Diagnosis: Candidiasis (Candida Infection)

The finding of pseudohyphae on KOH preparation confirms a diagnosis of candidiasis, and treatment depends on the anatomic site involved. 1, 2

Diagnostic Confirmation

KOH preparation demonstrating yeasts or pseudohyphae is diagnostic for Candida infection, eliminating the need for culture in most symptomatic cases 1, 3
The presence of pseudohyphae specifically indicates active infection rather than mere colonization 4, 5
Approximately 10-20% of asymptomatic individuals harbor Candida species, so treatment should only be initiated when symptoms are present 1, 3

For uncomplicated vulvovaginal candidiasis, single-dose oral fluconazole 150 mg achieves >90% cure rates and is the preferred treatment. 3

Alternative topical azole regimens (clotrimazole 1% cream, miconazole 2% cream) applied intravaginally for 1-7 days are equally effective 1, 3
Topical azoles achieve 80-90% cure rates and are more effective than nystatin 1, 2
Vaginal pH should be <4.5 in candidal vaginitis; if pH is elevated, consider alternative diagnoses 1

Apply topical azole antifungals (clotrimazole 1% cream or miconazole 2% cream) twice daily for 7-14 days. 2

Implement moisture control measures including keeping the area dry, using absorptive powders, and applying barrier creams to prevent recurrence 2

Oral fluconazole is superior to topical therapy and is the preferred treatment for oropharyngeal candidiasis. 1

Typical dosing: fluconazole 100-200 mg daily for 7-14 days 1
Alternative: itraconazole oral solution for 7-14 days, though less well tolerated 1
Topical therapy (clotrimazole troches or nystatin suspension) can be used for initial episodes but is less effective 1

Systemic therapy is required; fluconazole 200 mg every 12 hours for 14-21 days is highly effective. 1, 6

Itraconazole oral solution for 14-21 days is equally effective but less well tolerated 1
Endoscopic confirmation is ideal but a diagnostic trial of antifungal therapy is often appropriate before endoscopy 1
Esophageal candidiasis typically presents with odynophagia, retrosternal pain, and fever 1, 6

Oropharyngeal and esophageal candidiasis are indicators of significant immunosuppression, typically occurring with CD4+ counts <200 cells/µL 1
HIV-infected patients should receive the same treatment regimens as HIV-negative patients 1
Consider non-albicans species (particularly C. glabrata) in refractory cases, which may require culture for species identification 1, 3
C. glabrata requires non-azole therapy such as topical intravaginal boric acid or nystatin suppositories 3

Do not treat asymptomatic colonization—identifying Candida without symptoms is not an indication for treatment 1, 3
Do not use SPORANOX® (itraconazole) Oral Solution in patients with ventricular dysfunction or congestive heart failure unless benefit clearly outweighs risk 7
Voriconazole should be avoided in moderate-to-severe renal impairment when given intravenously due to accumulation of the vehicle SBECD; use oral formulation instead 8
If treatment fails, obtain vaginal culture to identify species before proceeding with alternative therapy, as non-albicans species account for 10% of cases and require different management 3