Oral and Cutaneous Candidiasis

For the past 2 weeks, a 13-year-old African American girl had fever and blisters on her lips. Two days earlier, a rash appeared under her arm and on her face. The rash caused slight discomfort, which she described as a burning, itchy sensation. The rash on her lip had persisted despite application of docosanol 10% cream; she had not used any prescription medications. She had no discharge from the affected areas. There was no history of sick contacts, animal exposure, or sexually transmitted diseases. She denied use of deodorant or any new cosmetics.

On examination, the girl was well-developed, well-nourished, and in no apparent distress. She had pale macerated areas at both angles of her mouth and thickened, pale, cracked, and macerated plaques in both axillae. Some satellite papules surrounded the macerated areas. Systemic and neurological findings were otherwise normal.

Microscopic examination of skin scrapings with a potassium hydroxide solution showed pseudohyphae, indicative of Candida species.

Candida often colonizes the mucous membranes and lower respiratory, GI, and genitourinary tracts. Mucus membrane candidiasis is far more common than cutaneous disease. About 30% of vaginitis in women is caused by Candida, and oral candidiasis (thrush) is seen in up to a third of infants. Although typically part of the normal skin flora, this commensal organism can become pathogenic, with increased fungal burden as a result of broad-spectrum antibiotic use, breakdown of normal mucosal and skin barriers, indwelling catheters, surgery, trauma, or immune dysfunction. Simultaneous occurrence of oral and cutaneous candidiasis is uncommon in children and teens who do not require treatment with oral antibiotics, inhaled corticosteroids, or oral contraceptives. This patient had no history of symptoms of diabetes or immunodeficiency (such as polyuria, polydipsia, polyphagia, weight loss, or recurrent infection). Results of a complete blood cell count and complete metabolic profile were unremarkable.

Cutaneous candidiasis occurs in skin folds where occlusion (by clothing or shoes) produces abnormally moist conditions (intertrigo). It presents with irritation and pruritic symptoms. Lesions typically have an irregular margin with erythema, cracking, and maceration. The skin appears soft and white, with surrounding satellite papules and pustules.

Angular cheilitis is characterized by erythema and fissuring at the corners of the mouth. In addition to Candida infection, angular cheilitis can be caused by Staphylococcus aureus infection, nutritional deficiency (zinc, iron, or riboflavin), celiac disease, and isotretinoin therapy. It most commonly occurs when a child with dry, chapped lips licks the lips and aggravates the condition.

A potassium hydroxide preparation of cutaneous or mucosal scrapings showing hyphae, pseudohyphae, or budding yeast forms confirms the diagnosis.

Treatment consists of a topical antifungal agent, such as mycostatin, miconazole, or clotrimazole. Severe cases may require adjunctive therapy with a systemic antifungal agent, such as fluconazole, itraconazole, or voriconazole. Topical mycostatin ointment, twice a day for 2 weeks, was prescribed for this patient. She returned in 3 weeks with complete resolution of her symptoms. The importance of keeping the axillary and oral areas dry to prevent reinfection was stressed.  

FOR MORE INFORMATION:
•Hay RJ. The management of superficial candidiasis. J Am Acad Dermatol. 1999;40:S35-S42.
•Segal E. Candida, still number one--what do we know and where are we going from there? Mycoses. 2005;48 Suppl 1:3-11.