On this page
Referral and warning signs
When to refer
Refer if: Diagnosis uncertain. Failure to respond to initial therapy. Recurrent infections. Suspected oesophageal or systemic involvement. Need for systemic antifungals (beyond single dose Fluconazole for VVC). Severely immunocompromised patient.
Red flags
- Odynophagia/Dysphagia (suggests oesophageal involvement).
- Signs of systemic infection/sepsis.
- Lesions unresponsive to appropriate topical therapy.
- Extensive or rapidly spreading cutaneous lesions.
Signs and symptoms
- Oral Candidiasis (Thrush): White patches/plaques on tongue/mucosa (wipeable), redness, soreness, altered taste. (See ODH019)
- Vulvovaginal Candidiasis: Itching, soreness, thick white 'cottage cheese' discharge, dyspareunia, external dysuria.
- Cutaneous Candidiasis (Intertrigo): Red, moist, often itchy rash in skin folds (groin, axillae, under breasts, abdominal folds), may have satellite pustules/papules.
- Chronic Paronychia: Swelling, redness, tenderness of nail folds, sometimes pus discharge.
- Oesophageal Candidiasis: Painful swallowing (odynophagia), retrosternal pain, difficulty swallowing (dysphagia). Often extension from oral thrush in immunosuppressed.
- Invasive/Systemic Candidiasis (Candidemia): Fever, sepsis syndrome, potential seeding to organs (eyes, kidneys, heart, brain) - occurs in severely ill/immunocompromised.
- Urinary Tract Candidiasis: Usually asymptomatic candiduria, may cause UTI symptoms in catheterized/diabetic/obstructed patients.
Risk factors
- Immunosuppression (HIV/AIDS, chemotherapy, long-term steroids, transplant).
- Antibiotic use (broad-spectrum).
- Diabetes mellitus (poorly controlled).
- Pregnancy.
- Oral contraceptive use.
- Use of inhaled corticosteroids.
- Xerostomia (dry mouth).
- Denture wearing.
- Obesity (intertrigo).
- Neonates/Infants.
- Indwelling catheters (IV, urinary).
- Major surgery / ICU stay.
Diagnosis
Clinical assessment
Diagnosis often based on characteristic clinical appearance of lesions in specific locations (oral white plaques, vaginal discharge, intertriginous rash, angular cheilitis).
Investigations
- Microscopy (KOH prep or Gram stain): Scrapings (oral/skin) or vaginal discharge showing yeast cells and pseudohyphae.
- Fungal Culture: Confirms Candida species, useful for recurrent/refractory cases or suspected non-albicans species.
- High Vaginal Swab (HVS) for microscopy/culture (vaginitis).
- Endoscopy with biopsy/brushings (for oesophageal candidiasis).
- Blood Cultures (for suspected candidemia - specialized bottles).
- Consider underlying risk factors (HIV test, blood glucose).
Diagnostic criteria
Clinical appearance +/- confirmation by microscopy or culture.
Management
Non-pharmacological management
- Address underlying risk factors (improve diabetic control, review medications, ART for HIV).
- Keep affected skin areas clean and dry (intertrigo).
- Good oral/denture hygiene.
- Remove indwelling catheters if possible (invasive candidiasis).
Pharmacological treatment
- Oral Candidiasis: (See ODH019)
- - Topical: Nystatin suspension/pastilles, Miconazole gel, Clotrimazole troches. (LOC: HC2+)
- - Systemic (if severe/refractory): Fluconazole PO. (LOC: HC3+)
- Vulvovaginal Candidiasis:
- - Topical Azoles: Clotrimazole pessary (100mg nightly x 6d, 200mg nightly x 3d, or 500mg single dose) OR Miconazole pessary/cream. (LOC: HC2)
- - Oral Azole: Fluconazole 150mg PO single dose (Avoid in pregnancy). (LOC: HC3)
- - Recurrent VVC: Longer courses of topical/oral azoles, or maintenance therapy (specialist).
- Cutaneous Candidiasis (Intertrigo):
- - Topical Antifungal Creams: Clotrimazole, Miconazole, Nystatin applied BID for 2-4 weeks. (LOC: HC2+)
- - Keep area dry (barrier creams, powders may help).
- - Systemic Fluconazole (150-200mg daily) if severe/widespread/refractory. (LOC: HC3+)
- Chronic Paronychia:
- - Keep hands dry.
- - Topical antifungals +/- topical steroids. (LOC: HC3)
- - Consider systemic Fluconazole (150-200mg daily) if severe/refractory. (LOC: HC4)
- Oesophageal Candidiasis:
- - Systemic Fluconazole 200-400mg daily PO/IV for 14-21 days. (LOC: HC3+)
- - Alternatives: Itraconazole solution, Voriconazole, Echinocandins, Amphotericin B (specialist).
- Invasive Candidiasis/Candidemia: Requires hospitalization, IV antifungals (Echinocandins like Caspofungin/Micafungin often first-line, or Fluconazole if susceptible, or Amphotericin B). Specialist management (RR).
Monitoring
Monitor clinical resolution. Monitor for recurrence, especially if underlying risk factors persist.
Complications
- Chronic discomfort/pain.
- Secondary bacterial infection.
- Oesophageal stricture (post-oesophagitis).
- Disseminated infection/sepsis (invasive disease).
Prevention
- Control underlying risk factors (diabetes, HIV).
- Good hygiene (oral, skin, denture).
- Judicious use of antibiotics/steroids.
- Prophylaxis in select high-risk groups (specialist).
Patient education
- Nature of yeast infection and contributing factors.
- Correct use of topical/oral medications.
- Importance of completing treatment course.
- Hygiene measures.
- Management of underlying conditions.
- When to seek follow-up.
Uganda-specific notes
Oral and vaginal candidiasis extremely common, especially in context of HIV. Oesophageal candidiasis is an AIDS-defining illness. Nystatin and Fluconazole are mainstays of treatment. Topical clotrimazole widely used for skin/vaginal forms.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.2.1
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23 (Oral Health - ODH019)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3 (STIs - Vaginal Discharge)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 7 (HIV Care - OIs)