Definition, Etiology, PathogenesisTop
1. Etiologic agent: Candida fungi, most often C albicans (see Candidiasis).
2. Reservoir and transmission: see Candidiasis.
3. Risk factors: Next to systemic factors (see Candidiasis), development of oral candidiasis is facilitated by mechanical injuries, decreased saliva secretion, and use of dentures. Skin fold candidiasis is facilitated by wearing clothes that are insufficiently airy, frequent hand soaking (interdigital candidiasis, fingernail candidiasis). Treatment-resistant, persistently recurrent mucocutaneous Candida spp infections occur in individuals with impaired cell-mediated immune response in chronic mucocutaneous candidiasis.
4. Incubation and contagious period: see Candidiasis.
Clinical Features and Natural HistoryTop
1. Oral candidiasis: Lesions are most often caused by proliferation of saprophytic yeast. The reservoir for yeast in the oral cavity is the tongue (central dorsal surface) as well as buccal and palatal mucosa. Acrylic parts of dentures are also inhabited by yeast. There are 2 types of candidiasis: primary and secondary (eg, in endocrinopathies and immunodeficiencies).
Clinical types of oral candidiasis:
1) Erythematous (atrophic) candidiasis is the most frequent type manifested by red, sharply demarcated, macular lesions, most often on the dorsal tongue surface. Filiform papilla atrophy is observed at eruption sites. Lesions can also be located on buccal, labial, pharyngeal, and palatal mucosa. Gingival involvement indicates significant immunodeficiency. Patients may feel burning pain.
2) Pseudomembranous candidiasis (thrush): Lesions may be limited or involve the entire oral cavity. White or yellowish soft coating containing blastospores, fungal pseudohyphae, and epithelial cells is observed, with erythematous margins. Wiping off the white coating reveals red mucous membrane surface with bleeding spots. Patients report dryness and burning in the oral cavity and taste disorders.
3) Chronic hyperplastic candidiasis (candidal leukoplakia) occurs rarely; predisposing factors include smoking, using dentures, and immunosuppression. The eruptions are white, cream-colored, or red hard papules and nodules with granular surface, impossible to be removed with a spatula. The lesions are located centrally on the dorsal surface of the tongue, on the palate, and usually under the denture plate or on the buccal mucosa.
4) Denture stomatitis resembles erythematous and hyperplastic candidiasis and occurs in 15% to 65% of individuals using dentures. Lesions are located on the hard palate under the denture plate. The disease has 3 stages: initially red spots visible at the opening of the palatal salivary glands, then erythema of the hard palate, and finally papillary hyperplasia of the mucous membrane in this area.
2. Angular cheilitis most often occurs in patients aged >50 years when saliva accumulates in mouth corners due to flaccid skin folds, in the case of suboptimal oral hygiene, after antibiotic therapy, or due to vitamin B deficiency. It is facilitated by using dentures. Usually it is a mixed-type infection caused by yeast and bacteria (C albicans, Staphylococcus aureus). Lesions include erythema of the mucous membrane and skin in mouth corners, fissure-like cracking and ulceration, and scabs.
3. Vulvovaginal candidiasis most often develops by proliferation and spread of saprophytic yeast in the vagina. Infections during sexual contacts are also possible. Vulvovaginal candidiasis may be the presenting manifestation of diabetes. The lesions include mucosal erythema and edema, caseous vaginal discharge, severe pruritus (in 90% of patients), burning, and sometimes dysuria. Unpleasant smell indicates a mixed infection with the presence of bacteria. Recurrent disease, defined as ≥4 infections in a year not associated with antibiotic therapy, is diagnosed in 5% of women with vulvovaginal candidiasis.
4. Candidiasis of the glans penis and prepuce (candidal balanoposthitis): Lesions are located on the glans penis and coronal sulcus of the penis. Initially small erythematous vesicles and pustules appear, then the eruptions merge and form an erythematous, oozing area, sometimes with white coating. Lesions may be accompanied by urethritis with edema and erythema of the urinary meatus, purulent discharge, and dysuria. Candidiasis of the glans penis and prepuce may be the presenting manifestation of diabetes.
5. Yeast intertrigo: Lesions are located in the intergluteal cleft, perianal area, inguinal folds, inframammary folds, and interdigital spaces of the hands and feet. Initially a dull white surface is observed, then exfoliation occurs, and dark red, glossy, wet, painful erosions appear. The disease focus is demarcated from the healthy skin with a rim of detached epidermis and surrounded by erythematous and exfoliating satellite lesions.
6. Diaper candidiasis in infants is caused by yeast present in stool. Skin irritation and maceration triggered by other factors present in stool and urine also play a role in the pathogenesis. Severe erythematous lesions are observed deeper in the skin folds in the groins and intergluteal cleft. Small pustules develop on the skin surface. Superficially exfoliating satellite eruptions—erythematous papules and plaques with superficial exfoliation—are observed.
7. Nail fold and nail plate candidiasis: Lesions include paronychia, detachment of the perionychium, edema, and erythema of the nail fold accompanied by pain. Nail matrix infection causes nail plate dystrophy. Nail plate surface becomes rough, dull, with transverse ridges. Fingernails are involved in 70% of cases.
Diagnosis is based on the clinical picture and positive result of mycologic examination. Direct examination (10% KOH) may be helpful. Blastospores and pseudohyphae are detected in 50% to 70% of patients. Culture should be performed when clinical symptoms indicate candidiasis and the direct examination result is negative; and when clinical symptoms persist or recur despite treatment.
In the case of infections of the external genitals, examination for a possible accompanying protozoal or bacterial infection is indicated.
1. Oral candidiasis: Aphthous lesions, lichen planus, leukoplakia.
2. Yeast intertrigo: Bacterial intertrigo, dermatophyte infections, erythrasma.
3. Nail candidiasis: Bacterial paronychia, dermatophyte onychomycosis, nail psoriasis.
Note: Use topical antifungal treatment in mild disease, and systemic treatment in patients not responding to topical treatment, in recurrent infections, or in patients with immunodeficiency.
1) Topical treatment: Use vaginal tablets and globules and creams containing polyene antibiotics (nystatin, natamycin), azole derivatives, iodine disinfectants, boric acid, or lactic acid bacilli. Topical therapy can be administered as a single dose or last for up to <20 days.
2) Systemic treatment (options): Oral fluconazole 150 mg in a single dose, oral itraconazole 200 mg in 2 doses on the first day of treatment or as a 100-mg dose bid for 3 days.
Treatment of recurrent vaginal candidiasis: Apart from treatment of acute infection, consider prophylactic management for 6 months; options: nystatin (1 vaginal tablet for 4 days after menstruation for 6 months), clotrimazole (2 vaginal tablets of 100 mg twice a week for 6 months), oral fluconazole (150 mg every 3 days, 3 doses in total, followed by a maintenance dose of 150 mg once a week for 6 months), oral itraconazole (200 mg or 400 mg once a month for 6 months).
Azole derivatives should not be used topically in the first trimester of pregnancy or orally during the entire pregnancy and lactation period.
1) Topical treatment: Creams and gels containing polyene antibiotics, azole derivatives, ciclopirox.
2) Systemic treatment (options): Oral itraconazole (200 mg bid for 7 days, repeated after 3 weeks), oral fluconazole (150 mg once a week until regrowth of a healthy nail).
Antifungal treatment: Powders or creams containing polyene antibiotics, azole derivatives, ciclopirox. Drugs are used bid or tid for 2 to 4 weeks and then continued for 7 days after lesion resolution.
Maintaining good personal hygiene.