What is the appropriate management for a cutaneous yeast infection?

Management of Cutaneous Yeast Infections

For cutaneous yeast infections (candidiasis of the skin), topical azole antifungals such as clotrimazole, miconazole, or nystatin applied to the affected area are the first-line treatment, with the critical adjunct of keeping the infected area dry. 1

Treatment Approach by Infection Type

Intertrigo and Primary Skin Candidiasis

• Topical therapy is sufficient for most cases: Apply topical azole antifungals (clotrimazole, miconazole) or polyene antifungals (nystatin) to the affected skin 1, 2
• Moisture control is essential: Keeping the infected area dry is as important as the antifungal medication itself, particularly in skin folds of obese or diabetic patients 1
• Application frequency: Typically applied 1-2 times daily until resolution 3

Candidal Paronychia

• Drainage is the most important intervention if there is an abscess or fluid collection 1
• Topical antiseptics are effective: Apply broad-spectrum, colorless, nonsensitizing antiseptics to the proximal nail fold, allowing them to wash beneath the cuticle 1
• Alternating regimen: Use an imidazole lotion alternating with an antibacterial lotion until cuticle integrity is restored, which may take several months 1
• Topical azoles are equally effective as oral therapy for paronychia specifically 4

Candidal Onychomycosis (Nail Plate Invasion)

When Candida has invaded the nail plate itself (not just paronychia), systemic therapy is required:

• Itraconazole is the most effective agent: 400 mg daily for 1 week per month (pulse dosing), repeated for 2 months for fingernail infection 1
• Toenail infections: Use 3-4 pulses of the same regimen for the less common toenail candidal infections 1
• Important distinction: Determine whether Candida is truly invading the nail plate versus merely colonizing it—look for distal nail plate erosion, underlying host abnormalities (like Raynaud's disease), and hyphae in the nail plate 4
• Topical therapy is insufficient for true nail plate invasion 1

Medication Selection Rationale

Azoles vs. Polyenes for Skin Infections

• Both azole and polyene antifungals are appropriate for cutaneous yeast infections 2, 4
• Azoles (clotrimazole, miconazole, ketoconazole) are fungistatic but highly effective for Candida species 3
• Polyenes (nystatin, amphotericin B) are also suitable for yeast infections of skin and mucous membranes 2
• Allylamines (terbinafine) are NOT effective for yeast infections—they work well for dermatophytes but poorly for Candida 5, 6

When to Consider Oral Therapy

Oral antifungal therapy is indicated when:

• The nail plate is invaded by Candida (onychomycosis) 1, 4
• The infection is severe or widespread 2
• Topical therapy has failed 4
• The patient is immunocompromised with mucosal involvement 4

For severe cutaneous yeast infections requiring systemic therapy:

• Fluconazole or itraconazole are the oral triazoles of choice 2
• Always combine oral therapy with topical antifungal treatment 2

Common Pitfalls to Avoid

• Don't use terbinafine for yeast infections: While excellent for dermatophytes, terbinafine has poor activity against Candida species 5, 6
• Don't treat paronychia systemically first: Drainage and topical therapy are usually sufficient 1
• Don't assume nail Candida requires systemic therapy: If it's only paronychia without nail plate invasion, topical therapy works 4
• Don't neglect moisture control: Antifungal medication alone without keeping the area dry will lead to treatment failure 1
• Don't use topical therapy for true onychomycosis: When the nail plate is invaded, systemic therapy is necessary 1, 4