Can Candida albicans infections occur under abdominal folds, particularly in individuals with conditions such as obesity, diabetes, or immunosuppression?

Candida Albicans Under Abdominal Folds

Yes, Candida albicans absolutely can and does cause infections under abdominal folds, particularly in individuals with obesity, diabetes, or immunosuppression—this represents cutaneous candidiasis affecting intertriginous areas where moisture, warmth, and skin-on-skin contact create ideal conditions for fungal overgrowth. 1

Pathophysiology and Risk Factors

Candida albicans is part of the normal commensal flora in 40-50% of humans, residing in the gastrointestinal tract and on mucocutaneous surfaces. 2 When local conditions favor fungal proliferation, this colonization can progress to symptomatic infection. 3

Key risk factors that predispose to cutaneous candidiasis in skin folds include:

• Diabetes mellitus (especially poorly controlled hyperglycemia, which promotes yeast attachment, growth, and impairs immune responses) 4, 5
• Obesity (creates warm, moist intertriginous areas ideal for fungal growth) 4
• Immunosuppression (from medications, HIV, or other conditions) 4, 6
• Prolonged antibiotic use (disrupts normal bacterial flora that typically controls Candida) 4, 6
• Corticosteroid use 4
• Poor hygiene (allows moisture accumulation and reduced air circulation) 2

Clinical Presentation

Cutaneous candidiasis under abdominal folds typically presents as:

• Erythematous, moist patches with satellite pustules at the periphery
• Maceration of skin in the affected fold
• Pruritus and burning sensation
• White or creamy exudate in severe cases

This is distinct from invasive candidiasis, which affects critically ill patients with intra-abdominal infections or candidemia and carries mortality rates of 45-50%. 7, 1

Diagnostic Approach

The diagnosis is primarily clinical, but can be confirmed with:

• KOH preparation showing budding yeast and pseudohyphae
• Fungal culture if diagnosis is uncertain or treatment fails 2

The key distinction here is that superficial skin fold infections represent true mucocutaneous candidiasis requiring treatment, not mere colonization. 1 Unlike finding Candida in stool (which represents colonization in the vast majority of cases), symptomatic skin infection with visible lesions requires antifungal therapy. 3

Treatment Strategy

First-line treatment involves:

• Topical antifungal creams (azoles such as clotrimazole, miconazole, or ketoconazole applied twice daily) 2, 4
• Keep the area dry and improve air circulation (use of absorbent powders, frequent cleaning and drying)
• Address underlying risk factors, particularly glycemic control in diabetic patients 4, 5

For recurrent or severe cases:

• Consider oral fluconazole if topical therapy fails 4
• Evaluate for uncontrolled diabetes or immunosuppression 5

Critical Pitfall

Do not confuse cutaneous candidiasis (which requires treatment) with asymptomatic colonization (which does not). 3 The presence of symptomatic skin lesions with erythema, maceration, and pruritus indicates true infection requiring antifungal therapy, whereas mere detection of Candida without clinical signs represents colonization. 3, 1

Establishing euglycemia is essential in diabetic patients, as hyperglycemia increases both the risk of incident infection and recurrence. 4, 5