CUTANEOUS CANDIDIASIS ::: Let us recapitulate our knowledge on CUTANEOUS CANDIDIASIS

CUTANEOUS   CANDIDIASIS

Let us recapitulate our knowledge on CUTANEOUS   CANDIDIASIS

 In the skin the most common site   is in the skin folds also called Candida intertrigo .

This   is seen under pendulous breasts between   overhanging abdominal folds in the groin and  rectal area   and in the axillae.

Type A:- Why more common at Skin folds  ??  contains heat  and moisture   providing   the environment suited     for yeast  infection. Hot   humid weather tight or  abrasive   underclothing  poor  hygiene   and inflammatory diseases   occurring  in the skin folds such as psoriasis  make a yeast  infection more   likely  in the axillae.

Skin folds   contains heat  and moisture   providing   the environment suited     for yeast  infection. Hot   humid weather  tight or  abrasive   underclothing  poor  hygiene   and inflammatory diseases   occurring  in the skin folds such as psoriasis  make a yeast  infection more   likely

Type A:--INTERTRIGO

  Obese people are at greatest risk. Itching  burning and   stinging  are the most    common symptoms apposing  skin folds  retain  moisture and become warm  macerated and inflamed,,  Candida is the most  common secondary  infection but  bacteria fungi  or viruses may be a factor . Erosions are possible Sweat  feces urine   and vaginal discharge may aggravate  intertrigo . The course  can be recurrent and chronic.

CLINICAL   FEATURES

 There are two presentations In the first type pustules form but become macerated under apposing  skin surfaces and develop into red papules with a fringe of moist  scale at the border. Intact   pustules may be found outside the opposing  skin  surfaces.

2) Type B:-The second type consists of a red   moist glistening plaque that extends to or just   beyond  the limits of the opposing   skin folds. The advancing border  is long and sharply defined  and has an ocean  wave shaped    fringe of macerated scale. The characteristic  pustule of  candiadiasis is not observed in intertriginous areas because it is macerated as soon as it forms .Pinpoint   pustules do appear  outside  the advancing   border and are an important   diagnostic  feature. There is a tendency for painful fissuring in the skin creases.

TREATMENT

A)                      General Measures

Education about the role  of moisture  and maceration is important . The following  techniques may be   recommended     drying  affected areas after bathing using a hand held  hair dryer  on low  heat  at least once a day  . Supportive clothing and  weight reduction air conditioning in warm     environments    and regular application   of a plain  or medicated  powder    to the areas.

For very inflammatory lesions open compresses three to four  times a day with water  or normal  saline will expedite  relief  of  symptoms. Cool   water compresses applied for   ½  hour     two  or three times  a day for just a few   days are rapidly effective in  controlling moisture and suppressing inflammation.

B)                     Topical Agents

A 1 or 2 week course of group  VI to VII topical steroids  may be all that  is necessary   . long  term continuous use of  topical steroids in skin  fold areas may result in atrophy and striae   0.1%  tacrolimus    may  be used   as an anti inflammatory  agent instead of topical   steroids   for initial    treatment or for cases   requiring   long term intermittent    treatment  Ciclopirox  cream  or lotion    twice daily  for 1-2 weeks  or until   resolved  is another option .  It  is a good practice  to add a  topical anti yeast  medication, such   as miconazole creams with   topical   steroids. To separate and expose   skin effectively  in order to promote  dryness  administer   while  the patient is in the supine   position. After clinical   resolution topical   antifungal   treatments may be continued twice weekly to prevent recurrence   and topical  steroids should be stopped.

1) Gentian violet      0.25to 2.0 5  and Castellani paint    are older   remedies  which   are effective but may sting and will stain clothing  bed linen and skin  

2)Systemic Agents

Outside  the setting  of chronic  mucocutenous   candiadiasis   chronic  systemic  suppressive    therapy  in immune suppressed  individuals    is discouraged due to the risk of colonization  with   resistant organisms.

Fulconazole

50 to 100 mg  daily for 14 days

150 mg  weekly for 2- 4  weeks

Itraconazole 200 mg  twice  daily for 14 days .

Treatemnt of individual lesions:--a)Tinea corporis – Griseofulvin  -500-1000 mg  / day   ( micro size )   or 375  - 500 mg /d  ( ultramicrosize )  x 2-4 weeks , Fluconazole – 150mg / week  2-4 weeks , terbinafine – 250 mg daily x 1-2 weeks , Itraconazole – 200mg / day x  1 week or 100 mg / day x2 weeks , Ketoconazole – 200-400  mg /day  for 2 weeks

b) Tinea  corporis (children ) Griseofulvin 15-20 mg /kg / day   ( micro size suspension )x2-4 weeks , Fluconazole -6 mg / kg/week  2-4 weeks , Terbinafine – 125 mg daily x 1weeks , Itraconazole – 3-5 mg / kg / day ( maximum 200  mg ) x 1 week ,Ketoconazole – not recommended

c)Tinea Pedis/manuum – Griseofulvin – 750-1000 mg  / day  ( micro size )  or  500- 750 mg / d ( ultramicrosize )  x 6-12 weeks ,  Fluconazole – 150-200 mg / week  x 4-6 weeks , Terbinafine – 250 mg daily x 2 weeks , Itraconazole   - 200-400 mg / day x 1 week , Ketoconazole – not recommended

 d) Tinea Pedis / manuum ( children )  Griseofulvin -  15-20  mg / kg / day  ( microsize   suspension ) x 4 weeks , Fluconazole   6 mg / kg / week x 4-6 weeks , Terbinafine -125  mg ( < 20-40 kg )  or 250 mg ( > 40 kg ) x 2 week , Itraconazole -  3-5 mg / kg /day ( maximum 200 mg ) x 1 week , Katoconazole – not  recommended 

e)  Tinea    Vesicular -  Griseofulvin – Not recommended , Fluconazole – 400 mg single dose repeat in 2 weeks   in needed , Teribinafine – oral therapy not   effective ,Itraconazole -  200 mg / day x 1 week Prophylaxis 200 mg BD 1 day / month  for 6 months in recurrent   disease , Ketoconazole – 400 mg single dose   400 mg single 200 mg OD for 5 days , 400 mg once a month for recurrent  disease

f) Vaginal candidiasis –Grisofulvin- Not effective , Fluconazole  - 200-400  mg daily  for 5 days ,  Tribinfine – Not effective , Itraconazole – 200 mg 3-5 days , Katoconazole -  150 mg single  dose

N B :-The oral agents are Fluconazole, Itraconazole. Tribinfine Amphotericin B, Grisofulvin