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Infections and infestations Skin and nail

Candida - skin

Last revised in April 2025

Candida is a yeast-like fungus which is part of the normal commensal flora of the human gastrointestinal tract and the vagina.

Candida - skin: Summary

  • Candida is a yeast-like fungus part of the commensal flora of the human gastrointestinal tract and the vagina. It is not part of the normal skin flora, but there may be transient colonization of fingers or body folds. 
  • Colonization with Candida is usually asymptomatic. However, if mucosal barriers are disrupted or immune defences lowered, it can cause infections ranging from non-life threatening superficial mucocutaneous disorders to invasive disseminated disease involving multiple organs. Candida albicans is the most common species causing infection in humans.
  • Candidal skin infections are common and are more likely to occur where skin rubs on skin (such as between skin folds) and where heat and moisture can lead to maceration and inflammation.
  • The diagnosis of candidal skin infection is usually made as a result of typical presenting clinical features; investigations are usually unnecessary. An underlying cause should be excluded if the skin infection is widespread or recurrent.
  • If systemic candidiasis is suspected (for example there is peritonitis or meningitis), hospital admission should be arranged.
  • If the infection is not widespread and the person is not significantly immunocompromised:
    • Adults should be treated with a topical imidazole (clotrimazole, econazole, miconazole, or ketoconazole) or topical terbinafine.
    • Children should be treated with topical clotrimazole, econazole, or miconazole.
  • If inflammation or itch are particularly problematic, a mildly potent corticosteroid cream (for example hydrocortisone 1%) should be prescribed (in addition to the topical antifungal cream) to be used once or twice a day for 7 days after which the person should be reviewed:
    • If there has been a significant improvement in symptoms, treatment should be continued for a further 7 days.
    • If there is no response to treatment, treatment should be discontinued and the diagnosis reassessed. 
  • If topical treatment is ineffective, infection is widespread, or the person is significantly immunocompromised: 
    • For people aged 16 years and older, oral fluconazole should be prescribed for 2 weeks after which response to treatment should be reviewed. If the infection has not completely resolved, consideration should be given to treating with oral fluconazole for a further 2 weeks (referral should be arranged if the infection persists after this); swabbing to identify the causative organism; seeking specialist advice; or arranging referral to a dermatologist. Clinical judgement should be used, taking into account the severity of infection (there should be a low threshold for early referral if infection is severe), the level of immunocompromise, and the response to treatment. 
    • For children younger than 16 years of age, or if fluconazole is contraindicated, specialist advice should be sought.
  • People with candidal skin infection should be advised to:
    • Avoid skin occlusion when possible.
    • Wash skin regularly with a soap substitute and ensure it is dried adequately.
    • Lose weight, if obesity is a contributing factor to skin fold rubbing.
  • Referral to a dermatologist should also be arranged if:
    • There is widespread or recurrent infection for which an underlying cause has not been identified in primary care.
    • The diagnosis is uncertain.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the diagnosis and management of candidal infections of the skin.

This CKS topic does not cover the management of oral or systemic candidiasis, nappy rash, candidal balanitis, candidal nail infections, or dermatophyte skin and nail infections. It also does not cover the prevention of candidal infections in susceptible groups.

There are separate CKS topics on Balanitis, Boils, carbuncles, and staphylococcal carriage, Candida - female genital, Candida - oral, Cellulitis - acute, Eczema - atopic, Fungal nail infection, Fungal skin infection - body and groin, Fungal skin infection - foot, Fungal skin infection - scalp, Impetigo, Nappy rash, and Paronychia - acute.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2025 — minor update. Removed a reference relating to causes and risk factors which was no longer relevant. 

Previous changes

October 2023 — minor update. Information added that the manufacturers of fluconazole advise a washout period of approximately 1 week (5-6 half-lives) before becoming pregnant, in line with the updated summary of product characteristics.

July 2022 — minor update. Added drug interaction between clotrimazole and tacrolimus.

June 2022 — reviewed. A literature search was conducted in May 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to recommendations have been made.

May 2017 — reviewed. A literature search was conducted in April 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to recommendations have been made.

January 2014 — minor update. Text updated to include information from the manufacturer regarding how much clotrimazole to apply to the skin.  

December 2013 — minor update. Text updated to reflect that the European Medicines Agency (EMA)'s Committee for Medicinal Products for Human Use (CHMP) has suspended the marketing authorization for oral ketoconazole. It should no longer be prescribed for the treatment of fungal infections.

August 2013 — minor update to the text to reflect recent guidance from the EMA regarding the use of oral ketoconazole  

June 2013 — reviewed. A literature search was conducted in May 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to clinical recommendations have been made. However, prescribing information nodes have been created for the topical antifungals and oral fluconazole.

August 2010 — minor update. Sulconazole 1% cream (Exelderm®) has been discontinued. The prescription has been removed. 

June 2009 — minor update. Econacort® cream (econazole 1% plus hydrocortisone 1% cream) has been discontinued. This prescription has been removed.

November 2008 to March 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

September 2008 — minor correction to the Changes section. 

August 2008 — minor update. Nystatin cream and ointment have been discontinued. The prescriptions have been removed and text amended to reflect this.

April 2008 — minor update to the text for oral ketoconazole to reflect the most recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance.

October to December 2005 — written. Validated in March 2006 and issued in May 2006. This is a new guidance and replaces the relevant sections that used to be in the CKS guidance on Candida — skin and nails. Information and recommendations have been updated following a full literature review. Oral fluconazole is now included as a treatment option for severe, extensive skin infections, or for the rare person unresponsive to topical treatment. A more detailed evidence section to support the recommendations has been included.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 June 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2022.

New policies

No new national policies or guidelines since 1 June 2022.

New safety alerts

No new safety alerts since 1 June 2022.

Changes in product availability

No changes in product availability since 1 June 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make an accurate diagnosis of candidal skin infections.
  • Manage people with candidal skin infections.
  • Arrange admission or referral as appropriate.
  • Provide appropriate advice to people with candidal skin infections and/or their family/carers.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Candida is a yeast-like fungus, part of the commensal flora of the human gastrointestinal tract and the vagina (in 13% of women) [Primary Care Dermatology Society, 2021].
    • It is not part of normal skin flora, but there may be transient colonization of fingers or body folds.
    • Colonization with Candida is usually asymptomatic. However, where mucosal barriers are disrupted or if host defences are lowered, it can cause infections (candidiasis) ranging from non-life-threatening superficial mucocutaneous disorders to invasive disseminated disease involving multiple organs [Patil, 2015; CDC, 2016; Primary Care Dermatology Society, 2021].
  • Candidiasis is common and includes [DermNet NZ, 2022]:
    • Intertrigo (skin fold infections) — this most commonly occurs in the groin, under the breasts, and the axillae. It may also affect antecubital fossae; umbilical, perineal, or interdigital areas; neck creases; and folds of the eyelids.
    • Oral candidiasis (infection of the oral mucosa) — see the CKS topic on Candida - oral for more information.
    • Genital infections, including:
      • Vulvovaginal candidiasis — see the CKS topic on Candida - female genital for more information.
      • Balanitis (inflammation of the glans penis) — see the CKS topic on Balanitis for more information.
    • Napkin dermatitis (nappy or diaper rash) — see the CKS topic on Nappy rash for more information.
    • Chronic paronychia (nail fold infection) — see the CKS topic on Paronychia - acute for more information.
    • Onychomycosis (nail plate infection) — see the CKS topic on Fungal nail infection for more information.
  • Chronic mucocutaneous candidiasis (or chronic mucocutaneous candidosis) is a rare condition occurring in childhood. It is characterized by recurrent (or persistent) and widespread candidal infections of the skin, mucous membranes, and nails [Primary Care Dermatology Society, 2021], and may be due to genetic predisposition, endocrinopathies, T-cell disorders, or low immunoglobulin levels [DermNet NZ, 2015].

What are the causes and risk factors for candidal skin infections?

  • Over 20 Candida species can cause infection in humans [CDC, 2016] [Primary Care Dermatology Society, 2021]:
    • Candida albicans is the most common species and is responsible for over half of candidal skin infections. 
  • Candidal skin infection is more likely where skin rubs on skin (such as between skin folds in an obese person) and where heat and moisture lead to maceration and inflammation [Kalra, 2014]. Other risk factors include [Primary Care Dermatology Society, 2021; DermNet NZ, 2022]:
    • Immunocompromise (such as due to HIV infection, chemotherapy, and the use of immunosuppressive drugs [such as corticosteroids]).
    • General debility, for example from cancer or malnutrition. 
    • Recent or concurrent use of drugs that promote candidal growth, particularly broad-spectrum antibiotics and inhaled or oral corticosteroids.
    • Extremes of ages — due to immature or weakened immunity. 
    • Diseases in which the barrier function of the skin is disturbed (such as psoriasis and seborrhoeic eczema).
    • Endocrine disorders, such as:
    • Iron deficiency anaemia — iron is the most common deficient essential micronutrient implicated in the colonization of Candida, as iron deficiency diminishes the fungistatic action of transferrin and other iron-dependant enzymes. See the CKS topic on Anaemia - iron deficiency for more information.
    • High-oestrogen contraceptive pill or pregnancy.
    • Poor hygiene.

What are the complications and prognosis of candidal skin infections?

  • Complications of candidal skin infection include soreness and itching (which may be severe). In people who are severely immunocompromised, the infection can become blood borne, leading to systemic/invasive candidiasis [CDC, 2017; Guarana, 2018; BMJ Best Practice, 2019]:
    • Candidemia (the presence of Candida species in the blood) is the most common manifestation of invasive candidiasis, with an estimated mortality rate of 19–30% [CDC, 2017].
    • Systemic/invasive candidiasis is a serious infection which can affect the heart, central nervous system, eyes, bones, and joints, leading to sepsis and/or organ-specific infections (such as pneumonia; meningitis; endocarditis; and mucocutaneous, osteoarticular, hepatosplenic, and peritoneal infections). It has an estimated mortality rate of up to 79% [Patil, 2015; Primary Care Dermatology Society, 2021].
  • Candida can complicate the treatment of psoriasis when biologic agents are used [Pietrzak, 2018].
  • The clinical course of a candidal infection depends on the type of candidiasis and the presence of any associated disorders or risk factors [BMJ Best Practice, 2019].
    • For most people, untreated candidiasis persists for months or years unless associated risk factors are treated or eliminated. 

Diagnosis of skin candida

How should I diagnose a candidal skin infection?

  • The diagnosis of candidal skin infection is usually made from characteristic clinical features. 
    • The appearance of the skin is variable, depending on the affected area. 
      • Soreness and itching is usual.
      • Thin-walled pustules with a red base may be present.
      • Scales may accumulate, producing a white-yellow, curd-like substance over the infected area.
      • In flexural areas (intertrigo), the skin fold is typically red and moist. As the condition develops, a typical fringed, irregular edge and pustular or papular satellite lesions may be present. 
      • If the web spaces of the toes or fingers are involved, marked maceration with a thick, crusty layer is usually prominent.
    • Detailed clinical features of other types of candidal skin infections are discussed in the CKS topics on: 
  • Investigations are not usually necessary but may be required to exclude a differential diagnosis or an underlying condition (such as diabetes or anaemia), especially in people with widespread or recurrent infection.
  • Swabs are not routinely recommended. However, swabs for microscopy and culture may be required if:
    • Secondary bacterial infection is suspected.
    • The person is immunocompromised.
    • The diagnosis is uncertain.

Basis for recommendation

These recommendations (and the characteristic features of candidal skin infections) are based on expert opinion in the Primary Care Dermatology Society (PCDS) information on Intertrigo and Candidal infection [Primary Care Dermatology Society, 2021] and the DermNet NZ information on Candida [DermNet NZ, 2022], in addition to review articles on candidal skin infections [Kalra, 2014; Kühbacher, 2017; Metin, 2018].

Investigating for an underlying cause in people with widespread or recurrent infection

  • CKS found no evidence or guidelines on when to investigate for an underlying cause of candidal skin infections, but has pragmatically suggested that this should be carried out if the infection is widespread or recurrent.
  • The recommendations on potential conditions to exclude have been extrapolated from the risk factors for developing candidal skin infections. See the section on Causes and risk factors for more information. 

When to swab

  • Expert opinion in review articles is that:
    • A skin swab is recommended if there is clinical suspicion of secondary bacterial infection [BMJ Best Practice, 2019].
    • Drug-resistant strains of Candida albicans and related species have been reported, especially in immunosuppressed people and people managed with prophylactic antifungal preparations [Proctor, 2021].
  • The recommendation to consider swabbing if the diagnosis is uncertain is based on what CKS considers to be good clinical practice.

What else could it be?

  • Differential diagnoses of candidal skin infection include: 
    • Atopic eczema — a chronic, relapsing, itchy skin condition thought to be caused by a genetic predisposition, skin barrier dysfunction, environmental factors (such as exposure to pets, house-dust mites, and pollen), and/or immune system dysfunction. See the CKS topic on Eczema - atopic for more information.
    • Bacterial skin infections, such as impetigo and cellulitis — see the CKS topics on Impetigo and Cellulitis - acute for more information.
    • Dermatophyte infections — usually more dry and scaly than candidal infections, with a more prominent border (with no satellite lesions). See the CKS topics on Fungal skin infection - body and groin, Fungal skin infection - foot, and Fungal skin infection - scalp for more information.
    • Erythrasma — well-circumscribed, red-brown patches, usually in the axillae and groin, caused by Corynebacterium minutissimum.
    • Flexural psoriasis — scaling is reduced or absent, and the skin appears 'glazed' with fissuring in the depth of the fold. The edges are usually sharply demarcated. See the CKS topic on Psoriasis for more information.

Basis for recommendation

The differential diagnoses of candidal skin infections are based on expert opinion in the Primary Care Dermatology Society (PCDS) information on Intertrigo [Primary Care Dermatology Society, 2021] and review articles of candidal skin infections [Metin, 2018; Benitez Ojeda, 2022].

Management

Scenario: Management of skin candida

From age 1 month onwards.

How should I manage a person with candidal skin infection?

  • Admit the person to hospital if systemic candidiasis is suspected (for example there is peritonitis or meningitis).
  • If the infection is not widespread and the person is not significantly immunocompromised, prescribe a topical antifungal treatment.
    • For an adult, prescribe a topical imidazole (clotrimazole, econazole, miconazole, or ketoconazole) or terbinafine.
    • For a child, prescribe topical clotrimazole, econazole, or miconazole.
    • See the prescribing information section on Topical antifungals for information on prescribing these treatments, including information on the frequency and duration of use.
  • If inflammation or itch is particularly problematic, consider prescribing a mildly potent corticosteroid cream (for example hydrocortisone 1%) in addition to the topical antifungal. 
    • Advise that the topical corticosteroid should be used once or twice a day for 7 days.
    • Review the person after 7 days of treatment.
      • If symptoms have resolved, stop the corticosteroid.
      • If there has been a significant improvement in symptoms, continue the corticosteroid for a further 7 days.
      • If there is no response to treatment, discontinue corticosteroid treatment and reassess the diagnosis. Consider seeking specialist advice where there is uncertainty.
    • See the CKS topic on Corticosteroids - topical (skin), nose, and eyes for detailed information on prescribing topical corticosteroids.
  • If topical treatment is not effective, the infection is widespread, or the person is significantly immunocompromised:
    • For adults and children aged 16 years and older, treat with oral fluconazole 50 mg a day for 2 weeks then review response to treatment.
      • If the infection has completely resolved, stop treatment.
      • If the infection has not completely resolved, consider the following: extending the course of fluconazole for a further 2 weeks (refer to a dermatologist if the infection persists after this); swabbing to identify the causative organism; seeking specialist advice; or referring to a dermatologist. Use clinical judgement, taking into account the severity of infection (there should be a low threshold for early referral if infection is severe), the level of immunocompromise, and the response to treatment. 
    • For children younger than 16 years of age, or if fluconazole is contraindicated, seek specialist advice.
    • See the prescribing information section on Fluconazole for information on prescribing this treatment, including the contraindications, cautions, adverse effects, and key drug interactions.
  • Offer appropriate advice to aid healing and prevent recurrence. In particular:
    • Advise the person to avoid skin occlusion when possible (for example tight clothing and non-breathable fabrics), and to change dressings, incontinence pads, or nappies (in babies) before they become saturated.
    • Advise the person to wash skin regularly with a soap substitute (for example emulsifying ointment) and ensure skin is dried adequately afterwards, especially in the skin folds.
    • If obesity is a contributing factor, offer advice on weight loss. See the CKS topic on Obesity for more information.
  • Refer to a dermatologist if:
    • There is widespread or recurrent infection for which an underlying cause has not been identified in primary care.
    • The diagnosis is uncertain.

Basis for recommendation

Arranging admission if systemic candidiasis is suspected
  • This recommendation is based on the fact that systemic/invasive candidiasis is a significant cause of morbidity and mortality. See the section on Complications and prognosis for more information.
Topical antifungal treatment
  • CKS found one systematic review on the treatment of candidal skin infections which found 41 articles involving 35 randomized controlled trials and 3711 patients [Taudorf, 2019]:
    • Miconazole, clotrimazole, and nystatin were the most frequently studied topical therapies which had similar efficacy and clinical cure rates of 73–100%.
  • Topical imidazoles are widely considered to be effective and are recommended in the Primary Care Dermatology Society (PCDS) information on Intertrigo [Primary Care Dermatology Society, 2021], review articles on skin infections [Kalra, 2014; Armstrong, 2016; Metin, 2018; Benitez Ojeda, 2022], and the British National Formulary (BNF) [BNF, 2022]. In addition, they are licensed for the treatment of fungal skin infections.
  • Topical terbinafine is licensed for the treatment of fungal skin infections in adults [ABPI, 2016].
Oral antifungal treatment
  • CKS found one systematic review on the treatment of candidal skin infections which found 41 articles involving 35 randomized controlled trials and 3711 patients [Taudorf, 2019]:
    • Oral fluconazole 150 mg weekly or 50 mg daily for 2–4 weeks was found to have similar efficacy to oral ketoconazole 200 mg daily and had clinical cure rates of 82–100%.
Managing problematic inflammation or itch
  • The recommendation to consider a mildly potent topical corticosteroid to alleviate inflammation and pruritus is based on expert opinion in the American Academy of Dermatology (AAD) Guidelines of care for superficial mycotic infections of the skin: mucocutaneous candidiasis [American Academy of Dermatology, 1996] and a review article [Metin, 2018].
  • The recommended duration of treatment is based on feedback from previous expert reviewers of this CKS topic, bearing in mind the potential for adverse effects (for example skin thinning and striae) with prolonged use.
  • Some experts recommend that topical corticosteroids should not be used alone because they increase the risk of fungal proliferation, worsening of symptoms, and the development of tinea incognito (an atypical skin appearance due to local corticosteroid application, which may mask true dermatophyte infection) [Erbagci, 2004; Gupta, 2004].
Managing treatment failure, widespread infection, and people who are significantly immunocompromised
  • Managing people aged 16 years and older
    • A number of review articles discussed the place of systemic treatments in managing candidal skin infections and concluded that they should not be routinely used, although there are situations in which they may be appropriate [Armstrong, 2016; Guarana, 2018; Taudorf, 2019]; CKS has listed these criteria. 
    • Fluconazole has a broad range of antifungal activity, including against Candida species. It is given orally for infections that do not respond to topical treatment (or when topical treatment cannot be used) [BNF, 2022].
      • The recommended dose and duration of fluconazole are based on the manufacturer's Summary of Product Characteristics [EMC, 2023] and the British National Formulary [BNF, 2022], which recommend 50 mg daily (100 mg daily in unusually difficult infections) given for 14–28 days (to a maximum of 6 weeks).
    • For managing treatment failure, CKS recommends using clinical judgement to decide whether to give another course of fluconazole, swab to identify the causative organism, seek specialist advice, or refer to a dermatologist, taking into account the severity of infection, the level of immunocompromise, and the response to treatment. 
    • The recommendation to consider swabbing is based on expert opinion in review articles, which state that:
      • If there is no improvement after antifungal treatment, bacterial culture and sensitivity tests should be performed [Janniger, 2005].
      • Drug-resistant strains of Candida albicans and related species have been reported, especially in immunosuppressed people and people managed with prophylactic antifungal preparations [Proctor, 2021].
      • A skin swab is recommended if there is clinical suspicion of secondary bacterial infection [BMJ Best Practice, 2019].
    • If management in primary care with a topical imidazole followed by oral fluconazole has not been successful, CKS advises considering referral to a dermatologist to ensure that the diagnosis is correct and for consideration of further treatment which is more appropriate to a secondary care setting. 
  • Managing children younger than 16 years of age
    • CKS recommends seeking specialist advice in children younger than 16 years of age because if topical treatment is not effective, the infection is widespread, or the child is immunosuppressed, assessment in secondary care may be more appropriate.
Offering appropriate advice to aid healing and prevent recurrence
Referral
  • The additional recommendations on when to refer people with candidal skin infections are based on what CKS considers to be good clinical practice. 
    • People with widespread or recurrent infection may have underlying predisposing factors (for example immunocompromise) which require investigation and may need further treatment only available in secondary care.
Treatments not recommended
  • Griseofulvin, itraconazole, and oral terbinafine are not licensed to treat candidal infections of the skin [BNF, 2022]. 
  • Oral ketoconazole should no longer be prescribed for the treatment of fungal infections as the risk of liver damage outweighs the benefits. For this reason, the European Medicines Agency (EMA)'s Committee for Medicinal Products for Human Use (CHMP) has suspended its marketing authorization [MHRA, 2013]. See the MHRA website for more information.
  • Combination products containing clotrimazole plus hydrocortisone and miconazole plus hydrocortisone are available (and are licensed) for the treatment of fungal skin infections with co-existing inflammation [BNF, 2022]. However, CKS does not recommend these products because they are licensed to be used once or twice a day for a maximum of 7 days, but topical antifungal treatment is usually required for a longer period. Prescribing a topical corticosteroid separately to the topical antifungal allows the corticosteroid to be used once or twice a day for the initial recommended duration of 7 days, and the antifungal treatment to be continued for the recommended frequency and duration.

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical antifungals

What do I need to know about topical antifungals?

  • Clotrimazole [ABPI, 2022]
    • Clotrimazole 1% cream is licensed for the treatment of all dermatomycoses due to yeasts (Candida species).
    • It should be applied to the affected area 2–3 times a day and continued for at least 2 weeks. 
    • Adverse effects include:
      • Local skin irritations, such as rash, pruritus, oedema, and skin peeling.
      • Damage to latex contraceptives — advise the person that clotrimazole may cause damage to latex contraceptives and can inactivate spermicidal contraceptives. Alternative contraceptive precautions should be used during treatment with (and for at least 5 days after stopping) topical clotrimazole.
    • There is an interaction between topical clotrimazole and tacrolimus with an increase in plasma tacrolimus levels with concurrent prescribing.
  • Miconazole [EMC, 2020]
    • Miconazole 2% cream is licensed for the treatment of mycotic infections of the skin and nails. 
    • It should be applied to the affected area twice a day and continued for 10 days after all skin lesions are healed.
    • Adverse effects include:
      • Damage to latex contraceptives — advise the person that topical miconazole may cause damage to latex contraceptives and can inactivate spermicidal contraceptives. Alternative contraceptive precautions should be used during treatment with (and for at least 5 days after stopping) topical miconazole.
    • Miconazole, including the topical formulations, can enhance the anticoagulant effect of warfarin [MHRA, 2016].
      • If miconazole and warfarin are used concurrently, monitor the anticoagulant effect of warfarin; if necessary, reduce the dose of warfarin.
      • Advise the person to seek medical advice if they notice signs of over-anticoagulation during concurrent treatment, such as sudden unexplained bruising, nosebleeds, or blood in the urine.
  • Econazole [ABPI, 2019]
    • Econazole 1% cream is licensed for the treatment of fungal infections of the skin.
    • It should be applied to the affected area twice a day and continued until all skin lesions are healed.
    • Adverse effects include:
      • Damage to latex contraceptives — advise the person that topical econazole may cause damage to latex contraceptives and can inactivate spermicidal contraceptives. Alternative contraceptive precautions should be used during treatment with (and for at least 5 days after stopping) econazole.
    • Systemic econazole is known to interact with oral anticoagulants. Due to the limited systemic availability of topical preparations, clinically relevant interactions are rare; however, the manufacturer of econazole advises that caution should be exercised (and anticoagulant effect should be monitored) during concurrent use with an oral anticoagulant.
  • Ketoconazole (for people aged 18 years and older) [EMC, 2020]
    • Ketoconazole 2% cream is licensed for the treatment of cutaneous candidosis in adults.
    • It should be applied to the affected area once or twice a day and continued for a few days after all skin lesions are healed.
    • Adverse effects include local skin irritations, such as rash and pruritus.
      • The effect of topical ketoconazole on latex contraceptives is unknown.
    • No drug interaction studies have been performed.
  • Terbinafine (for adults only) [ABPI, 2016]
    • Terbinafine 1% cream is licensed for the treatment of yeast infections of the skin, especially those caused by the genus Candida.
    • It should be applied thinly to the affected area once or twice a day for 14 days.
    • Adverse effects include local skin irritations, such as rash, burning sensation, and pruritus.
      • These symptoms must be distinguished from hypersensitivity reactions, such as widespread pruritus, rash, bullous eruptions, and hives, which are reported in sporadic cases and require discontinuation of treatment with terbinafine.
    • There are no known drug interactions with terbinafine cream.

[BNF, 2022]

Oral fluconazole

What are the contraindication and cautions for oral fluconazole?

  • Do not prescribe:
    • Oral fluconazole to:
      • People with acute porphyria.
      • Pregnant women.
        • The manufacturer recommends a washout period of approximately 1 week (corresponding to 5-6 half-lives) after a single-dose or discontinuation of a course of treatment for women before they become pregnant.
      • People taking certain drugs.
    • High or repeated doses of oral fluconazole to:
      • Breastfeeding women.
  • Prescribe oral fluconazole with caution to people:
    • At risk of QT interval prolongation — this includes people with cardiomyopathy, sinus bradycardia, arrhythmias, hypokalaemia, hypomagnesaemia, hypocalcaemia, and those taking other drugs known to cause QT interval prolongation (such as tricyclic antidepressants, antipsychotics, and antiarrhythmics).
    • With hepatic impairment or taking concurrent hepatotoxic drugs, due to the risk of hepatic necrosis — discontinue treatment if signs or symptoms of hepatic disease develop (such as severe abdominal pain, jaundice, or weakness).  
    • With renal impairment (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m2) — use the usual initial dose then halve any subsequent doses.
    • Who are taking certain drugs.

[EMC, 2023; BNF, 2022]

What are the adverse effects of oral fluconazole?

  • Adverse effects of oral fluconazole include the following. 
    • Common or very common:
      • Abdominal discomfort, diarrhoea, nausea, and flatulence.
      • Headache.
      • Rash — discontinue treatment if the infection becomes invasive or systemic.
    • Uncommon:
      • Alopecia.
      • Adrenal insufficiency.
      • Dizziness.
      • Vomiting, dyspepsia, and taste disturbance.
      • Hepatic disorders.
      • Hyperlipidaemia.
      • Seizures.
      • Pruritus, anaphylaxis, angioedema (in children), hypersensitivity reactions (in adults), Stevens-Johnson syndrome, and toxic epidermal necrolysis.
    • Frequency unknown:
      • Hypokalaemia.
      • Leucopenia and thrombocytopenia.
  • Severe cutaneous reactions are more likely in people with AIDS.

[EMC, 2023; BNF, 2022]

What drug interactions are associated with oral fluconazole?

  • Fluconazole inhibits the metabolism of drugs metabolized by the cytochrome P450 enzymes CYP2C9 (potently), CYP3A4 (moderately), and CYP2C19. This may result in a higher and/or prolonged action of these drugs, including adverse effects. The enzyme-inhibiting effect of fluconazole persists 4–5 days after discontinuation of fluconazole treatment due to the long half-life of fluconazole. 
    • The following drugs are contraindicated (or should be avoided) during treatment with fluconazole:
      • Ergotamine — there is an increased risk of ergotism.
      • Erythromycin — concurrent use with fluconazole has the potential to increase the risk of cardiotoxicity (prolonged QT interval and Torsades de Pointes) and consequently sudden heart death.
      • Pimozide — concurrent use with fluconazole may lead to QT prolongation and rare occurrences of Torsade de Pointes.
      • Quetiapine.
      • Reboxetine.
    • Concurrent treatment with fluconazole and the following drugs should be done with caution (concurrent use should be monitored; dose adjustments may be indicated):
      • Aminophylline and theophylline.
      • Avanafil.
      • Ciclosporin.
      • Coumarins, such as warfarin. 
      • Diazepam (risk of prolonged sedation).
      • Fentanyl.
      • Midazolam (risk of prolonged sedation).
      • Phenytoin.
      • Rifabutin (increased risk of uveitis).
      • Statins — the risk of myopathy and rhabdomyolysis increases when fluconazole is given with statins metabolized through CYP3A4 (atorvastatin and simvastatin) or through CYP2C9 (fluvastatin). If concurrent treatment is necessary, monitor for symptoms of myopathy and rhabdomyolysis, and monitor creatine kinase. Discontinue the statin if a marked increase in creatine kinase is observed or if myopathy/rhabdomyolysis is diagnosed or suspected.
      • Sulfonylureas (such as gliclazide and glipizide) — if concurrent use is indicated, advise the person to seek medical advice if they have symptoms of hypoglycaemia (for example nervousness, sweating, and/or trembling).
      • Tacrolimus and sirolimus.
      • Tretinoin — fluconazole possibly increases the risk of tretinoin toxicity.
      • Zidovudine — fluconazole increases the risk of zidovudine toxicity. 
  • Other possible drug interactions of fluconazole include:
    • Clopidogrel — fluconazole possibly reduces the antiplatelet effect of clopidogrel.
    • Hydrochlorothiazide — the plasma levels of fluconazole may be increased by 40%; however, no adjustment in dosage of fluconazole is required. 
    • Rifampicin — metabolism of fluconazole may be accelerated by rifampicin, leading to reduced plasma concentrations.
  • For a complete list of possible drug interactions of fluconazole, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).

[EMC, 2023; BNF, 2022]

Supporting evidence

This CKS topic is largely based on expert opinion in the Primary Care Dermatology Society (PCDS) information on Intertrigo and Candidal infection [Primary Care Dermatology Society, 2021] and the DermNet NZ information on Candida [DermNet NZ, 2022], in addition to review articles on candidal skin infections [Kalra, 2014; Kühbacher, 2017; Metin, 2018], a systematic review on treatment [Taudorf, 2019], and guidance from the British National Formulary [BNF, 2022]. The rationale for each recommendation is discussed in the relevant basis for recommendation section.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of candida - skin.

Search dates

May 2017 - May 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • candidiasis, cutaneous/, skin diseases, infectious/, intertrigo/, exp candida/, exp dermatomycoses/, skin.tw, candid$.tw, intertrigo.tw, thrush.tw, moniliasis.tw.
  • Candid$ adj3 (skin or intertrigo or cutaneous).ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2016) SPC for Lamisil 1% w/w Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2018) SPC for Canesten Antifungal Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. www.medicines.org.uk/emc/
  • ABPI (2019) SPC for Pevaryl 1% topical cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc
  • ABPI (2021) SPC for miconazole gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2022) SPC for Canestan Thrush Soft Gel Pessary 500mg vaginal capsule. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
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  • Janniger, C.K., Schwartz, R.A., Szepietowski, J.C. and Reich, A. (2005) Intertrigo and common secondary skin infections. American Family Physician 72(5), 833-838. [Abstract]
  • Kalra, M.G., Higgins, K.E. and Kinney, B.S. (2014) Intertrigo and secondary skin infections. American Family Physician 89(7), 569-573. [Abstract] [Free Full-text]
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  • MHRA (2013) Oral ketoconazole: do not prescribe or use for fungal infections — risk of liver injury outweighs benefits. Drug Safety Update 7(1), S1.
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