Cutaneous Candidiasis Treatment & Management
Topical antifungal agents including miconazole nitrate (Micatin, Monistat-Derm) or clotrimazole (Lotrimin, Mycelex) creams are curative. One-time oral therapy with fluconazole (150 mg) or itraconazole (600 mg) is effective and may be a more attractive alternative to some patients, but it is more costly.
Topical therapy is sufficient in most patients. Evaluate asymptomatic sexual partners and treat them if they are affected. If persistent lesions spread beyond the genitalia, consider the possibility of diabetes, and assess for the disease.
Topical preparations usually are effective. Some authors recommend the use of oral nystatin in conjunction with topical agents to lower the risk of systemic infection.
Oropharyngeal candidiasis in the infant
Most patients can be treated with nystatin oral suspension. Treat for 10-14 days or until 48-72 hours after resolution of symptoms. Dosage for preterm infants is 0.5 mL (50,000 U) to each side of mouth 4 times/day; dosage for infants is 1 mL (100,000 U) to each side of the mouth 4 times/d.
Candidosis of the nipple
Treat nipple candidosis for 2 weeks using an antifungal cream after each feeding. The baby must be treated simultaneously with nystatin swabbed on all 4 gum lines and in the oral cavity, along with a few ingested drops, for 2 weeks. Babies may have no symptoms of oropharyngeal candidiasis and still be reinfecting their mothers. Careful hygiene is also important. Frequent changing and washing of bras in boiling water (along with anything the baby puts in its mouth, eg, pacifiers) is necessary. Gentian violet is not used because it stains badly and may irritate the infant's mouth. If candidosis of the nipple goes untreated, it may extend, and oral treatment for the mother may be necessary. Cultures often are not pure and usually are not helpful.
Candidal diaper dermatitis
Treatment for candidal diaper dermatitis includes practical measures that reduce the amount of time the diaper area is exposed to hot and humid conditions. Air drying, frequent diaper changes, and generous use of baby powders and zinc oxide paste are adequate preventive measures. For topical therapy of candidal diaper dermatitis, nystatin, amphotericin B, miconazole, and clotrimazole are effective and almost equivalent in efficacy.
Oral candidiasis in adults
Treatment with a topical agent such as nystatin (1:100,000 U/mL, 5 mL oral rinse and swallow qid) or clotrimazole troches (10 mg 5 times/d) usually is effective. In most patients, extend the duration of antifungal therapy at least twice as long as the termination of clinical signs and symptoms of candidosis. Reserve oral fluconazole, 100 mg once daily for 2 weeks, for patients with more severe disease.
With denture stomatitis, improved oral hygiene with removal of dentures at night, vigorous brushing to remove plaque, and disinfecting (swish and spit) with chlorhexidine gluconate (Peridex) usually is adequate treatment. Topical therapy with clotrimazole troches or nystatin may be used for lesions that do not respond to the above measures. For more resistant cases oral fluconazole, 100 mg/day for several weeks, in addition to the above measures, may prove effective.
Treatment is targeted to keeping the skin dry, with
the addition of topical nystatin powder, clotrimazole, or miconazole twice daily, often in conjunction with a midpotency corticosteroid. Patients with extensive infection may require the addition of fluconazole (100 mg PO qd for 1-2 wk) or itraconazole (100 mg PO qd for 1-2 wk). Many anecdotally based remedies exist for intertrigo that have been used in dermatology offices for years with success. The remedies have focused on both drying the moist inflamed area and treating the candidosis. The treatments are adjusted based on whether the inflammation is acute (wet and red), subacute (red +/- maceration), or chronic (red and dry)
For acute intertrigo, Domeboro solution, Castellani paint, or vinegar/water (1 tbsp vinegar per qt room-temperature water) may be applied twice per day for 5-10 minutes for 3-5 days as needed. Dry the area with a hair dryer (no heat). Apply a shake lotion twice per day (mixture: 40 g USP talc, 40 g zinc oxide, 10 g glycerin; mix into slurry or milkshake consistency, add distilled water up to 120 mL, dispense in 180-mL [6 oz] bottle). Place a large bath towel under breasts or in pendulous areas twice per day. Castellani paint (carbol fuchsin) is messy, but nightly painting may help when nothing else does. Some patients respond well to triamcinolone-nystatin cream.
For subacute intertrigo, benzoyl peroxide wash may be used to cleanse the area instead of application of vinegar or Castellani paint. A topical anticandidal cream of choice is applied twice per day, with or without a mild hydrocortisone cream (no refills for the latter).
For chronic intertrigo, the zinc-talc shake lotion may be used once or twice daily, and the hydrocortisone cream/antifungal mixture may be applied at night. Local hyperhidrosis may be treated with antiperspirants (ie, Arrid Extra Dry Unscented, Dry Idea) on a long-term basis. These products, along with the more concentrated Drysol (aluminum chloride 20%), may sting macerated skin. Nystatin in talc (100,000 U/g or 15 g) may be applied twice per day for a few days, then tapered and replaced with unscented baby powder as a powder-approach alternative.
Sundaram et al  noted that candidal intertrigo can be treated with filter paper soaked in Castellani paint.
Treatment with topical agents usually is not effective but should be tried for chronic candidal paronychia. Drying solutions or antifungal solutions are used. Oral therapy with either itraconazole (pulse dosing with 200 mg bid for 1 wk of each of 3 consecutive mo) or terbinafine (250 mg qd for 3 mo) is recommended.
Candidosis and HIV
Topical therapy with agents such as nystatin and clotrimazole require a minimum of 20-30 minutes of drug contact with the oral mucosa. Treatment with topical therapies may be effective in the early stages of HIV infection, and it becomes less effective with disease progression. Oral treatment with a 2-week course of antifungal therapy (itraconazole, fluconazole, ketoconazole) is indicated in more refractory cases. In patients who are significantly immunocompromised, maintenance therapy on an intermittent (alternate days to twice weekly dosing of ketoconazole 200 mg or fluconazole 100 mg) or continuous basis may be required to provide symptomatic relief. In general, the goal is the cessation of therapy once clinical symptoms have subsided, since prolonged therapy increases the likelihood of the development of drug-resistant organisms.