Cutaneous candidiasis

This topic focuses on the management of candidal infection affecting the skin. For management of other conditions caused by Candida species, see:

Candida infection presents as patches of moist, confluent erythema on the skin, sometimes with vesicles and satellite pustules, and often with slight scaling. It usually occurs in flexures, the submammary area and other skin folds. Immunocompromised patients are more likely to present with disseminated cutaneous candidiasis, which requires systemic treatment.

Candida infection of the skin is a complication of conditions that make the skin moist or macerated. Candida infection usually occurs in patients with predisposing factors (eg broad-spectrum antibiotic use, diabetes, general debility, immunodeficiency, obesity, immobility), and may be superimposed on other dermatoses.

Diagnosis of candidal skin infection is usually clinical. However, consider taking a swab for microscopy and culture in immunodeficient or hospitalised patients to confirm the species of Candida. There have been reports of the emerging drug-resistant yeast Candida auris in AustraliaPublic Health England, 2017Swannell, 2020.

Remove or modify predisposing factors if possible (eg investigate for and treat diabetes, treat any co-existing dermatoses, review and cease nonessential oral antibiotics). Keep affected areas dryPappas, 2016, and consider using a barrier cream (eg soft white paraffin, zinc oxide).

For topical antifungal treatment of cutaneous candidiasis, use:

1bifonazole 1% cream topically, once daily until skin is clear bifonazole bifonazole bifonazole

OR

1clotrimazole 1% cream topically, twice daily until skin is clear clotrimazole clotrimazole clotrimazole

OR

1econazole 1% cream topically, twice daily until skin is clear econazole econazole econazole

OR

1ketoconazole 2% cream topically, once daily until skin is clear ketoconazole ketoconazole ketoconazole

OR

1miconazole 2% cream topically, twice daily until skin is clear miconazole miconazole miconazole

OR

1terbinafine 1% cream topically, once daily until skin is clear. terbinafine terbinafine terbinafine

Symptoms typically resolve after 2 weeks; however, resolution may take longer in some patients (eg immunocompromised patients).

If needed for inflammation or severe pruritus, add a mild topical corticosteroid. Use:

hydrocortisone 1% cream topically, twice daily for 2 weeks1. hydrocortisone hydrocortisone hydrocortisone

If response to topical treatment is poor, or topical treatment is impractical, oral therapy is appropriate. Use:

fluconazole 150 mg orally, once a week for 2 to 4 weeksTaudorf, 2019. fluconazole fluconazole fluconazole

Do not use griseofulvin because it is not active against Candida albicans. Oral terbinafine is not used for treatment of cutaneous candidiasis.

If cutaneous candidiasis persists despite oral treatment, take a swab for microscopy and culture to confirm the presence of Candida species, and refer the patient for specialist advice.

Nipple thrush (cutaneous candidiasis occurring on the nipple) can be treated as for cutaneous candidal infection of any other body area. Pain with breastfeeding can be the only sign of nipple candidiasis. If the patient is breastfeeding, topical miconazole is recommended because it is safe for the infantThe Royal Women's Hospital, 2018. Miconazole can be applied to the nipple after a feed, and any excess cream should be wiped off before the next feedThe Royal Women's Hospital, 2021. If the infant has oral candidiasis, see the Antibiotic guidelines for treatment information.

Congenital cutaneous candidiasis is a generalised widespread infection that presents as a diffuse rash in infants within the first week of birth. Unlike other Candida infections of the skin, congenital cutaneous candidiasis is not a complication of conditions that make the skin moist or macerated. Prompt systemic antifungal treatment is often required. If an infant presents with a diffuse pustular rash in the first week of birth, urgently refer for dermatologist or paediatrician adviceKaufman, 2017.

1 Hydrocortisone 1% cream is available as a combination product with clotrimazole 1% or miconazole 2%.Return