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This site is intended for healthcare professionals

Cutaneous
Candidiasis Treatment &
Management
Updated: May 22, 2018
Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD more...

TREATMENT

Medical Care
Candidal vulvovaginitis
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.

Candidal balanitis
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.

Congenital candidosis
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.

Intertrigo
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 [42] noted that candidal intertrigo can be treated with filter paper soaked in
Castellani paint.

Paronychia
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.

Guidelines
Related clinical guidelines have been released by the Infectious Diseases Society of America.
[43] See Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the
Infectious Diseases Society of America.

Medication