Candidiasis

Candidiasis is a fungal infection caused by Candida species (most commonly Candida albicans). It thrives in warm, moist environments and often follows a disruption in the body’s normal flora.

• Vulvovaginal Symptoms: Patients report intense pruritus (itching) and a burning sensation, especially during urination (dysuria) or intercourse.

• Discharge: A characteristic thick, white, "cottage cheese-like" vaginal discharge.

• Oral Symptoms: Patients may complain of a cottony feeling in the mouth, loss of taste, or soreness when eating or swallowing.

• Systemic/Severe Signs: 

  • Laryngeal: Changes in voice or hoarseness (dysphonia).

  • Esophageal: Painful swallowing (odynophagia) or feeling like food is "stuck."

  • Immunocompromised: Patients with HIV, uncontrolled diabetes, or those on chemotherapy may report systemic symptoms like fever and chills.

1. Vulvovaginal Examination:

   • Skin/Mucosa: Bright red (erythematous), swollen (edematous) vulva and vaginal walls. The rash often appears "glazed" or dry.

   • Discharge: Adherent, white, curd-like plaques on the vaginal walls.

   • Satellite Lesions: Look for small red papules or pustules just beyond the main edge of the rash (a classic sign of cutaneous candidiasis).

2. Oral Examination (Thrush):

   • Plaques: White or creamy-yellow "curd-like" patches on the tongue, soft palate, or buccal mucosa.

   • Scrapability: Unlike some other oral lesions, these plaques can typically be scraped off with a tongue depressor, often revealing an angry, red, and sometimes bleeding base underneath.

3. Systemic Signs: In rare, disseminated cases (Candidemia), patients may present with fever, hypotension (low blood pressure), and a generalized rash.

Crucial Note for Darker Skin Tones

• Erythema Presentation: In darker skin, the "bright red" inflammation may appear more violaceous (purple), dark brown, or grayish. This can sometimes lead to an underestimation of the severity of the inflammation.

• Differential Diagnosis:

  • Inverse Psoriasis: Can mimic candidiasis in skin folds but lacks the "cottage cheese" discharge and satellite pustules.

  • Erythrasma: A bacterial infection that appears as reddish-brown patches in folds; it lacks the inflammatory "fire" of Candida and glows coral-red under a Wood's lamp.

  • Lichen Sclerosus: Must be ruled out if there is chronic itching and white thinning of the skin (parchment-like) rather than a temporary "curd" discharge.

Antifungal Medications

Topical: For vulvovaginal infections, antifungal creams (e.g., clotrimazole, nystatin) applied over 1, 3, or 7 days are highly effective.

Oral: Fluconazole 150 mg is typically prescribed for single-dose therapy, but recurrent cases may require repeated dosing (Days 1, 4, 7) or long-term prophylaxis (weekly for six months).

Systemic Candidiasis

For severe cases like systemic candidiasis, systemic antifungals like caspofungin, fluconazole, or amphotericin B are indicated, especially in immunocompromised patients.

Management for Denture-Associated Cases

Patients with denture stomatitis should discontinue denture use for two weeks while applying topical antifungals. Probiotics are also beneficial as adjunct therapy.

Precautions for High-Risk Patients

Patients with obesity, diabetes, or those on immunosuppressive medications should be monitored closely, as these conditions increase recurrence and complications, such as intertrigo or bronchopulmonary candidiasis.

Darker Skin Tones – Specific Treatment Risks:

Post-Inflammatory Changes: Severe candidal intertrigo (infection in skin folds) can leave behind temporary hypopigmentation or lingering hyperpigmentation once the infection clears. Reassure the patient that this usually resolves over several months.

Steroid Caution: Avoid using strong topical steroid creams alone; while they may stop the itch temporarily, they "fuel" the fungal growth (incognito infection) and can cause skin thinning (atrophy) which is highly visible.

DermNet NZ – Vulvovaginal Candidiasis: https://dermnetnz.org/topics/vulvovaginal-candidiasis

StatPearls – Oral Candidiasis (2024 update): https://www.ncbi.nlm.nih.gov/books/NBK545281/

CDC – Vaginal Candidiasis Treatment: https://www.cdc.gov/fungal/diseases/candidiasis/genital/index.html