Fungal Rash Around Mouth in Pediatric Patients
Diagnosis
This presentation is most consistent with oral candidiasis (thrush) with perioral extension, caused by Candida albicans in the majority of cases. 1, 2
The diagnosis is primarily clinical, characterized by:
- White, curd-like plaques on the oral mucosa (tongue, palate, buccal mucosa) that can extend to perioral skin 3, 4
- Erythematous base when plaques are removed 4
- Possible angular cheilitis (cracking at mouth corners) secondary to candidal infection 3
Diagnostic confirmation can be achieved through fungal smear demonstrating hyphae, culture, or therapeutic response to antifungal treatment. 3 The microscopic demonstration of fungal hyphae on PAS smear is highly diagnostic. 3
First-Line Treatment
For oral candidiasis in pediatric patients, nystatin oral suspension (100,000 units/mL) is the recommended first-line treatment: administer 1 mL four times daily for 7-14 days. 5, 6
Treatment Algorithm by Severity
Mild to Moderate Cases:
- Nystatin oral suspension 100,000 units (1 mL) applied directly to affected oral and perioral areas 3-4 times daily for 7-10 days 5, 7
- Continue treatment for at least 48 hours after symptom resolution 5, 7
- For young children, apply with clean finger or cotton swab to affected areas 5
Alternative First-Line Option:
- Miconazole oral gel 15 mg every 8 hours 5, 6
- This has superior clinical cure rates (85.1%) compared to nystatin gels (42.8-48.5%) 5
Severe or Refractory Cases:
- Oral fluconazole 3-6 mg/kg once daily for 7 days 5, 7, 8
- This is reserved for cases that fail topical therapy or severe presentations 5, 7
- For children ≥5 years, itraconazole solution 2.5 mg/kg twice daily is an alternative 6
Critical Treatment Principles
Complete the full 7-14 day treatment course even after symptoms resolve to prevent recurrence and ensure mycological cure. 5, 7 Premature discontinuation is the most common cause of treatment failure. 7
The treatment endpoint should be mycological cure, not just clinical symptom resolution. 5, 7
Special Considerations and Risk Factors
Evaluate for predisposing factors:
- Dummy/pacifier use (44% colonization rate in one study) 9
- Immunocompromised states 3
- Recent antibiotic use 2
- Diabetes mellitus 3
- Decreased salivation 3
For breastfeeding-associated candidiasis, treat both mother and infant simultaneously with miconazole cream applied to maternal nipples/areola after each feeding. 5
Sterilize pacifiers, bottles, and toys regularly during treatment to prevent reinfection. 5
Monitoring and Follow-Up
Clinical improvement should occur within 48-72 hours of initiating treatment. 7 If no improvement occurs, consider:
- Non-albicans Candida species (particularly C. glabrata or C. krusei) 6
- Underlying immunodeficiency requiring evaluation 5
- Need for systemic antifungal therapy 5, 7
For recurrent infections (≥4 episodes/12 months), suppressive therapy with fluconazole 100-200 mg three times weekly may be necessary after initial control. 6
Common Pitfalls to Avoid
- Do not discontinue treatment when symptoms improve - this leads to recurrence and potential resistance development 7
- Do not use miconazole oral gel in neonates - concerns exist regarding triazole resistance generation 6
- Do not rely solely on clinical appearance - fungal smear or culture confirmation strengthens diagnosis, especially in atypical presentations 3
- Do not forget ophthalmologic examination in cases of systemic candidiasis - required for all candidemia cases 6