Cutaneous candidiasis

candida · candidiasis · thrush · intertrigo · candidal intertrigo · yeast infection

Inflammation in a skin fold with satellite lesions beyond the edge - and often a pointer to diabetes.

GPBand C

Red flags

Extensive, recurrent or unusually resistant disease - check glucose, and consider immunosuppression including HIV
Oesophageal symptoms with oral candidiasis - suggests significant immunosuppression
Systemic upset or signs of invasive infection in an immunocompromised or critically ill patient
Candidiasis in a neonate that is extensive or congenital
Secondary bacterial infection with spreading cellulitis

Recognise

On light skin

Moist, glazed, beefy-red inflammation within the fold with a scalloped edge, surrounded by small satellite papules and pustules.

On brown and black skin

The beefy redness is not available as a sign; affected folds may look darker, violaceous, grey or simply macerated and glistening. The anatomy and the satellite lesions are the diagnosis - involvement of the depth of the fold itself, a scalloped border, and discrete small papules or pustules scattered beyond the main area. Feel for the moist, macerated texture. Post-inflammatory hyperpigmentation in the folds afterwards is common, persistent, and frequently mistaken for continuing infection or for acanthosis nigricans.

In any skin tone

The fold itself is involved - irritant dermatitis spares the fold, candida occupies it
Satellite lesions beyond the main area - the most useful single sign
Moist, macerated, glazed surface with a scalloped edge
Soreness and burning rather than the itch of tinea
Recurrent or extensive candidiasis should prompt a glucose check - undiagnosed diabetes is a common underlying cause

Distribution

Moist, occluded, warm sites: skin folds under the breasts and abdomen, the groin, axillae, between the toes, the nappy area, and the angles of the mouth. Involves the fold itself, unlike irritant dermatitis.

Photographs

Oral candidiasis in a child who had recently taken antibiotics. Thick creamy-white plaques sit on the dorsum of the tongue with inflamed red mucosa showing through the gaps. **The plaques can be scraped off, leaving a raw red base** - that is the bedside test that separates thrush from leukoplakia or a simple coated tongue. In an adult with no obvious cause, ask why: inhaled steroids, diabetes, or immunosuppression including undiagnosed HIV.
Fitzpatrick II (Fitzpatrick type estimated from the photograph, not stated by the source) · James Heilman, MD · Wikimedia Commons - Human tongue infected with oral candidiasis.jpg · CC BY-SA 3.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Tinea corporis, cruris and pedis — Tinea cruris has a raised active scaly edge, spares the scrotum, and lacks satellite lesions
Nappy rash, candida, and patterns that should worry you — The same distinction in infants: irritant dermatitis spares the folds, candida involves them
Atopic eczema and infected eczema — Flexural eczema is itchy, symmetrical and lacks satellite pustules
Impetigo — Bacterial infection of a macerated fold can coexist and may need separate treatment
Angular cheilitis — Candidal infection at the mouth angles is the commonest cause of angular cheilitis - look in the mouth when you see cracked corners

What to do in the ED

Treat with a topical antifungal under local policy; an oral azole for extensive or resistant disease. CKS is the only source this entry rests on - read the topic before prescribing
Check a capillary glucose or HbA1c in recurrent, extensive or unexplained candidiasis
Keep the area dry and separated - drying thoroughly, a barrier preparation, and air to the fold do as much as the antifungal
A short course of a mild topical corticosteroid may be added for marked inflammation alongside antifungal treatment - CKS supports this; take the preparation and duration from the topic and the BNF rather than from this page
Treat coexisting bacterial infection where present
Address the underlying contributors: continence, moisture, occlusive clothing, weight, and glycaemic control

Disposition

Topical treatment and discharge with GP follow-up, including glucose testing where indicated. Refer or admit only for invasive disease or significant immunosuppression.

Safety-netting

Keep the area as clean, dry and open to the air as you can - this matters as much as the cream. Return if it spreads, if the skin breaks down, if it becomes hot and painful with a fever, or if it keeps coming back. If it recurs, please have a blood sugar test, because repeated thrush can be the first sign of diabetes.

Sources

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