What is the treatment for candida infections on the lips, oral pharynx, and skin?

Treatment of Candida Infections on Lips, Oral Pharynx, and Skin

For candida infections on the lips, oral pharynx, and skin, fluconazole 100-200 mg daily for 7-14 days is the most effective first-line treatment for moderate to severe cases, while topical agents like clotrimazole or nystatin are appropriate for mild cases. 1, 2

Treatment Based on Location and Severity

Oropharyngeal Candidiasis (Thrush)

• For mild cases: Clotrimazole troches (10 mg 5 times daily) or nystatin suspension (100,000 U/mL, 4-6 mL four times daily) or pastilles (200,000 U, 1-2 pastilles 4-5 times daily) for 7-14 days 2, 1
• For moderate to severe cases: Oral fluconazole (100 mg/day for 7-14 days) is superior to topical therapy 2, 1
• Itraconazole solution (200 mg/day for 7-14 days) is as effective as fluconazole and should be vigorously swished in the mouth before swallowing 3
• Ketoconazole and itraconazole capsules are less effective than fluconazole due to variable absorption 2

Esophageal Candidiasis

• Systemic therapy is required; topical therapy is ineffective 2
• Fluconazole (100 mg/day for 14-21 days) or itraconazole solution (200 mg/day) are highly effective 2
• Treatment should continue for 2 weeks following resolution of symptoms 3
• For patients unable to swallow, parenteral therapy should be used 2

Candidal Skin Infections

• Topical azoles and polyenes (clotrimazole, miconazole, nystatin) are effective 2, 4
• Keeping the affected area dry is important, especially for intertrigo in skin folds 2
• For paronychia (nail fold infection), drainage is the most important aspect of treatment 2, 5

Management of Refractory Cases

Fluconazole-Refractory Oropharyngeal Candidiasis

• Itraconazole solution (>200 mg/day orally) is effective in approximately two-thirds of cases 2, 1
• For patients unresponsive to fluconazole, itraconazole 100 mg twice daily is recommended 3
• Amphotericin B oral suspension (1 mL four times daily of 100 mg/mL suspension) can be effective in patients who don't respond to itraconazole 2
• Intravenous amphotericin B (0.3 mg/kg/day) may be used as a last resort 2

Fluconazole-Refractory Esophageal Candidiasis

• Itraconazole solution (>200 mg/day orally) 2
• Intravenous amphotericin B (0.3-0.7 mg/kg/day) for otherwise refractory disease 2

Special Considerations

Denture-Related Candidiasis

• Thorough disinfection of the denture in addition to antifungal therapy is required for definitive cure 2, 1
• Patients should be advised to discard or disinfect oral hygiene aids that may be contaminated 6
• A disinfecting solution of equal parts hydrogen peroxide and water or 2% chlorhexidine gluconate solution may be used 6

Immunocompromised Patients

• HIV-infected patients may require more aggressive initial therapy 1
• For recurrent infections in HIV patients, suppressive therapy with fluconazole 100-200 mg three times weekly is recommended 1
• Antiretroviral therapy should be used whenever possible to reduce recurrent infections in HIV-infected patients 2, 1

Important Clinical Pitfalls

• Treatment should continue for the full recommended duration even if symptoms resolve quickly 1
• Oropharyngeal fungal cultures are of little benefit as many individuals have asymptomatic colonization 2
• Azole-refractory infections are more common in patients with prior azole use and severely immunocompromised patients 2
• Candida albicans is the most common cause, but other species like C. glabrata and C. krusei may cause infections that are more resistant to standard treatments 2, 7
• Chronic mucocutaneous candidiasis requires a long-term approach similar to that used in AIDS patients with rapidly relapsing oropharyngeal candidiasis 2