What is the next step in treating a patient with a candida infection in the groin area that is not responding to nystatin (antifungal medication) cream applied once a day?

Treatment of Nystatin-Refractory Groin Candidiasis

Switch to oral fluconazole 150 mg as a single dose for uncomplicated cutaneous candidiasis, or if severe/recurrent, use fluconazole 150 mg every 72 hours for 2-3 doses. 1

Critical First Step: Optimize Current Therapy

Before switching agents, recognize that nystatin once daily is subtherapeutic—the standard dosing for topical nystatin is 4 times daily, not once daily 1, 2. This underdosing is likely the primary reason for treatment failure. However, given the poor efficacy of nystatin even at proper dosing (clinical cure rates only 32-54% versus 87-100% for fluconazole), switching to a systemic azole is the superior approach 2.

Recommended Treatment Algorithm

For Uncomplicated Groin Candidiasis (Most Common)

• Oral fluconazole 150 mg as a single dose is the treatment of choice 1, 3
• This achieves equivalent or superior results compared to any topical regimen 1
• Alternatively, use topical azoles (clotrimazole or miconazole) applied twice daily for 7-14 days if oral therapy is contraindicated 1
• Keep the area dry, as moisture control is essential for treatment success 1

For Severe or Recurrent Disease

• Fluconazole 150 mg every 72 hours for a total of 2-3 doses 1
• If symptoms persist beyond 7-14 days, consider this a complicated infection requiring extended therapy 1

For Fluconazole-Refractory Cases

If the infection fails to respond to fluconazole after 7-14 days, escalate to:

• Itraconazole solution 200 mg once daily for up to 28 days (effective in approximately two-thirds of fluconazole-refractory cases) 4, 2
• Alternative: Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 4

Critical Diagnostic Considerations

Obtain fungal culture and susceptibility testing if the infection is refractory to initial azole therapy 4. This is essential because:

• Non-albicans species (particularly C. glabrata and C. krusei) may be present and require different management 1, 4
• C. glabrata frequently demonstrates azole resistance and may require alternative agents 1
• Nystatin actually has superior efficacy against C. glabrata compared to fluconazole (64.3% vs 12.5% cure rates), so if cultures reveal C. glabrata, consider nystatin suppositories 100,000 units daily for 14 days 1, 5

Alternative Agents for Azole-Resistant Organisms

If C. glabrata or azole-resistant Candida is identified:

• Topical boric acid 600 mg in gelatin capsules daily for 14 days (must be compounded by pharmacist) 1
• Nystatin suppositories 100,000 units daily for 14 days 1
• Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 1

Common Pitfalls to Avoid

• Do not continue nystatin once daily—this dosing is inadequate and will lead to persistent infection 1, 2
• Do not use echinocandins or newer azoles for cutaneous infections—they do not achieve adequate tissue concentrations for skin infections 6
• Reassess the diagnosis if treatment fails—consider dermatophyte infection, eczema, psoriasis, or contact dermatitis as alternative diagnoses
• Address predisposing factors: diabetes control, obesity, moisture/friction in skin folds, antibiotic use 1

When to Consider Systemic/Severe Disease

If the patient has systemic symptoms or immunocompromise, consider:

• Intravenous echinocandin (caspofungin 70 mg loading dose, then 50 mg daily; micafungin 100 mg daily; or anidulafungin 200 mg loading dose, then 100 mg daily) 4
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily 4