Cutaneous candidiasis is arguably the most common form of candidiasis. The infection involves the very outer-most layers of the skin. Healthy skin is quite resistant to candidal infection and in essentially all cases a predisposing factor is present. Although neither invasive nor life-threatening, these forms of localized candiasis can be very irritating to the patient. The most common and important forms of candidal skin infections are:

Name	Location	Type of lesions
Intertrigo	Axillae, groin, skin folds (beneath breasts, or rolls of abdominal fat)	Well demarcated areas of erythema and maceration with satellite papules and pustules
Erosio interdigitalis blastomycetica	Finger or toe webspace	Eroded erythematous area surrounded with macerated skin
Diaper rash	The lesions begin in the infant's perianal area and then spread toward the genitalia and the inner thighs	Eroded areas surrounded with discrete scaling and occasional pustules
Candidal balanitis	Glans penis and inner aspect of the foreskin	Multiple distinct pustules and diffuse erythema
Perianal candidiasis	Anal region	Progressively worsening erythema and maceration
Candidal folliculitis	Any hairy areas of the body that are frequently covered or occluded by clothing	Small pustules at the base of the hair follicles

Other unusual and less frequently seen forms of candidal skin infections include:

Generalized cutaneous candidiasis. This is a process characterized by a spreading rash with vesicles that can affect the genitocrural and anal areas, trunk and extremities (including hands and feet). It can occur both in children and adults [648].
Candidal granulomas. These lesions present as large, dry, wart-like hyperkeratotic processes. Although a solitary candidal granuloma can occur without obvious cause, these unusual lesions usually occur as part of the syndrome of chronic mucocutaneous candidiasis. The classic histopathology finding is a hyperkeratotic and granulomatous lesion, with Candida found only in the cornified cell layer of the epidermis [648, 1424].
Disseminated candidiasis is on occasion associated with skin lesions. Unlike all of the other forms of cutaneous candidiasis in which the infection starts on the outside and works in, this form of candidiasis is from the inside out. That is, it is due to hematogenous spread of the infection from the blood to the skin. The cutaneous lesions of invasive candidiasis can be quite non-descript and are discussed elsewhere.
Congenital cutaneous candidiasis. This condition is part of an unusual but characteristic condition which is fully discussed under neonatal candidiasis.

The key factor in essentially every case of cutaneous candidiasis is prolonged exposure of normally dry skin to moisture. With few exceptions (see the next paragraph), this disease can really only begin in warm and moist areas. Therefore, occupations that require frequent immersion of hands in water also predispose to this condition. Obesity predisposes due to the difficulty with keeping the skin dry between rolls of fat. Diabetes and the use of systemic or topical corticosteroids also favor the occurrence of these infections, but moisture and warmth are still required [743].

There are only a few exceptions to the requirement for exposure to moisture:

Premature infants have extremely thin skin, and cutaneous candidiasis of the neonate develops readily and can (unlike any of the other forms of cutaneous candidiasis) progress to invasive and disseminated infection. See our discussion of neonatal candidiasis for additional details.
Candidal granulomas develop spontaneously on dry skin in individuals with chronic mucocutaneous candidiasis.
The cutaneous lesions of invasive candidiasis have an entirely different pathogenesis and do not require moist skin.

Symptomatically, pruritus (itching) and irritation of the affected areas are the usual complaints. More severe lesions can also be quite painful, especially if located in regions where clothing binds tightly.

While topical antifungal agents are valuable in the treatment of cutaneous candidiasis, effective and prompt relief is best achieved by applying these principles:

Patient education is as or more important than use of antifungal drugs. Patients should understand the importance of avoiding occlusions, favor dryness and promote good hygiene of the affected area [89].
Topical antifungal agents are a key part of the treatment of cutaneous candidiasis. The most commonly used agents are listed in the table below. Due to their intrinsic drying properties, powder preparations (e.g., miconazole) can be particularly useful for intertrigo.
Short course of topical corticosteroid agents can help ease symptoms in severe cases.
Oral nystatin may be given to infants with recurrent diaper rash. This is thought to reduce bowel colonization with Candida and thus reduce the rate of recolonization of the perianal skin [743].
Systemic therapy with azoles is not usually needed. However, selected patients with extremely widespread disease and/or difficult-to-control predisposing factors (e.g., poorly controlled diabetes) may benefit from short courses of treatment with fluconazole, ketoconazole, or itraconazole.

Topical Agents for Treatment of Cutaneous Candidiasis

Drug (Trade Names)	Drug format	Usage
Amphotericin B (Fungizone®)	3% cream, lotion, ointment	Apply to affected area twice to four times/day
Butenafine (Mentax®)	1% cream	Apply to affected area once daily
Clotrimazole (Lotrimin, Mycelex®)	1% cream	Apply to affected area twice/day
Econazole (Spectazole®)	1% cream	Apply to affected area once to twice/day
Ketoconazole (Nizoral®)	2% cream	Apply to affected area once daily
Miconazole (Monistat-Derm®, Micatin®)	2% cream, powder, spray	Apply to affected area twice/day
Nystatin (Mycostatin®)	cream, ointment, powder	Apply to affected area twice/day
Terbinafine (Lamisil®)	1% cream	Apply to affected area twice/day
Tolnaftate (Tinactin®)	1% cream	Apply to affected area twice/day

References

89. Anonymous. 1996. Guidelines of care for superficial mycotic infections of the skin: Mucocutaneous candidiasis. J. Amer. Acad. Dermatol. 34:110-5.

648. Edwards, J. E., Jr. 1995. Candida species, p. 2289-2306. In J. E. Bennett (ed.), Principles and Practice of Infectious Diseases, vol. 2. Churchill Livingstone, New York.

743. Fitzpatrick, T. B., R. A. Johnson, K. Wolf, M. K. Polano, and D. Suurmond. 1997. Candidiasis: Cutaneous Candidiasis, p. 718-727. In M. J. Wonsiewicz (ed.), Color atlas and synposis of clinical dermatology: common and serious diseases. The McGraw-Hill Companies, New York.

1424. Mandell, G. L. 1995. Skin, soft tissue, bone, and joint infections, p. 6.5. In D. L. Stevens (ed.), Atlas of Infectious Diseases, vol. II. Chruchill Livingstone, Philadelphia.