What is the treatment for Candida (fungal) infections?

Treatment of Candida Intertrigo (Cutaneous Candidiasis)

For Candida intertrigo, topical azole antifungals (clotrimazole, miconazole, or ketoconazole) applied twice daily for 2-4 weeks are the first-line treatment, with oral fluconazole 150 mg as a single dose or 100-200 mg daily for 7-14 days reserved for extensive or refractory cases. 1, 2

Primary Treatment Approach

Topical Therapy (First-Line)

• Apply topical azole antifungals (clotrimazole 1%, miconazole 2%, or ketoconazole 2% cream) to affected intertriginous areas twice daily for 2-4 weeks 1, 2
• Topical nystatin cream or ointment (100,000 units/gram) applied 2-4 times daily is an alternative option, though azoles are generally more effective 1
• Keep affected skin folds dry and reduce moisture accumulation by using absorbent powders or barrier creams after antifungal application 2

Systemic Therapy (For Extensive or Refractory Disease)

• Oral fluconazole 150 mg as a single dose can be used for widespread cutaneous candidiasis 3, 2
• For more severe or persistent intertrigo, fluconazole 100-200 mg daily for 7-14 days is recommended 1, 3
• The daily dose is the same whether administered orally or intravenously due to rapid and complete oral absorption 3

Species-Specific Considerations

Fluconazole-Susceptible Species (C. albicans, C. tropicalis, C. parapsilosis)

• These species respond well to standard fluconazole dosing with efficacy rates of 82-93% 4
• Topical azoles remain highly effective for localized cutaneous infections 1, 2

Fluconazole-Resistant Species (C. glabrata, C. krusei)

• C. glabrata requires higher fluconazole doses (400 mg daily) or alternative agents, with only 50% efficacy at standard doses 4
• C. krusei is intrinsically resistant to fluconazole and should not be treated with this agent 4, 5
• For resistant species, topical amphotericin B cream or systemic echinocandins may be necessary 1

Critical Management Points

Address Predisposing Factors

• Control underlying diabetes mellitus, as hyperglycemia promotes Candida growth 2
• Reduce obesity-related skin fold moisture through weight management when feasible 2
• Discontinue or minimize unnecessary antibiotic use that disrupts normal skin flora 2
• Manage immunosuppression appropriately in transplant recipients or patients on corticosteroids 2

Common Pitfalls to Avoid

• Do not use fluconazole in patients with recent azole exposure or prophylaxis, as this increases resistance risk 2, 5
• Avoid premature discontinuation of topical therapy; treat for the full 2-4 week course even if symptoms resolve earlier 1
• Do not rely on fluconazole monotherapy for C. krusei infections, as intrinsic resistance will lead to treatment failure 4, 5

Treatment Duration and Monitoring

• Continue topical antifungal therapy for at least 2 weeks after clinical resolution to prevent relapse 1
• For oral fluconazole, a single 150 mg dose is often sufficient for uncomplicated cases, but 7-14 days may be needed for extensive disease 3, 1
• If no improvement occurs within 7-10 days, consider culture and susceptibility testing to identify resistant species 4, 5

Alternative Agents for Refractory Cases

• Itraconazole solution 200 mg daily can be effective for fluconazole-refractory cutaneous candidiasis 1, 6
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily, is another option for resistant infections 1
• Topical amphotericin B cream combined with barrier protection may be necessary for multi-drug resistant species 1