• Rarely causes severe disease in the immunocompetent host. It becomes a pathogen when changes or host defense (locally or systematically) allow for overgrowth and invasion of the organism.
• Not part of the normal flora of skin
• Frequently found as normal flora in mouth, gastrointestinal (GI) tract, respiratory tract, and vaginal tract.

• Include acute atrophic candidiases (glossitis) and angular cheilosis (perleche).
• Candidal glossitis occurs secondarily to broad-spectrum oral antibiotic therapy and commonly includes the complaint of glossodynia. Perleche results from chronic licking of the corners of the mouth, severe overbite, or occasionally from orthodontic braces.

• Colonization in healthy children of the oral mucosa, GI tract, respiratory tract, and vaginal mucosa are fairly common. Rates of colonization have been shown to increase substantially in hospitalized or chronically ill patients.
• Transmission appears to require direct contact with susceptible mucous membranes or cutaneous sites.
• Systemic or disseminated dz is usually hematologically spread from oral or GI lesions, or skin puncture sites.

• The most common of the allergic response syndrome to Candida are the candidids (id rashes), characterized by a papulovesicular or scaling plaque-like eruption that can include flexor or extensor surfaces of the upper extremities, extensor surfaces of thighs, and occasionally the hands, face, or trunk.
• Other clinical allergic syndromes include mucous colitis, generalized pruritus (with or without characteristic rash), chronic asthma exacerbations, and possibly a cause of erythema annulare.

• Other diaper rashes: atopic, seborrheic, bacterial, or occlusional.
• Mouth lesions: aphthous stomatitis, acute necrotizing gingivitis (trench mouth or Vincent angina), herpes gingivostomatitis or other viral causes of stomatitis (i.e., coxsackievirus)
• Intertrigenous infections: serborrheic and atopic dermatidites
• Vaginitis: gonorrhea, trichomonas, chlamydia, gardnarella, shigella, streptococcus, chemical or mechanical irritants
• Systemic disease: bacterial infection or sepsis

Question: Is the thrush recurrent?
Significance: Reinoculation can occur from bottle or mother’s nipples, pacifiers, or toys (see Therapy).

Question: Were antibiotics used?
Significance: Oral thrush and monilial diaper dermatitis are forms of candidiasis in infants, but can occur in older children after treatment with systemic antibiotics.

Question: Was the vaginal discharge accompanied by itching?
Significance: Candidal vulvovaginitis, the first clinical manifestation is usually labial pruritus, progressing to a local burning sensation, swelling of the labia, external dysuria, and a white watery or cheesy (curd-like) vaginal discharge.

Finding: Oral lesions
Significance: Can be of the buccal or lingual mucosa, gingiva, or tongue and have a characteristic white, friable, cheesy pseudomembrane that when scraped away reveals reddened, denuded, and sometimes ulcerated mucosa.

Finding: Rash
Significance: The rash of monilial diaper dermatitis is initially scattered, erythematous papules that progress and coalesce into a deeply erythematous, weeping, confluent rash, classically with a scalloped vesiculopapular or scaling border and papular, erythematous satellite lesions.

Test: Direct light microscopic observation
Significance: The diagnosis of mucosal, cutaneous, and vaginal candidiasis depends on clinical observation but can be confirmed by direct light microscopic observation of material scraped gently from the lesions and Gram stained or mounted with 10% or 20% potassium hydroxide (to lyse cellular debris) for the long, branching hyphae of C. albicans.

Test: Cultures
Significance: Mucosal or cutaneous scrapings, blood, urine, CSF, bone marrow, tissue biopsy, abscess aspirate, and bronchial lavage fluid can be cultured for C. albicans to confirm infection.

Test: CT scan
Significance: Is used to help identify deep organ lesions (liver, spleen, brain, kidney).

• Removal of the white pseudomembranous material with a plain tongue blade or with a cotton-tipped applicator dipped in nystatin suspension after feeds will often clear lesions after several days.
• More extensive, recurrent, or persistent oral lesions can be treated with nystatin suspension, 1 to 2 mL (of 100,000 units/mL) solution in each cheek, after meals, four to six times a day until 2 days after the lesions have cleared. Miconazole oral gel has been shown to be more effective, but is not available in the United States.
• Bottle nipples and pacifiers should be boiled for 5 minutes, at the beginning and end of a course of treatment, to avoid reinoculation.
• Recurrent thrush in a breast-fed infant may be indicative of colonization of the mother’s nipples with C. albicans; this can be eliminated by topical treatment of the nipples with nystatin cream four times a day for 5 to 7 days.
• In older patients, nystatin suspension is used as a swish swallow of 500,000 units every 4 to 6 hours for at least 7 days, or in oral tablet form, 500,00 to 1,000,000 units three times a day. Clotrimazole lozenges are also effective for older patients; 10 mg dissolved in mouth every 4 to 6 hours for 1 week.
• Gentian violet is no longer recommended for the treatment of oral candidiasis.
• For severe or persistant infection (immunocompromised host): fluconizole or ketoconazole are effective.

• Usually treated in an inpatient setting due to severity of illness, underlying disease process, and/or need for the intravenous route of drug administration.
• Treatment should also address removal of iatrogenic or predisposing factors if possible (e.g., removal of contaminated indwelling line or catheter).
• Antifungal agents commonly used:
  • Amphotericin B: 0.25 to 1.0 mg/kg/d, or 1.5 mg/kg every other day; given over 4 to 6 hours intravenously (after initial test dose; see hospital formulary) for 4 to 6 weeks for systemic infections.
  • Flucytosine: 150 mg/kg/d in four divided doses, given orally. Used to supplement amphotericin B in severe infections, alone for treatment of oropharyngeal or esophageal candidiasis (check susceptibility testing)
  • Ketoconazole: used for immunocompromised children with thrush or esophagitis at 3.3 to 6.6 mg/kg/d, given orally, until lesions clear (maximum of 400 mg/d).
• The toxicity of amphotericin (rigors, anemia, thrombocytopenia, and nephrotoxicity) requires close monitoring and may limit its use.

• INFECTION CONTROL
• Sterilization of bottle nipples and toys to prevent reinoculation of oral candidiasis as previously mentioned
• Avoidance of long courses of broad-spectrum antibiotics
• Careful attention to the maintenance of sterility of intravenous catheters and their skin entrance sites

• Need to maintain a high index of suspicion for systemic or disseminated disease in the immunocompromised host
• Consider in any patient with predisposing factors who has persistent fevers despite antibiotic therapy, a diffuse maculopapular rash, or unexpected eye complaints.

Q: When should an older child with thrush be worked up for possible immunodeficiency?
A: The cause for thrush in an older child (out of the infant period) should be carefully sought. Most often the cause is a recent course of antibiotic therapy.

Q: Is Nystatin effective therapy for vaginal candida?
A: No. Clortrimazole and other azole drugs are more effective.

American Academy of Pediatrics. Candidiasis. In: Peter G, ed. 1997 red book: report of the Committee on Infectious Diseases, 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:162–164.

Feign RD, Cherry JD, eds. Textbook of pediatric infectious diseases, 3rd ed. Philadelphia: WB Saunders, 1992:805–808, 1907–1913.

Hoppe JE. Treatment of oropharyngeal candidiasis and candidal diaper dermatitiis in neonates and infants: review and reappraisal. Pediatr Infect Dis J 1997;16(9):885–894.

Hurwitz S. Clinical pediatric dermatology. Philadelphia: WB Saunders, 1981. Chapters 2, 3, 13.