Diagnosis and Management of Cutaneous Candidiasis in Bedridden Patients

Diagnostic Approach

Aggressively evaluate skin lesions through culture aspiration, biopsy, or surgical excision as they may be caused by resistant microbes, yeast, or molds 1
Serum fungal antigen tests (1,3-β-D-glucan or galactomannan) have low sensitivity, particularly in patients already receiving antifungal agents 1
Consider imaging studies (CT, MRI, ultrasound) if blood cultures are persistently positive for Candida species 3
Recovery of fungi from aspiration or biopsy of skin warrants aggressive systemic antifungal therapy 4

First-line therapy for systemic or disseminated candidiasis is an echinocandin (caspofungin: 70 mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200 mg loading dose, then 100 mg daily) 5
Alternative therapy for systemic or disseminated candidiasis is fluconazole 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily for patients unlikely to have fluconazole-resistant Candida species 5
For chronic disseminated candidiasis, initial therapy with lipid formulation AmB (3-5 mg/kg daily) or an echinocandin for several weeks, followed by oral fluconazole 400 mg daily 2
Continue therapy until lesions resolve on repeat imaging, which usually takes several months 2

For fluconazole-resistant species (C. krusei, C. glabrata), use an echinocandin, lipid formulation AmB, or voriconazole 6
Surgical treatment should be considered for patients with skin and soft tissue changes caused by angioinvasive molds (Mucor, Rhizopus, Aspergillus) 4
For patients with debilitating persistent fevers, short-term (1-2 weeks) treatment with nonsteroidal anti-inflammatory drugs or corticosteroids can be considered 2

Discrete pink to red papules (0.5-1.0 cm) usually found on trunk and extremities 4
Lesions may develop central pallor or become hemorrhagic 4
Up to 13% of patients with invasive disseminated candidiasis develop single or multiple nodular skin lesions 4
Painful myositis is most common with Candida tropicalis infection 4
Muscle and soft tissue abscess formation is uncommon but may occur following immune recovery 4
Trichosporon beigelii infection can mimic candidiasis with multiple erythematous macules to maculopapular lesions 4
Cutaneous mold infections may resemble ecthyma gangrenosum due to angioinvasion 4

Daily bathing with chlorhexidine for bedridden patients to decrease the incidence of bloodstream infections 6

Premature discontinuation of antifungal therapy can lead to relapse 2
Fluconazole-resistant yeast (C. krusei and C. glabrata) are increasingly common due to widespread use of azole prophylaxis 4