CANDIDIASIS

Candidiasis is an acute or chronic,superficial or disseminated mycotic infection caused by the fungus candida albicans and occasionally by other species of candida.It commonly involves skin & the mucous membranes and sometimes the viscera.

FACTORS PREDISPOSING TO CANDIDIASIS

1)    Local factors:

Tissue damage, moisture, warmth, maceration, Topical corticosteroids, prolonged catheterization, etc.

2)    Physiological states:

Infancy, pregnancy, old age

3)    Metabolic & endocrinal factors:

Iron deficiency, Diabetes mellitus, Obesity, Cushing’s syndrome

4)    Immuno compromised status:

·       Primary or secondary to malignancy, AIDS, prolonged administration of antibiotics, systemic corticosteroids, oral contraceptive pills, cytotoxic drugs,etc

·       Development of candidiasis in an HIV infected patient indicates deterioration of his immune status.

CLASSIFICATION OF CANDIDIASIS

Based on the anatomical site involved,candidiasis is classified into the following clinical syndromes:

                                           CANDIDIASIS

              MUCOSAL                            CUTANEOUS                            SYSTEMIC

Acute pseudomembranous           Paronychia                   Gastrointestinal

Chronic hyperplastic                       Intertrigo                Bronchopulmonary

Angular chelitis                         Diaper candidiasis                  Renal

Denture stomatitis                          Nodular                              Joints

Vaginitis & Balinitis                        Candidiasis                 Heart,Meningeal

CLINICAL SYNDROMES:

The clinical features of candidiasis vary depending upon whether the infection involves skin or mucous membrane. On keratinized surface of skin, the infection causes well  marginated, erythematous, scaling pustules, whereas on the mucous membrane, the infection produces white, cheesy deposits surrounded by  erythema.

Candidial Paronychia:

Candidial paronychia is a chronic inflammation of one or more nail folds.It is characterized by redness and swelling of the affected nail fold.The initial event is injury to the cuticle followed by detachment of the nail fold from the dorsal surface of the nail plate.This leads to the formation of pocket which then collects within it food debris etc. and facilitates growth of bacteria as well as fungi.The affected nail folds are sometimes painful and tender.Often,there is concomitant bacterial infection and beads of pus are exuded on pressing the affected nail fold. Subsequently, the nail becomes dystrophic, often ridged and develops green or brown colour.

This condition is usually found in housewives,washerwomen,people practicing manicure & pedicure,in those whose hands are constantly immersed in water for prolonged periods.

Nodular Candidiasis of Napkin Area:

This condition is a atypical reaction to the candida infection, manifesting as bluish-brown nodules or cutaneous horn like lesions.It involves the napkin area over the buttocks,genitalia,upper thighs and pubis.

Topical application of steroids is an important aetiological factor.

Chronic Mucocutaneous Candidiasis:

It is a distinct syndrome characterized by persistent,superficial candidial infection of the skin,nails and mucous membrane of the mouth and genitals, refractory to conventional topical therapy. It is not a single disease entity but is a manifestation of various underlying primary defects in cell mediated immune responses.

Systemic Candidiasis:

Under conditions leading to immunocompromisation, candida may cause systemic disease and involve the lungs,oesophagus,intestines or urinary tract. Candidemia may occur following prolonged use of indwelling catheters for intravenous infusions or in intravenous drug abusers,Rarely,hematogenous spread of candida may lead to meningitis, bone and joint lesions.

The underlying disease and iatrogenic factors predisposing to infection must always be sought and treated in all forms of systemic candidiasis.

Candidial Intertrigo:

Candidial intertrigo is characterized by erythema,moist exudation with an irregular ,fringed margin and subcorneal pustules in the affected area.Satellite pustules may develop and rupture leaving erosions and peeling skin.In case of interdigital space involvement,there is marked maceration.

It involves intertriginous areas of skin like interdigital spaces, genitocrural, perianal. Inframammary and axillary  folds. It most commonly occurs in obese and diabetic individuals.

Candidial intertrigo should be differentiated from tinea,seborrhoeic dermatitis,bacterial intertrigo and flexural psoriasis.

Oral Thrush: 

Oral thrush usually involves buccal mucosa,tongue,gums or palate and in severe cases in  pharynx too pseudomembrane is formed by fungal mycelia,desquamated epithelial cells,fibrin,leucocytes and food debris attaching to inflamed epithelium.It is loosely attached to the inflamed mucosa and when removed,leaves behind erosions and bleeding.The lesions are often painful and interfere with eating.

The condition commonly occurs in premature babies,neonates and in old people with poor resistance. In neonates it can be acquired from the birthcanal of the mother.

Angular Cheilitis:(Perleche)

Basically,perleche is a form of intertrigo which may be caused by different factors, of which candida is the commonest.Riboflavin deficiency,presence of moisture due to persistent salivation or licking of the lips,depth of the fold and malocclusion of teeth are some other factors which predispose to infection.

Denture stomatitis:

This condition is characterized by bright red or dusky erythema of the affected mucous membrane, sharply defined at the margin of the denture.The epithelium is often shiny,atrophic,oedematous and eroded.

Balanoposthitis:

Candidial balanoposthitis involves skin of the glans penis and prepuce,causing inflammation of fissuring.In mild cases, tiny papules develop on the glans a few hours after sexual intercourse, grow into vesicles,pustules and rupture leaving a scaly edge. The patient complains of soreness and pain while passing urine.

The status where both sexual partners have symptomatic genital candidiasis is known as ‘Conjugal Candidiasis’.

In either of the above case,the sexual partner of the patient should be simultaneously treated , even if asymptomatic. In persistent or recurrent cases, the patient and sexual partner should be investigated for Diabetes mellitus.

Vulvovaginitis:

Candidial vulvovaginitis is characterized by beefy red erythema of the affected vulvar skin and vaginal mucosa accompanied by creamy white, thick curdy flecks of vaginal discharge. In some cases,it may extend to cause intertrigo of groins and natal cleft.In severe cases,subcorneal pustules may be seen peripherally.Patient usually complains of soreness,pruritus and dyspareunia.

It most often occurs in diabetics because of high concentration of sugar in urine, in women during pre-menstrual period, during pregnancy, in women taking oral contraceptive pills and in patients with AIDS.

It  should be differentiated from Trichomonas infection,bacterial vulvovaginitis, physiological leucorrhoea during pregnancy and dermatoses affecting the vulva.

INVESTIGATIONS FOR CANDIDIASIS:

1)   Direct examination under the microscope:

Lesions are scraped with blunt end of a scalpel and the material is mounted in 2-3 drops of 10% KOH solution.When viewed directly under a microscope, it reveals gram positive yeasts and pseudohyphae, often associated with inflammatory cells.

The presence of pseudohyphae suggests candida as a pathogen.Blastophores and pseudohyphae can be demonstrated by H & E stain.

2)   Culture of the selective material on Sabouraud’s Dextrose Agar:

Candida albicans forms white,creamy colonies on Sabouraud’s dextrose agar in 2-3 days. The species is identified by rounded, refractile, double walled chlamydospores,produced by subcultures on corn-meal agar for 24-96 hours at room temperature and by germ tube formation.

TREATMENT FOR CANDIDIASIS:

Treatment can be classified into two ways:

Topical and Systemic:

Topical:

1)   Imidazoles:

Miconazole               2% gel/lotion/cream/powder twice daily

Clotrimazole             1% cream/gel/lotion/powder

                                   100 mg vaginal tablet once daily for 6 days

                                                    Or 500mg single dose vaginal tablet.

                Econazole           1% ointment, 150 mg vaginal tablet twice daily

Newer molecules like eberconazole,sertaconazole are also available.

2)   Ethanolamine derivative:

Ciclopirox olamine     1% cream twice daily

3)   Polyne antibiotics:

Nystatin       1 Lac units vaginal tablets BID for 2 weeks

Natamycin   2% cream or 25 mg vaginal tablets for 1 week.

Systemic:

1)   Polyne antibiotics:

Amphoterecin B    0.3-.7mg/kg per day IV over 4-8 hrs in

                                  systemic disease

Nystatin                   5 lacs units thrice daily in Intestinal

                                   Candidiasis.

2)   Azoles:

Ketoconazole       200 mg orally OD or BID for 2 weeks in

                                Mucocutaneous candidiasis.

Fluconazole           150 mg single dose orally for vaginitis &

                                 Balanitis.

                             150 mg once weekly for three weeks for

                              recurrent vaginal candidiasis.

Itraconazole        200mg/day for 3 days for vaginitis and

                               Balanitis.

                              200 mg on first day of menstrual cycle for

                     three months  for recurrent vaginal candidiasis.

PREVENTIVE MEASURES AGAINST CANDIDIASIS:

Avoid:

·       Prolonged warking in water.

·       Tight fitting clothes,synthetic or woolen undergarments and socks.

·       Closed and tight footwears.

Advised:

·       Maintain good personal hygiene

·       Use gloves and cotton liners while working in water.

·       Use loose clothing and absorbent cotton undergarments and socks.

·       Use open footwear.

·       Thoroughly dry the intertriginous areas and apply simple talcum or an antifungal powder.

·       Simultaneously treat the sexual partner, even if asymptomatic, in case of balanitis and vaginitis.

BY:

   DR CHETAN LALSETA

                                                                             M.D.(Skin & V .D)

    CONSULTANT DERMATOLOGIST & COSMETOLOGIST

   “C POINT”—A UNIT OF MCSPL

    SHRADDHA HOSPITAL,INDIRA CIRCLE CHOWK,

     RAJKOT-360005

      www.cpoint.in  

    www.mcspl.in

    www.drlalseta.blogspot.com

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