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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
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