What is the most appropriate pharmacotherapy for a 4-month-old female infant with a red, confluent rash, pustules, and satellite papules in the diaper area, suggestive of a fungal infection, particularly candidiasis, given her history of oral antibiotic therapy for otitis media (inflammation of the middle ear) and normal body temperature (normothermia)?

From the Guidelines

The most appropriate pharmacotherapy for this 4-month-old female infant with a diaper rash is topical nystatin (option B). The clinical presentation describes a candidal diaper dermatitis, characterized by a red, confluent rash with sharply demarcated borders, pustules, and satellite papules in the diaper area. This fungal infection is commonly caused by Candida albicans and often occurs following antibiotic therapy, which this infant has recently received for otitis media. Antibiotics can disrupt the normal flora, allowing for overgrowth of yeast.

Key Points to Consider

• Topical nystatin is an antifungal medication that effectively treats candidal infections by binding to sterols in the fungal cell membrane, creating pores that lead to cell death.
• The medication should be applied to the affected area with each diaper change after gentle cleansing until the rash resolves, typically within 7-10 days.
• Keeping the diaper area clean and dry will help speed recovery.
• Mupirocin would be appropriate for bacterial infections, while oral antifungals or intravenous amphotericin B would be excessive for a localized candidal diaper dermatitis in an otherwise healthy infant. According to the most recent guidelines for the management of candidiasis, published in 2016 1, topical therapy is recommended for localized cutaneous candidiasis, which aligns with the presentation of this infant's diaper rash. The earlier guidelines from 2000 1 also support the use of topical agents for primary cutaneous disease in healthy infants, further reinforcing the choice of topical nystatin for this patient.

From the FDA Drug Label

INDICATIONS AND USAGE Nystatin Topical Powder is indicated in the treatment of cutaneous or mucocutaneous mycotic infections caused by Candida albicans and other susceptible Candida species. CLINICAL PHARMACOLOGY ... Nystatin is an antibiotic which is both fungistatic and fungicidal in vitro against a wide variety of yeasts and yeast-like fungi, including Candida albicans... DOSAGE AND ADMINISTRATION Very moist lesions are best treated with the topical dusting powder. Adults and Pediatric Patients (Neonates and Older): Apply to candidal lesions two or three times daily until healing is complete.

The most appropriate pharmacotherapy for the 4-month-old female infant with a rash in the diaper area is Topical nystatin. The rash is described as a red, confluent rash with sharply demarcated borders, pustules, and satellite papules, which is consistent with a cutaneous or mucocutaneous mycotic infection caused by Candida albicans. Nystatin topical powder is indicated for the treatment of such infections, and it can be applied to the affected area two or three times daily until healing is complete 2, 2, 2.

From the Research

Diagnosis and Treatment of Diaper Dermatitis

The patient's symptoms, including a red, confluent rash with sharply demarcated borders, pustules, and satellite papules in the diaper area, are consistent with diaper candidiasis, a type of diaper dermatitis caused by Candida albicans 3.

Treatment Options

• Topical nystatin is a commonly used treatment for cutaneous candidiasis, including diaper candidiasis, and has been shown to be effective in eradicating Candida organisms 4, 5.
• Topical mupirocin has also been shown to be effective in treating diaper candidiasis, with a study demonstrating that it can eradicate Candida organisms and promote healing of excoriated wounds 6.
• Oral ketoconazole is not typically used as a first-line treatment for diaper candidiasis, and its use may be limited by potential side effects and resistance 4, 5.
• Oral cephalexin is an antibiotic and would not be effective in treating a fungal infection such as diaper candidiasis.
• Intravenous amphotericin B is typically reserved for severe, systemic fungal infections and would not be appropriate for treating diaper candidiasis.
• No pharmacotherapy is not a suitable option, as treatment is necessary to eradicate the infection and promote healing.

Recommended Treatment

Based on the evidence, topical nystatin (option B) is a suitable treatment option for diaper candidiasis, and topical mupirocin (option A) may also be considered. However, the most appropriate pharmacotherapy would be topical nystatin, as it is a commonly used and effective treatment for cutaneous candidiasis, including diaper candidiasis 4, 5.