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Patient Story
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A 2-month-old infant is being seen for a diaper rash and the pediatrician notes that the tongue and mouth are covered in white (Figure 121-1). A diagnosis of thrush and Candida diaper dermatitis is made. The child is treated with oral nystatin for the mouth and topical clotrimazole for the diaper dermatitis.

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FIGURE 121-1

Thrush in an otherwise healthy infant. (Used with permission from Richard P. Usatine, MD.)

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Introduction
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Cutaneous and mucosal Candida infections are seen commonly in infants with thrush and diaper rash (Figure 121-2). Also children and teens with obesity, diabetes, and/or immunodeficiency are at higher risk of developing Candida infections.

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FIGURE 121-2

Candida diaper dermatitis in an otherwise healthy infant. Note the satellite lesions and the pink color. (Used with permission from Richard P. Usatine, MD.)

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Synonyms
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Thrush.

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Epidemiology
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  • Candida superinfected diaper dermatitis is highly prevalent in healthy infants (Figures 121-2 and 121-3).

  • Candida thrush is not uncommon in healthy infants (Figure 121-1).

  • Candidemia is a major source of morbidity and mortality in neonatal intensive care units (NICU).1 This chapter focuses on cutaneous Candida infections only.

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FIGURE 121-3

Candida diaper dermatitis after a course of antibiotics for otitis media. Note how the dermatitis has spread up the abdomen but follows the diaper distribution. There are visible satellite lesions. (Used with permission from the Cleveland Clinic Children’s Hospital Photo Files.)

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Etiology and Pathophysiology
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  • Cutaneous infections caused by Candida species are primarily Candida albicans.

  • C. parapsilosis and C. albicans infections are the most frequent causes of candidemia in the NICU.1

  • C. albicans has the ability to exist in both hyphal and yeast forms (termed dimorphism). If pinched cells do not separate, a chain of cells is produced and is termed pseudohyphae.2

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Risk Factors
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Infancy, prematurity, hospitalization, being in the NICU, obesity, diabetes, immunodeficiency, HIV, use of oral antibiotics, and use of inhaled or systemic steroids.

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Diagnosis
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Clinical Features
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  • Ask about recent antibiotic or steroid use in the history.

  • Typical distribution—Diaper area (Figure 121-3), glans penis, vulva, inframammary (Figure 121-4), under abdominal pannus, between fingers, in the creases of the neck, and in the corners of mouth in angular cheilitis.

  • Morphology on the skin—Macules, patches, plaques that are pink to bright red with small peripheral satellite lesions (Figure 121-3).

  • Physical exam—Thrush appears as a ...

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