Candidiasis is a
superficial fungal infection, which is very common in infants and young
children caused by the yeast-like fungus Candida albicans. C. Albicans is
a commensal of the oral cavity, gastrointestinal tract and vagina.
It has long been
recognized that the very old, the very young and the very ill are
susceptible to oral thrush. The organism changes its behavior and becomes
pathogenic under certain conditions
and maceration of the skin as in diaper dermatitis by napkins and plastic
Age Group - infants
and young children are more susceptible to candidiasis than adults.
especially for long and repeated courses mainly in infants where some
practitioners give antibiotics with every case of fever even if it is
viral in origin. This may predispose to overgrowth of Candida due to
suppression of normal resident flora.
corticosteroid therapy as in chronic skin diseases or in allergic
such as with diabetes.
The clinical picture
varies according to the site involved. These may be cutaneous, muco
cutaneous or mucosal lesions.
Fig. 82. Cutaneous Candidiasis
Fig. 83. Tinea pedis (Candidiasis)
The intertriginous areas
are common sites for Candida infection particularly in infants and young
children due to occlusion and maceration of skin.
The lesion appears as an
erythematous eruption with smaller lesions on the periphery known as
In adults and school age
children the interdigital involvement is common causing inflammation and
The nails may be infected
leading to localized inflamed swollen peri-ungual tissue, where beads of
pus can be squeezed from the lesion.
Oral Candidiasis (Thrush)
This is a common
infection particularly in infants and young children. White non-adherent
plaques appear on to the buccal mucosa and the palate surrounded by
erythematous areas. A sharply defined patch of creamy, crumbly, curd-like
white pseudomembrane appears which when removed, leaves an underlying
erythematous base. This membrane consists of desquamated epithelial cells,
fibrin, leukocytes, food debris, and fungal mycelium that attaches it to
the inflamed epithelium.
Fig. 84. Crural Candidiasis (Satellites)
Fig. 85a&b.. Mucosal Candidiasis
The lesion may involve
the tongue and most of the oral mucosa, giving the appearance of
white mottled sheet. This may interfere with feeding of infants
where they can‘t tolerate bottle-feeding or some acid food or beverages
such as orange juice.
In chronic cases the
infection may extend to the angles of the mouth to the muco-cutaneous
junction leading to fissuring and even bleeding from the angle of the
Fig. 86. Candidal
This condition is more
common in adults especially housemaids whose hands are continuously
immersed in water. The lesion begins as painful inflammation of the side
of the nail. Beads of pus may be expressed from the lesion. Secondary
infection by staphylococci is common.
This is common also
during pregnancy and in infancy. Vaginal mucosa becomes red macerated and
may be covered with white membrane. This may be accompanied by vaginal
whitish creamy discharge .The adjacent skin may be involved and becomes
red, scaly and may show some satellite pustules.
Normal subjects have
antibodies, humoral and cellular, to Candida albicans and to other Candida
species. The term "candida allergy" is also used to describe a
variety of symptoms ranging from headache to malaise and depression
secondary to colonization of the gastrointestinal tract with the yeast.
Bullous annular erythema
and generalized pruritus.
Treatment of candidiasis
Aeration and dryness of
the skin especially in infants using diapers.
Hygiene of the mouth
especially in mucocutaneous candidiasis.
Eradication of candida
reservoir in the mouth, the gut and genitalia in infants, children and
nursing mothers is of prime importance.
In infants suspensions of
Nystatin, Amphotericin or Miconazole gel applied several times a day are
usually adequate medications for treating oral thrush for two weeks.
and Natamycin are all highly effective against Candida species and most
other yeast pathogens. Imidazole, Clotrimazole, Miconazole and Econazole
are very effective medications.
The newer Triazoles,
Fluconazole and Itraconazole are also effective in these conditions and
have the additional advantage of having lower rates of complication and
The usual adult daily
Ketoconazole 200 mg,
itraconazole 100 mg and Fluconazole 50-100 mg. Resistance to Ketoconazole
have been reported.
Treatment of Oral
In infants suspensions of
Nystatin, Amphotericin or Miconazole gel applied several times a day are
usually adequate for treating oral thrush.
In the adult patient,
removal of the dentures at night and careful hygiene is important.
Frequent sucking of
Amphotericin lozenges, which lack the bitter taste of Nystatin.
Amphotericin tablets are also effective.
Daktarin gel and oral
suspensions of Nystatin.
The duration of the
treatment varies according to the type and extent of the skin lesion.
Treatment duration is about 10-14 days. This may be enough in acute cases
but in chronic hyperplastic candidiasis it must be continued for many
Angular Candidiasis -
imidazole cream or ointment may be enough . Pufexamac(Flogocid) is cheaper
and gives good results.
itraconazoles usually give good results especially when Candida infection
Congenital candidiasis -
localized lesions of candidiasis can be treated by topical preparations.
Systemic Candidiasis -
Amphotericin, Flucytosine , Fluconazole, orally and paranterally may be
required to control systemic infections .
Candidiasis may appear on
newborn few weeks after labor in two forms.
Skin and mucous membrane
lesions : may result from infection from infected genital tract of the
mother during labor .
Oral candidiasis may
appear alone during suckling .
follow infection of the mother‘s genital tract. Candida infection
affects skin and internal organs such as the lungs and gastrointestinal
tract. This type is serious and there may be high mortality rate.
The face and chest are
the first affected by the rash, which generally spreads over the next few
days after delivery.
The primary skin lesions
are diffuse, pinkish, maculopapular eruption which is present at birth or
appear later after few hours. The lesions are typically discrete vesicles
or pustules on an erythematous base. The lesions generally progress to a
vesicular phase, and then either to a pustular or a bullous phase, over a
period of 1 to 3 days. More or less the whole skin surface may be
affected, including the palms and soles.
Oral involvement is
usually absent, and the napkin area tends to be spared, at least
When infection is
localized to the skin, the rash clears within a week with an appropriate
topical therapy, with post inflammatory desquamation. The general
condition of the child is usually not affected.
Candida may invade
internal organs mainly the gastrointestinal tract and the respiratory
system leading to premature babies and high mortality rates .
Such widespread skin
infections are believed to follow contamination of the skin surface during
birth and to the high incidence of intra-uterine infection or vaginal
DUE TO SAPROPHYTIC MOULDS
saprophytes may colonize either normal skin or devitalized skin tissue
causing fungal infection.
colonize the scalp and toe-clefts.
Fusarium appears to colonize damaged tissues firmly and causes secondary
Alternaria species are
now well recognized as causing a nodular or ulcerative skin infection.
Correction of local
precipitating factors such as maceration, occlusive dressings.
Topical antifungal agents
may be required.
It may be necessary to
use intravenous Amphotericin B in some systemic cases.
The newer Azole agents
such as Ketoconazole, Fluconazole or Itraconazole may be helpful and are
(Mycotic Otitis Externa)
This is a chronic fungal
infection of the external auditory canal . Fungi mainly Asperigillus
species may be isolated from swabs or scrapings where these fungi may be
saprophytic or pathogenic .
The external ear becomes
inflamed, painful, itchy and weeping with serosanguinous discharge .
In advanced cases of true
mycotic otitis, an overgrowth of fungal hyphae may produce a mass of white
material which appears as a damp cotton wool lodged in the external canal.
Asperigillus Niger is the
causative organism where the mat of fungus is often covered by black
In severe cases necrotic
otitis externa may develop . This form may spread to involve other sites
including the middle ear and the mastoids.
The pinna may be the site
of several mycotic diseases including Chromomycosis , Sporotrichosis and
Tinea but such infections usually spare the external auditory meatus.
Diagnosis of mycotic
Smear: swab taken gently
from the ear.
Culture to detect the
type of mould.
Careful toilet, with
removal of debris and fungal materials from the ears, is of paramount
importance especially in infants and young children .
applications have been suggested:
Applying 2% Thymol in 70%
alcohol during cleansing of the ears followed by 50% Metacresyl acetate or
olive oil on a cotton wool left for 24 h.
Nystatin powder puffed
into the ear for Asperigillus infections and for Candida, but regular
toilet to remove debris and excess powder is required.
Clotrimazole lotion has
been employed with success in both Asperigillus and Candida infections.
Sporotrichosis is a
chronic fungal infectious disease caused by Sporothrix Schenkeii. The
organism lives as a saprophyte in grasses and plants where an accidental
injury will facilitate the inoculation of the organism into the skin . The
disease is more common in hot and humid environments .
lesion appears at the site of inoculation, which later ulcerates. Nodules
then appear along the draining lymphatic forming multiple subcutaneous
granuloma that may ulcerate. Papillomatous or draining fistulae are formed
later on. Regional lymph nodes are enlarged.
Disseminated type :
This type is rare .
Clinically multiple subcutaneous painless , soft abscess is formed which
ulcerates and formes fistulae . Systemic involvement of the lungs ,
gastrointestinal tract , bones and central nervous system is rare .
Treatment depends on
different factors. The advice of an experienced practitioner in deep
mycoses may be required in some cases.
Potassium iodide in large
doses by mouth is effective in the localized types and should be continued
for 3-4 weeks after clinical cure. It is the drug of choice for the
cutaneous form. The adult dose may be 40 drops of potassium iodide daily.
The treatment course is usually from 6-8 weeks.
A recommended schedule is
5 drops initially, then increasing to 50 drops of saturated KI three times
a day. Patient tolerance may require a lower maximum dose .
Itraconazole in doses of
100-200 mg daily is effective but it appears that the length of treatment
is not significantly different to that used with potassium iodide. It may,
however, be useful in patients who do not respond to the latter or in
B or Miconazole may also be helpful. Ketoconazole produces variable
results in Sporotrichosis and in many cases there is no response to this
This is a systemic deep
fungal infection caused by Coccidioides immitis.
Modes of Infection
The organism is present
in the soil, vegetables, and especially fruits .
Infection is by
inhalation of dust contaminated with the spores of the fungus.
The disease is wide
spread in endemic areas especially in dry windy summer months.
The incubation period may
be from few days to several weeks.
Mild respiratory symptoms
with non-specific symptoms such as high fever, chills, night sweating ,
headache , backache, malaise and bronchopneumonia.
eruption simulating drug eruption or measles appears in infants and
children which manifests early with the onset of infection.
Erythema nodosum on the
chins, thigh, buttocks, may present after the respiratory symptoms subside
The disease is usually
self-limiting, where most cases recover spontaneously. Few cases pass to
the disseminated form from the localized lesions to lungs, bones, viscera,
Skin lesion presents with
subcutaneous abscess and forming draining sinuses. Healing is by tissue
destruction and scarring .
Diagnosis: Skin biopsy is
, 0.25 mg/kgm body weight . The dose should be increased gradually where
0.1mg/kgm may be the optimum daily dose .
This is a systemic deep
fungal infection .
Types of Blastomycosis
This is a deep fungal
infection caused by Blastomyces dermatidis, which is endemic in North
lesion: small nodules appear along the draining lymphatics.
Granulomatous type -
the infection is in the lungs and the skin lesions occur due to direct
spread from the lung .
Skin lesions are multiple
warty vegetations discharging pus mostly on the exposed areas.
Healing leaves white
intravenously is an effective medication.
The disease is almost
always primary in the lungs. The disease is endemic in certain areas in
south America (Brazil, Argentina, and Venezuela) and is caused by the
fungus Paracoccidiosis. Dissemination may occur affecting skin and
Modes of infection
Picking the teeth
Chewing infected leaves .
Extraction of teeth with
infected tools .
Skin lesions: micro
abscesses and ulceration appear on the skin.
inoculation may occur leading to ulceration, which heal by scarring and
destruction to the mouth , nose and face that may lead to severe pain and
Lymph nodes abscesses:
lymph nodes may break down with ulceration and is accompanied by secondary
infection of the skin .
Visceral lesions: may
be due to hematogenous spread.
Amphotericin B is an
effective medication .
Chromoblastomycosis is a
deep fungal infection caused by various fungi mainly Cladosporium
carrionii and Philaphora verrucosa .
The lesions affect
usually the feet or lower extremities in patients walking barefooted .
Small ecchymotic papule
or warty lesion appears at the site of the fungal inoculation. Satellites
may appear where the extremity becomes swollen and covered by verrucous
lesions resembling cauliflower or common warts .
Nodules coalesce forming
larger lesions that may heal by scarring Cicatricial lesions may develop
which cause sclerosis and disfiguration.
containing giant cells and focal cell infiltrate .
The fungus appears as
brown, spherical clusters with thick dark cell wall and coarsely pigmented
granular cytoplasm .
Surgical excision and
B may have some effect .
Histoplasmosis is a
systemic mycoses caused by the saprophyte, histoplasmosis capsulatum,
which is present in the soil. Dissemination of infection to the skin is
infrequent. The disease has a serious prognosis in children .
type: a chancre develops accompanied by regional lymphadenopathy.
Purpura: this is the
commonest manifestation of histoplasmosis in children. This is due to
involvement of the reticulo-endothelial system and purpura is an
indication of the severity of the disease.
this type presents with dissemination of infection to the nasopharynex.
The lesion begins as indurated solid plaque, which ulcerates deeply
causing more destruction to tissues or may form a granulomatous lesion.
Skin lesions may appear
in crops leading to ulcers or umbulicated nodules and papules.
infection is common , where pyoderma, furuncles and abscesses may involve
the infected areas.
Amphotericin B is the
drug of choice.
Cryptoccosis is a
systemic mycoses caused by Creptococcus neoformans which is present in the
soil, dust and as a saprophyte on the human skin.
Primary pulmonary type -
manifests with mild cough ,chest pain and fever. The disease can be
diagnosed radiologically at this stage.
Central nervous system -
manifestations are due to dissemination of the disease causing
intracranial hypertension. These include restlessness, depression,
hallucination, headache, vertigo, nausea and vomiting.
Skin manifestation -
dissemination of the disease to the skin presents with indolent rubbery
acniform papules or pustules on the face. Ulceration and granulomatous
lesions may occur.
Amphotericin B usually
gives good results.
Nocardiosis is a systemic
mycoses caused by Nocardia asteroids and N. Brazilians.
Pulmonary type - presents
with cough, anorexia, night sweats and weight loss.
Skin manifestations -
these are variable which may be multiple abscesses draining from the chest
lesions, vesicular eruption or with cutaneous nodule at the site of
inoculation of the causative fungi.
Other types of
antibiotics such as penicillin and Tetracyclines may be effective.
Mycetoma is a systemic
mycoses caused by the group Streptomyces Somaliens, S. Madura and other
species such as Nocardia group. The disease appears mainly in the western
Hemisphere, South America and Africa.
Skin lesions present with
subcutaneous swelling on the interdigital spaces, buttocks, and chest or
on other areas. The nodules are painless, and indolent. Ulceration may
follow with draining sinuses of the foot.
Treatment depends on the
type of the lesion and the causative organism.
In the early stage
removal of the affected area or even amputation of the affected limb in
severe and extensive lesions.
Sulfadiazine in Nocardia
lesions may be effective.
Rhinosporidosis is a
polypoid disease that involves mainly the nasal mucosa. Young children and
adults are commonly affected. The disease is caused by Rhinospedium
seeberi. The disease is endemic in India, Ceylon, South America, Italy and
other parts of the world .
The lesions affect mainly
the nasal mucosa. Other areas involved are the lacrimal sac, ears, vulva
and penis. Pinkish, papillomatous, fissured lesions develop which become
fissured and bleed later one. Rectal and vaginal lesions present with the
Hay RJ. Chronic
dermatophyte infections. I. Clinical and mycological features. Br J
Dermatol 1982; 106: 1-6.
Eng RHK, Corrado ML,
Cleri D et al. Infections caused by Actinomyces viscosus. Am J Clin
Pathol 1981; 75: 113-16.
Aronson IK, Soltani
K. Chronic mucocutaneous candidiasis. A review. Mycopathologia 1976; 60:
Blank F, Mann SJ.
Trichophyton rubrum infection according to age, anatomical distribution
and sex. Br J Dermatol 1975; 92: 171-4.
Tropical Medicine and Communicable Diseases. London: Bailliere Tindall,
Bouza E, Dreyer JS,
Hewitt Wl et al. Coccidioidal meningitis: an analysis of thirty one
cases and review of the literature. Medicine 1981; 60: 139-44
Chandler FW, Watts
JC. Pathologic Diagnosis of Fungal Infections. Chicago: ASCP Press,
Clayton YM, Connor
BL. Comparison of clotrimazole cream, Whitfield‘sointment and nystatin
ointment for the topical treatment of ringworm infections, pityriasis
versicolor, erythrasma and candidiasis. Br J Dermatol 1973; 89: 297-303.
DeFelice R, Galgiani
JN, Campbell SC et al. Ketoconazole treatment of coccidioidomycosis:
evaluation of 60 patients during three years of study. Am J Med 1982;
Drutz DJ, Catanzaro
A. Coccidioidomycosis. Parts I and II. Am Rev Resp Dis 1978; 117:
Degreef H, Marien
K, De Veylder H et al. Itraconazole in the treatment of
comparison of two daily dosages. Rev Infect Dis 1987; 9 (Suppl. 1):
De Vroey C.
Epidemiology of ringworm (dermatophytosis). Semin Dermatol 1985; 4:
Drouhet E. African
histoplasmosis. In: Hay RJ, ed. Tropical Fungal Infections.
Goodwin RA, Loyd
JE, DesPrez RM. Histoplasmosis in normal hosts. Medicine 1981; 60:
DCE, ed. Antifungal
Chemotherapy. Chichester: John Wiley & Sons, 1980:255-83.
Del Palacio Hernanz
A, Delgado Vicente S, Menendez Ramos F et al. Randomized comparative
clinical trial of itraconazole and selenium sulfide shampoo for the
treatment of pityriasis versicolor. Rev Infect Dis 1987; 9 (Suppl. 1):
English MP, Gibson
MD, Warin RP. Studies in the epidemiology of tinea pedis.
VI. Tinea pedis in
a boys‘ boarding school. Br Med J 1961; i: 1083-6.
Njoku-Obi ANU. Tinea capitis in school children in East Nigeria.Mykosen
1986; 29: 132-44.
English MP, Gibson
MD. Studies in the epidemiology of tinea pedis. I and II. Tinea pedis in
school children. Br Med J 1959; i: 1442-5, 1446-8.
English MP. Fungi
and nails. Br J Dermatol 1976; 94: 697-701.
Fredriksson T. Propylene glycol in the of pityriasis versicolor. Acta
Derm Venereol 1980; 60: 92-3.
Gentles JC, Evans
EGV. Foot infection in swimming baths. Br Med J 1973; 3:260-2.
Villalba I, Galarza S et al. Itraconazole in pityriasis versicolor;
ultrastructural changes in Malassezia furfur produced during treatment.
Rev Infect Dis 1987; 9 (Suppl. 1): S134-8.
Hay RJ. Management
of chronic mucocutaneous candidosis. Clin Exp Dermatol 1981; 6: 515-19.
Hay RJ, Midgley G.
Short course ketoconazole therapy in pityriasis versicolor.Clin Exp
Dermatol 1984; 9: 571-3.
Hay RJ, Midgley G.
Short course ketoconazole therapy in pityriasis
versicolor. Clin Exp
Dermatol 1984; 9: 571-3.
Hay RJ. New oral
treatments for dermatophytosis. Ann N Y Acad Sci 1988;544: 580-5.
Howell SA, Clayton
YM, Phan QG et al. Tinea pedis: the relationship between symptoms and
host characteristics. Microbiol Ecol In Health & Disease 1988; 1:
Hay RJ, Clayton YM,
Griffiths WAD et al. A comparative double-blind study of ketoconazole
and griseofulvin in dermatophytosis. Br J Dermatol 1985; 112:691-6.
Jacobs P. Cutaneous
coccidioidomycosis. In: Stevens DA, ed. Coccidioidomycosis, a Text.
Current Topics in Infectious Disease. New York: Plenum, 1980: 213-24.
Kligman AM. Tinea
capitis due to M. audouinii and M. canis. Arch Dermatol 1955; 71:
Krowchuk DP, Lucky
AW, Primmer SI. Current status of the identification and management of
tinea capitis. Pediatrics 1983; 72: 625-31.
Leyden JJ, Kligman
AM. Interdigital athletes foot: the interaction of dermatophytes and
residual bacteria. Arch Dermatol 1978; 114: 1466-72.
Lynch PJ, Minkin W,
Smith EB. Ecology of Candida albicans in candidiasis of the groin. Arch
Dermatol 1969; 99: 154-60.
Larsh HW, Schwartz
J. Accidental inoculation blastomycosis. Cutis 1977; 19: 334-5.
McAleer R. Fungal
infections of the scalp in Western Australia. Sabouraudia 1980; 8:
Mok WY, Barreto da
Silva MS. Mycoflora of the human dermal surface. Canada J Microbiol
1984; 30: 1205-9.
MacManus EJ, Jones
JM. The use of ketoconazole in the treatment of blastomycosis. Am Rev
Resp Dis 1986; 133: 141-3.
Ohman SC, Dahlen G,
Moller A et al. Angular cheilitis: a clinical and microbial study. J
Oral Pathol 1985: 15: 213-17.
Pahwa VK, Chamiyal
PC, Suri PN. Mycological study of otomycosis. Indian J Med Res 1983; 77:
Shuttleworth D. Dermatophyte onychomycosis in children. Clin Exp
Dermatol 1989; 14: 203-5.
Rasmussen JE, Ahmed
AR. Trichophytin reactions in children with tinea capitis. Arch Dermatol
1978; 114: 371-2.
Treatment of superficial and subcutaneous mycoses. In: Speller Roberts
SOB. In: Speller DCE, ed. Antifungal Chemotherapy. Chichester: JohnWiley
& Sons, 1980: 225-83.
Rook A, Woods B.
Cutaneous cryptococcosis. Br J Dermatol 1962; 74: 43-9.
Silberfarb PM, Tosh FE. Cutaneous cryptococcosis. Arch Dermatol 1971;
Histoplasmosis. New York: Praeger, 1981.
Brown JR. Human
actinomycosis. A study of 181 subjects. Hum Pathol 1973; 4: 319-30.
Sarosi GA, Davies
SF. Blastomycosis. Am Rev Resp Dis 1979; 120: 911-38.
Whyte RK, Hussain
Z, De Sa D. Antenatal infections with Candida species. Arch Dis Child
1982; 57: 528-35.
Lasagni-A ; Oriani-A; Gelmetti-C Pediatric -Dermatol .1991 8 (1) 9-12.
Wells RS, Higgs JM,
MacDonald D et al. Familial chronic mucocutaneous candidiasis. J Med Genet
1972; 9: 642-3.