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limited to moist skin folds), esophagitis, and vaginitis (see GYN section). In adults, disease commonly
occurs in diabetics, the immunocompromised, and after antibiotic treatment for other disorders. Inhaled and
oral corticosteroid preparations also increase risk. Disseminated, life-threatening infection can also occur in
severely immunocompromised persons.
Subjective: Symptoms
Oral thrush: Usually asymptomatic; may cause mouth discomfort or difficulty swallowing. Esophageal
thrush: Painful or difficult swallowing. Intertrigo: Local burning-like pain, often with pruritus. Vaginal thrush:
Itching, dyspareunia (pain with intercourse) and change in the odor or consistency of vaginal discharge.
Focused History: Do you have difficulty or pain with swallowing? (suggests esophageal or oral lesions) Do
you have diabetes? Have you recently taken antibiotics or corticosteroids? (hyperglycemia, antibiotic or steroid
exposure may precede oral or vaginal disease)
Objective: Signs
Using Basic Tools: Inspection: Oral/esophageal: white plaques, which are scraped to reveal an
erythematous base and are seen on any oral mucosal surface except the tongue. Cutaneous (intertrigo
or vulvar): erythematous, shiny rash with small “satellite” lesions at its periphery. Candidal vaginitis is
associated with a curd-like vaginal discharge (see Symptoms: GYN Problems: Candidal vaginitis).
Using Advanced Tools: Lab: Potassium hydroxide (KOH) wet mount of scrapings or discharge reveals
typical yeast, usually with pseudohyphae and/or hyphae. (see Lab Procedures: KOH)
Assessment:
Differential Diagnosis
Oropharyngeal candidiasis - particulate debris secondary to poor oral hygiene (debris is usually easily
removed)
Esophageal candidiasis - esophagitis due to herpes simplex, cytomegalovirus, aphthous ulcers, and toxins
Candidal vaginitis - trichomoniasis, bacterial vaginosis (can be differentiated with wet mount)
Plan:
Treatment
Primary: Oropharyngeal candidiasis - nystatin solution, 400,000-600,000 units qid po as a swish and
swallow x 7 - 14 days. Esophageal candidiasis - fluconazole, 200 mg/day po or IV x 14 days. Intertrigo
- nystatin powder or clotrimazole or miconazole cream twice daily until resolved. Candidal vaginitis - see
GYN Problems section.
Alternative: Oropharyngeal candidiasis - clotrimazole troches (lozenges), 10 mg 5/day, oral fluconazole,
50-200 mg/day, itraconazole, 100-200 mg/day, or ketoconazole, 200 mg/day. Esophageal candidiasis -
itraconazole 100-200 mg/day, or intravenous amphotericin B, 0.3-0.5 mg/kg/day, in refractory cases.
Primitive: Gentian violet applied topically.
Patient Education
General: This is a superficial infection that should resolve with standard therapy. It can occur in healthy
people, but could indicate other disease such as diabetes or immunocompromise.
Medications: Topical antifungals have virtually no adverse effects associated with their use. The oral azoles,
fluconazole, itraconazole, and ketoconazole are all well tolerated. These drugs may interact with other
drugs processed through the liver, causes the levels of drugs such as oral diabetes, seizure, and anticlotting
medications. Ketoconazole that is used long-term may affect steroid hormones, causing irregular menses
in women and decreased libido or breast tissue enlargement in men. All may rarely cause severe liver
damage. Malaise, nausea, vomiting, weight loss, and infusion site phlebitis (vein inflammation) may also occur.
Decreased blood potassium and magnesium often complicate therapy. Intravenous use of amphotericin B is
associated with infusion-related fever, headache, chills, myalgias, and rigors. Use of amphotericin B can also
cause anemia and reversible kidney dysfunction.
Prevention and Hygiene: None necessary