Definition
A.A fungal infection of the mucous membranes and/or skin, candidiasis is caused by the Candida albicans fungus.
Incidence
A.It occurs frequently in women, children, and the elderly population.
Pathogenesis
A.An overgrowth of C. albicans occurs when mucous membranes and/or skin are exposed to moisture, warmth, and an alteration in the membrane barrier.
Predisposing Factors
A.Immunosuppression.
B.Use of antibiotics.
C.Hyperglycemia.
D.Chronic use of steroids.
E.Frequent douching by women.
F.Adults who wear dentures.
G.Urinary/fecal incontinence.
Common Complaints
A.Oral: Persistent white patch on the tongue or roof of mouth may be slightly reddened with or without crevices on the tongue.
B.Vaginal: Thick, white, cottage-cheese-like
vaginal discharge with or without vaginal itching.
C.Genital: Bright, red rash with well-demarcated satellite lesions advancing to pustules or erosions in genital area.
D.Males: Erythemic rash that may advance to erosions on the genitalia/scrotal area.
Subjective Data
A.Question the patient about onset, duration, and location of lesions.
B.Determine whether the patient has a history of previous infections.
C.Inquire into medical history and current medications.
D.Rule out the presence of any other current medical conditions.
Physical Examination
A.Inspect:
1.Assess skin and mucous membranes for discharge and lesions.
2.Observe location and severity of lesions. Document size, diameter, and characteristics of lesions.
B.Palpate: Palpate lymph nodes in neck and groin.
Diagnostic Tests
A.Vaginal and genital infections need to be evaluated for sexually transmitted infections (STIs), especially if the patient is sexually active with multiple partners. Vaginal/genital culture specimen should be sent for gonorrhea/chlamydia testing.
B.Other specimens to consider include wet prep/potassium hydroxide (KOH) 10% solution, Gram stain vaginal culture for candida.
Differential Diagnoses
A.Oral candidiasis:
1.Leukoplakia.
2.Stomatitis.
B.Genital area:
1.Candidiasis.
2.Bacterial infection.
3.Bacterial vaginosis.
4.Chlamydia.
5.Gonorrhea.
6.Trichomoniasis.
Plan
A.Patient teaching:
1.Instruct the patient on applying medication to the skin.
2.Advise the patient to avoid scratching the site and keep fingernails short.
B.Pharmaceutical therapy: Choose one of the following pharmaceutical therapies:
1.Oral:
a.Nystatin (Mycostatin) oral suspension 100,000 U/mL, four times daily for 7 to 10 days.
b.Gentian violet aqueous solution, 2% for adults, one to two times per day.
c.Lotrimin buccal troches, five times per day for 2 weeks.
2.Topical:
a.Nystatin cream, three to four times per day for 7 to 10 days.
b.Mycolog-II: Apply sparingly to skin twice daily until resolved.
3.Vaginal:
a.Clotrimazole 1% cream, 5 g intravaginally for 4 to 7 days.
b.Miconazole 2% cream, 5 g intravaginally for 7 days (over-the-counter [OTC]).
c.Terconazole 0.8% cream, 5 g intravaginally for 3 days.
d.Terconazole 80 mg vaginal suppository, at bedtime for 3 days.
e.Fluconazole (Diflucan) 150 mg, oral tablet one time.
Follow-Up
A.None indicated unless not resolved or complications arise.
Consultation/Referral
A.Consult a physician if not resolved within 2 weeks.
Individual Considerations
A.Pregnancy:
1.Most effective medications for pregnant women are clotrimazole, miconazole, and terconazole.
2.Recommend a full 7-day course of treatment during pregnancy.
B.Adults:
1.Consider immunosuppression in all adults with oral candidiasis (HIV, diabetes, chemotherapy, leukemia).
2.Adults with oral lesions need to be assessed for leukoplakia, especially if the patient has a history of smoking or using chewing tobacco.
C.Geriatrics:
1.Risk factors for fungal infections in the elderly: denture wearers, intravascular catheters, resident in long-term care facility, renal failure, prolonged ICU stay, systemic administration of broad spectrum antibiotics, parenteral nutrition, recent abdominal surgery, neutropenia, and use of corticosteroids.
2.Studies posited that elderly populations are susceptible to bloodstream candida infections (candidemia) characterized by a high mortality rate. To avoid candidemia, practitioners must treat fungal infections promptly, encourage prevention measures, and continually assess for relapses.