What is the plan of care for a fungal infection of the groin and labia that did not respond to nystatin powder and has progressed to a wound?

Management of Fungal Infection of the Groin and Labia with Wound Development

For a fungal infection of the groin and labia that failed to respond to nystatin powder and has progressed to a wound, treatment should consist of oral fluconazole 150 mg every 72 hours for 3 doses, combined with a topical azole cream applied twice daily for 7-14 days. 1

Assessment and Diagnosis

• Confirm diagnosis through physical examination looking for:
  • Erythema, excoriation, fissures in the groin and labial area
  • Presence of wound with possible secondary infection
  • White, thick discharge if present
• Laboratory confirmation:
  • Perform KOH preparation to visualize yeast or hyphae
  • Consider fungal culture if diagnosis is uncertain or treatment failure occurs
  • Check pH (should be normal at 4.0-4.5 for typical candidiasis)

Treatment Approach

First-Line Treatment

1. Oral therapy:

   • Fluconazole 150 mg every 72 hours for 3 doses 1
   • This systemic approach is necessary due to:
     • Previous treatment failure with topical nystatin
     • Presence of wound indicating complicated infection

2. Topical therapy (concurrent):

   • Apply azole cream (clotrimazole 1% or miconazole 2%) to affected area twice daily for 7-14 days 1
   • Extend application 1-2 cm beyond visible lesions
   • Continue treatment for at least 7 days after clinical clearing 2

Wound Care

• Gentle cleansing with mild soap and water
• Keep area clean and dry between applications
• Avoid tight-fitting clothing and synthetic underwear
• Consider non-adherent dressing if wound is exudative

For Non-Responsive Cases

If no improvement after 7 days or worsening of symptoms:

• Consider alternative diagnosis or mixed infection
• Switch to a different azole or consider boric acid (600 mg) vaginal capsules daily for 14 days 1
• For suspected non-albicans species (particularly C. glabrata), consider boric acid as it may be more effective 1

Special Considerations

If C. glabrata is Suspected or Confirmed

• C. glabrata often responds poorly to azole therapy 1
• Consider boric acid contained in gelatin capsules (600 mg) intravaginally daily for 14 days 1
• Nystatin intravaginal suppositories may be effective for C. glabrata when azoles fail 3

For Recurrent Infections

• After successful treatment, consider maintenance therapy with fluconazole 150 mg weekly for 6 months 1
• Address predisposing factors:
  • Evaluate for diabetes or immunosuppression
  • Review medications (antibiotics, corticosteroids)
  • Recommend cotton underwear and loose-fitting clothing

Follow-up

• Schedule follow-up within 7-10 days to assess treatment response
• If wound is not healing or infection persists, consider:
  • Culture to identify specific pathogen and sensitivities
  • Evaluation for underlying conditions affecting immune response
  • Possible referral to dermatology or gynecology

Prevention of Recurrence

• Maintain good hygiene practices
• Keep area dry (use absorbent powders without cornstarch)
• Wear loose cotton clothing
• Change out of wet clothing promptly
• Avoid potential irritants (perfumed soaps, douches)

The presence of a wound following failed nystatin treatment indicates this is a complicated vulvovaginal candidiasis requiring more aggressive therapy than typical cases. The combination of oral and topical antifungals provides comprehensive treatment targeting both the superficial infection and potential deeper tissue involvement.