Candida - skin and oral

Scope

This guideline covers antifungal treatment for cutaneous and oral Candida infection.

For genital thrush (male and female) please refer to Candida, genital thrush in the genital guidelines.
For nipple thrush please refer to nipple and breast thrush in pregnancy and postpartum guidelines.
For angular cheilitis please refer to the angular cheilitis in dental guidelines.

Systemic Candida infection, Candida infection of the ear canal and oesophageal candidiasis are outside the scope of this guideline.

Oesophageal candidiasis can be associated with immunocompromise including HIV infection and requires further investigation and referral to an appropriate specialist.

Comments from the Expert Advisory Group

Diagnosis is generally made on clinical grounds.

In case of treatment failure, it may be necessary to send samples for fungal culture.

Review modifiable risk factors in case of recurrence and refractory disease.

Image 1: cutaneous candidiasis                                                        

Image source/credit: Dermnet

 

 

 

 

 cutaneous-candidiasis

Image 2: cutaneous candidiasis

Image source/credit: Dermnet

 

 

 

 

 

 

 

 

 

 cutaneous-candidiasis2

Image 3: infant oral candidiasis

Image source/credit: Dermnet

 

 

 

 

 

 

 

 

 cutaneous-candidiasis3

Image 4: adult oral candidiasis

Image source/credit: Dermnet

 

 

 

 

 cutaneous-candidiasis4

Treatment

Cutaneous candidiasis
Cutaneous candidiasis: 1st choice options (topical therapy)
Drug Dose Duration Notes
Clotrimazole 1% cream Apply every 8 to 12 hours 4-6 weeks To prevent relapse, treatment should be continued for at least two weeks after the disappearance of all signs of infection

OR

Miconazole 2% cream

 

Apply to affected area every 12 hours

 

2-6 weeks

 

Continue for 7 – 10 days after legions have healed

Oropharyngeal candidiasis
Oropharyngeal candidiasis: 1st choice options
Drug Dose Duration Notes

Miconazole 20mg/mL oral gel

 

 

 

 

 

 

 

 

 

Neonate: 1ml two to four times daily after feeds*

2-3 months: 1.25ml to be applied four times daily after feeds*

≥4 months: 1.25ml to be applied four times a day after feeds

Adults and children 2 years of age and older: 2.5ml to be applied four times a day after meals

 

The treatment should be continued for at least a week after the symptoms have disappeared

 

 

 

 

 

 

 

 

 

*Unlicensed use in infants < 4 months due to choking risk. Lower age limit increased to 5-6 months for infants who are pre-term or exhibiting slow neuromuscular development.

The gel should not be swallowed immediately, but kept in the mouth as long as possible.

The dose should be divided into smaller pea-sized portions; gel should be smeared in baby’s mouth after feeds with a clean finger, ensuring there are no clumps of gel in the mouth.

For oral candidiasis, dental prostheses should be removed at night and brushed with the gel.

OR

Nystatin 100,000 units/ml oral suspension

 

 

 

 

 

 

Neonate: birth – 1 month: 1mL every 8 hours

Infant: 1 month – 2 years: 1-2mL every 6 hours

Adult and children > 2years: 5mL every 6 hours

 

Usually for 7 days - continue for 48 hours after clinical cure, if signs and symptoms persist beyond 14 days re-evaluate

 

 

 

 

Keep suspension in contact with oral mucosa for as long as possible before swallowing.

 

 

 

 

Systemic treatment – Adults (reserved for recurrent cutaneous or oropharyngeal candidiasis)

Cutaneous candidiasis (Adults) : systemic therapy

(reserved for recurrent cutaneous candidiasis)
Drug Dose Duration Notes

Fluconazole


150 mg once weekly

2 to 4 weeks

Recurrent cutaneous candidiasis (as distinct from genital candidiasis) should be referred. See guideline for recurrent vulvovaginal candidiasis

Use with caution in patients with hepatic dysfunction.

Avoid fluconazole (and all oral azoles) in pregnancy.

OR

Fluconazole

 

50 mg once daily

 

2 to 4 weeks

Oropharyngeal candidiasis (Adults): systemic treatment

(reserved for recurrent oropharyngeal candidiasis)

As recurrent oropharyngeal candidiasis may indicate an underlying condition patients should be referred

Fluconazole

 

 

 

 

Loading dose: 300mg on Day 1

Subsequent dose: 150mg once daily

 

 

7 to 21 days (until oropharyngeal candidiasis is in remission)

 

 

 

Longer periods may be used in patients with severely compromised immune function.

Use with caution in patients with hepatic dysfunction.

Avoid fluconazole (and all oral azoles) in pregnancy.

 

 

OR

Itraconazole**

 

 


100mg every 24 hours

 

 

14 days

 

 

Take capsules immediately after a meal for maximum absorption.

Not recommended in patients with active or chronic liver disease.

Avoid itraconazole (and all oral azoles) in pregnancy**
 ** Women of childbearing potential taking itraconazole should use contraceptive precautions. Effective contraception should be continued until the menstrual period following the end of itraconazole therapy.

General Advice for Self-Care

Self-management of cutaneous candidiasis

Candidiasis is particularly likely to affect flexures in warm weather especially in those living with obesity. Keeping these areas dry, particularly skin folds can help prevent recurrence.

Self-management of oral candidiasis

Practice good oral hygiene

  • Brush teeth regularly
  • Use warm saline water as a mouth wash
  • Avoid use/overuse of antiseptic mouthwashes, as they alter the flora of the mouth
  • Rinse mouth out with water after using a steroid inhaler
  • Smoking is a risk factor for oral candidiasis and smoking cessation should be considered

Denture wearers:

  • Clean dentures with an anti-candidal preparation, such as 1% sodium hypochlorite solution
  • Remove dentures overnight

Patient Information

Safe Prescribing (visit the safe prescribing page)

  • Doses are oral and for adults unless otherwise stated
  • Renal impairment dosing table
  • Safety in Pregnancy and Lactation
  • Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
  • Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed December 2022

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