What is the best cream to use for a recurrent groin rash in a patient with high moisture, incontinence, and multiple sclerosis (MS), that is wheelchair-bound and has shown response to nystatin (antifungal) powder?

Treatment of Recurrent Groin Candidiasis in Wheelchair-Bound Patient with Incontinence

For this recurrent groin candidiasis in a high-moisture environment, switch from nystatin powder to a topical azole cream (clotrimazole or miconazole) applied twice daily for 14 days, followed by maintenance therapy with the same agent applied once daily to prevent recurrence, combined with aggressive moisture management strategies.

Rationale for Treatment Selection

The response to nystatin powder confirms this is a candidal infection, but the recurrence pattern indicates you need both more effective antifungal therapy and prevention strategies 1.

Why Topical Azoles Over Nystatin

• Clotrimazole, miconazole, and nystatin demonstrate similar complete cure rates of 73-100% for cutaneous candidiasis, but azoles have superior efficacy in high-moisture environments 1
• Topical azole creams penetrate better into skin folds and maintain contact with affected areas longer than powders in the groin region 1
• Nystatin powder is FDA-indicated for cutaneous candidiasis but is not formulated for optimal adherence in moisture-prone intertriginous areas 2

Treatment Algorithm

Initial Treatment Phase (14 days):

• Apply clotrimazole 1% cream OR miconazole 2% cream to affected groin area twice daily for 14 days 1
• These agents have equivalent efficacy and either can be selected based on availability 1

Maintenance Phase (ongoing):

• After initial clearance, continue the same topical azole cream once daily indefinitely to prevent recurrence 3
• This mirrors the approach for recurrent vulvovaginal candidiasis, which requires maintenance therapy in high-risk patients 3

If Topical Therapy Fails:

• Consider oral fluconazole 150 mg every 72 hours for 3 doses, as this patient has complicated candidiasis (recurrent disease in an abnormal host with wheelchair-bound status and incontinence) 3
• Oral fluconazole demonstrates equal efficacy to topical agents and may be superior when moisture barriers prevent adequate topical penetration 1

Critical Moisture Management

The recurrence pattern strongly suggests inadequate moisture control is the primary driver of treatment failure, not antifungal resistance:

• Implement barrier creams containing zinc oxide or petrolatum after antifungal application to protect skin from urine exposure
• Ensure frequent incontinence product changes (every 2-3 hours minimum)
• Allow air exposure to groin area when safely possible (30-60 minutes twice daily)
• Consider absorbent textile barriers between skin folds

Special Considerations for MS Patients

• MS patients on disease-modifying therapies have increased risk of fungal infections, though invasive candidiasis remains rare 4
• The wheelchair-bound status creates persistent occlusion and moisture, making this a complicated candidiasis case requiring extended therapy 3
• Monitor for signs of systemic involvement (fever, spreading erythema beyond groin) which would require systemic therapy 3

Why Not Continue Nystatin

• While nystatin powder temporarily resolves symptoms, the powder formulation is suboptimal for moisture-rich environments where it clumps and loses contact with skin 2
• Nystatin cream could be considered, but topical azoles have broader evidence base for intertriginous candidiasis 1
• The recurrence pattern indicates need for maintenance therapy, which is better established for azoles 3

Alternative if Azole-Resistant Candida Suspected

If the rash fails to respond to topical azoles after 14 days:

• Consider Candida glabrata or azole-resistant species, which would require nystatin cream (not powder) applied twice daily for 14 days 5
• Nystatin demonstrates 64.3% cure rate for C. glabrata compared to only 12.5% for fluconazole 5
• Obtain fungal culture to guide therapy if resistance suspected 3