and
In general, the various syndromes may
be familial or sporadic.
When rhey present in childhood, lesions
are detected before the age of 3 years.
Oral lesions or diaper dermatitis appear
first, followed by angular cheilitis
(perleche), lip fissures, nail and
paronychial involvement, vulvovaginitis,
and cutaneous involvement. Cutaneous
lesions may appear with an
erythematous, serpiginous border or
areas of brownish desquamation on a
background of mild erythema.
Nail involvement is
markedly thickened and
dystrophic nail places
whose entire thickness is
invaded by Candida, The
paronychial areas are red
and edematous, there
may be pus, and the
fingertips are often
There are multiple
conditions that have been
associated with CMC.
Most notably these
esophagitis or laryngitis,
diabetes mellitus, vitiligo,
and iron deficiency.
In superficial candidal infections, the
diagnosis can be made by examining skin
scrapings and observing typical budding
yeasts with hyphae or pseudohyphae. C.
albicans grows readily on Sabouraud’s agar
with added antibiotics and is usually
recommended for isolation. Whitish mucoid
colonies grow within 2 to 5 days.
In systemic candidiasis with skin lesions, the
diagnosis usually can be made from
histopathologic examination and culture of
appropriate skin biopsy specimens.
Blood culture results often are negative in this
Serologic studies using immunodiffusion,
counterimmunoelectrophoresis, and latex
agglutination methods may be somewhat
helpful in the diagnosis; however, false-
negative and false-positive reactions are
Direct microscopic examination for
the presence of yeast provides rapid
evidence to support the clinical
Body fluids such as urine and
cerebrospinal fluid should be
centrifuged and the sediment
examined directly to increase the
probability of finding yeast.
Sputum, surgical biopsy specimens,
and tissue scrapings must be treated
with a clearing agent such as 10
percent KOH and ink before the
material is examined.
Candida appears as oval budding
cells, elongated filamentous cells
connected end to end
(pseudohyphae), or septate hyphae.
Organisms are seldom seen
within the pustule but can be
visualized in the stratum
corneum with the aid of a
periodic acid Schiff (PAS)
The histologic examination
of a candidal granuloma
hyperkeratosis and a dense
dermal infiltrate consisting
granulocytes, plasma cells,
and multinucleated giant
In cases of uncomplicated oral candidiasis, nystatin
suspension or clotrimazole troches are effective.
However, in recurrent cases, oral azoles are proven
to be more effective.
CANDIDAL VULVOVAGINITIS AND BALANITIS
Two therapeutic options exist when dealing with candidal vaginitis.
There are many topical imidazoles that are effective, such as
butoconazole, miconazole, and clotrimazole, available over the
counter, and tioconazole, econazole, and terconazole available by
prescription. They may be used for 8 or 7 days.All these topical
agents are safe to use during pregnancy. Oral fluconazole,
itraconazole, and ketoconazole offer efficacy similar to that of
Prophylactic regimens can be used to prevent recurrent cases. A
weekly clotrimazole 500 mg tablet intravaginally or fluconazole 150
mg/week orally has been shown to prevent recurrences.
The recommended treatment for candidal balanitis is topical
clotrimazole cream or a single 150 mg dose of fluconazoler
Intertrigo has been treated successfully with topical
antifungals in cluding nystatin and topical imidazole
creams. Miconazole powder can be use to dry moist
Chronic paronychia due to Candida is resistant to
therapy. All wet work should be minimized, and a
topical imidazole in solution form is the ideal
treaunent. Four percent thymol in chloroform or
absolute alcohol is drying and may be a suitable
alternative. Oral ketoconazole also may be used.
Amphoteri cin B is available in newer lipid based
formulations. Also, caspofungin is available for
treating disseminated candidiasis.