Eduovisual
Skin & Subcutaneous Tissue
Cutaneous candidiasis and intertrigo
— Intertrigo: inflammatory dermatosis of opposed skin folds caused by friction, heat, moisture, and maceration; often secondarily infected
— Cutaneous candidiasis: superficial infection by Candida albicans (and increasingly non-albicans species) of moist skin, mucocutaneous junctions, or nail folds
— In adults, intertrigo and candidal superinfection coexist in the majority of symptomatic skin-fold rashes
— Patient with burning/itching in inframammary, abdominal pannus, inguinal, gluteal cleft, axillary, or interdigital web spaces
— Obese, diabetic, incontinent, immobilized, or recently antibiotic-treated patient with new fold rash
— Diaper rash extending beyond the convex surfaces into the creases (versus irritant diaper dermatitis, which spares creases)
— Postpartum or lactating patient with sore, shiny, erythematous nipples ± deep breast pain → suspect nipple/ductal candidiasis
— Caregivers, dishwashers, bartenders with chronic paronychia
— Diabetes mellitus (especially HbA1c >8% or new hyperglycemia)
— Obesity (BMI ≥30), hyperhidrosis, occlusive clothing
— Recent broad-spectrum antibiotics, inhaled or systemic corticosteroids
— Immunosuppression: HIV, chemotherapy, biologics, solid-organ transplant
— Urinary or fecal incontinence in elderly/bedbound patients
— Pregnancy, oral contraceptives (estrogen-driven vaginal colonization)
— Recurrent or atypical cutaneous candidiasis is a screening trigger for occult diabetes—check fasting glucose or HbA1c
— In adults, recurrent mucocutaneous candidiasis without other risk factors should prompt HIV testing
— Frequent misdiagnosis as eczema or tinea leads to inappropriate topical steroid monotherapy and worsening
Board pearl: A new diagnosis of intertriginous candidiasis in a non-obese, non-diabetic, non-immunosuppressed adult is itself an indication to screen for diabetes and HIV—the rash can be the sentinel finding.
— Beefy-red, sharply demarcated erythematous plaques in skin folds with satellite papules and pustules at the periphery
— Burning > itching; soreness worsens with sweating, walking, exercise
— Maceration with whitish, curd-like exudate in the depth of the fold
— Common sites: inframammary, panniculus, inguinal/genitocrural, axillary, interdigital (toe and finger web)
— Diaper candidiasis: confluent erythema involving the inguinal creases, satellite lesions, often after diarrhea or antibiotics
— Erosio interdigitalis blastomycetica: macerated white plaque in the third web space of the hand—classic in dishwashers and diabetics
— Candidal paronychia: chronic, tender, erythematous proximal nail fold with loss of cuticle ± greenish nail dystrophy
— Candidal balanitis: glans erythema, white plaques, often after intercourse with a partner with vulvovaginal candidiasis
— Perlèche (angular cheilitis): macerated fissures at oral commissures; often coexists with denture stomatitis
— Congenital cutaneous candidiasis: diffuse neonatal eruption from in-utero exposure
— Duration, prior treatments (especially OTC antifungals and topical steroids—steroid monotherapy worsens candidiasis)
— Recent antibiotics, inhaled steroids (perlèche, oral thrush)
— Glycemic control: last HbA1c, polyuria/polydipsia, weight changes
— Continence, mobility, bathing frequency (in elderly or post-surgical patients)
— Occupational wet work (hands), athletic activity (groin/feet)
— Sexual history and partner symptoms for balanitis
— Breastfeeding history for nipple candidiasis—ask about infant oral thrush
Key distinction: Candidal intertrigo involves the depth of the fold with satellite lesions, whereas tinea cruris spares the scrotum and shows central clearing with an active raised border, and inverse psoriasis shows well-demarcated, shiny red plaques without satellites or pustules. Recognizing satellite pustules at the edge of the main plaque is the single most useful bedside discriminator.
— Beefy-red erythema with glistening, moist surface in the fold
— Satellite pustules and papules beyond the main plaque—pathognomonic
— Maceration, scaling collarettes at the advancing edge
— Fissuring at the depth of the fold (inframammary, intergluteal)
— Whitish pseudomembranous exudate (especially mucocutaneous junctions)
— Lift the pannus, inframammary folds, and scrotum—lesions hide in dependent skin
— Spread toe web spaces; look for soggy white maceration (web-space candidiasis vs interdigital tinea)
— Examine oral cavity: thrush raises pretest probability for cutaneous candidiasis and suggests immunosuppression
— Inspect nails: loss of cuticle, bolstered erythematous proximal nail fold = chronic paronychia
— Genital exam: in men, glans and prepuce; in women, vulvar erythema with thick white discharge
— Diaper area in infants: creases involved with satellites (vs irritant which spares creases)
— Look for secondary bacterial infection: honey crusting (Staph), foul odor, purulent drainage, surrounding cellulitis with warmth and induration
— Assess for fluctuance suggesting abscess (especially intergluteal/perianal)
— Check for lymphangitic streaking or regional adenopathy
— Vital signs: fever, tachycardia, hypotension suggest invasive infection—rare but possible in neutropenic or burn patients
— In diabetics, perform a foot exam and check glucose/HbA1c at the visit
— Photograph or sketch distribution; recurrence patterns matter for chronic therapy decisions
— Note BMI, mobility, continence status—drives prevention plan
— Quantify body surface area involvement to gauge need for systemic therapy
Step 3 management: Any candidal intertrigo with expanding erythema, fever, or purulence is no longer "uncomplicated" — obtain bacterial culture, start empiric anti-staphylococcal coverage (e.g., cephalexin or TMP-SMX if MRSA suspected), and continue antifungal therapy; arrange short-interval follow-up in 48–72 hours.
— Characteristic distribution + beefy-red plaques + satellite pustules → empiric treatment is appropriate without testing
— Reserve laboratory confirmation for atypical, refractory, recurrent, or immunocompromised presentations
— KOH preparation (10–20% potassium hydroxide): scrape the advancing edge or unroof a satellite pustule; look for pseudohyphae and budding yeast
— Add DMSO or chlorazol black to accelerate keratin dissolution
— Wood's lamp: does NOT fluoresce for Candida (helpful to rule out coral-red erythrasma → Corynebacterium minutissimum)
— Skin scrape for fungal culture (Sabouraud agar) if KOH negative but suspicion high, or to identify non-albicans species in refractory disease
— Swab purulent areas for Gram stain and culture (especially Staph/Strep)
— Consider MRSA nasal screening in recurrent skin/soft tissue infection
— Fasting glucose or HbA1c for any adult with new, recurrent, or extensive candidal intertrigo
— HIV testing for recurrent mucocutaneous candidiasis in adults without obvious risk factor
— TSH, CBC if features suggest systemic immunosuppression
— Iron studies and zinc level in recurrent perlèche
— Persistent rash despite 4–6 weeks of appropriate therapy
— Atypical morphology raising concern for Hailey-Hailey disease, extramammary Paget, inverse psoriasis, cutaneous T-cell lymphoma, or glucagonoma (necrolytic migratory erythema)
— Punch biopsy of the active edge; request PAS or GMS staining for fungi
— Generally not indicated
— Obtain ultrasound or MRI if deep abscess, necrotizing infection, or osteomyelitis suspected (perianal, diabetic foot web space)
Board pearl: A patient with "treatment-resistant" groin rash who has a coral-red Wood's lamp fluorescence has erythrasma, not candidiasis—treat with topical or oral erythromycin or clindamycin, not antifungals. This is a favorite Step 3 distractor.
— Indicated for recurrent, refractory, or post-treatment failure cases
— Sabouraud dextrose agar with chloramphenicol; growth in 2–5 days
— Identifies non-albicans species (C. glabrata, C. krusei, C. parapsilosis, C. auris) with relevant resistance profiles
— C. glabrata and C. krusei: reduced fluconazole susceptibility
— C. auris: emerging multidrug-resistant species; report to public health and isolate
— Reserved for invasive disease, recurrent failure of azoles, or immunocompromised hosts
— CLSI broth microdilution standards
— Echinocandin and amphotericin susceptibility for refractory non-albicans
— PAS or GMS staining: pseudohyphae and budding yeasts in the stratum corneum, with subcorneal pustules and neutrophilic infiltrate
— Helps exclude mimickers: inverse psoriasis (regular acanthosis, Munro microabscesses without organisms), Hailey-Hailey (suprabasal acantholysis—"dilapidated brick wall"), extramammary Paget (intraepithelial adenocarcinoma cells)
— PCR-based fungal panels: increasing availability for rapid speciation, useful in tertiary settings
— MALDI-TOF mass spectrometry on cultures speeds species ID
— Beta-D-glucan and serum mannan/anti-mannan: for suspected invasive candidiasis (not cutaneous)
— Confirmed diabetes: order HbA1c, lipid panel, urine albumin/creatinine, dilated eye exam referral as part of new-onset diabetes care
— HIV-positive: CD4 count, viral load, opportunistic infection screen
— Chronic mucocutaneous candidiasis (CMC) of childhood onset: evaluate for AIRE mutation (APECED), STAT1 gain-of-function, or IL-17 axis defects; refer to immunology
— Diabetic foot with web-space candidiasis and deep ulceration: plain films first, MRI if osteomyelitis suspected (per IDSA diabetic foot guidelines)
— Recurrent perianal/intergluteal abscess: pelvic MRI to evaluate fistulous disease
Key distinction: Cutaneous candidiasis ≠ invasive candidiasis. Cultures of skin yield Candida frequently as colonization; only clinical correlation justifies treatment. Blood cultures, beta-D-glucan, and ophthalmology referral are for candidemia, a different disease entity.
— Uncomplicated: localized intertrigo in an immunocompetent host → topical antifungal + barrier/drying measures
— Moderate: extensive surface area, multiple sites, or significant inflammation → topical antifungal + low-potency topical steroid for first 2–3 days
— Complicated/refractory: immunocompromised, diabetic with poor control, failure of 2–4 weeks topical therapy → systemic antifungal
— Superinfected: add antibacterial therapy
— Drying: pat dry after bathing, use cool hair dryer on folds, avoid occlusive synthetics
— Barrier: zinc oxide paste or petrolatum on adjacent intact skin
— Separation: cotton or absorbent dressings (e.g., InterDry with antimicrobial silver) placed in folds
— Absorbent powders: cornstarch is contraindicated (feeds yeast); use miconazole powder instead
— Weight loss counseling, breathable clothing, frequent diaper changes in infants
— Continence management in elderly: scheduled toileting, barrier creams, treat underlying UTI
— Confirm diagnosis of diabetes, initiate or intensify therapy
— Counsel that persistent hyperglycemia perpetuates candidiasis—HbA1c <7% is reasonable target for most
— Reduce SGLT2 inhibitor if recurrent genital candidiasis (risk class effect)
— Step 1: Confirm diagnosis clinically (± KOH)
— Step 2: Screen for diabetes/HIV when indicated
— Step 3: Apply non-pharmacologic measures
— Step 4: Topical antifungal × 2–4 weeks
— Step 5: Reassess at 2 weeks; if no improvement, KOH/culture, consider alternate diagnosis or systemic therapy
— Step 6: Address recurrence drivers (weight, glucose, continence, occupation)
Step 3 management: For a diabetic patient with recurrent inframammary candidiasis, the single most important long-term intervention is glycemic control—not a stronger antifungal. Document HbA1c improvement as part of the management plan; this is a value-based-care talking point favored on Step 3.
— Azoles: clotrimazole 1%, miconazole 2%, ketoconazole 2%, econazole 1% — apply BID × 2–4 weeks; continue 1 week after clearance
— Nystatin cream/ointment/powder: covers Candida only (not dermatophytes); useful when diagnosis is certain
— Ciclopirox 0.77%: broad spectrum, covers Candida, dermatophytes, and some bacteria
— Naftifine and terbinafine have less reliable anti-Candida activity—prefer azoles or nystatin
— Low-potency steroid (hydrocortisone 1–2.5%) combined with or alternated with antifungal for severe inflammation × 3–5 days only
— Avoid combination products like clotrimazole-betamethasone in intertriginous areas → betamethasone is mid-high potency and causes striae, atrophy, and steroid rebound in folds (classic Step 3 wrong answer)
— Fluconazole 150 mg PO weekly × 2–4 weeks, or 100–200 mg daily × 1–2 weeks
— Itraconazole 100–200 mg daily × 1–2 weeks: better non-albicans coverage but more drug interactions
— Indications: extensive intertrigo, recurrent disease, immunocompromised, chronic paronychia, refractory perlèche
— Diaper candidiasis: nystatin or clotrimazole cream with each diaper change × 7–14 days; zinc oxide barrier on top
— Paronychia (chronic): keep dry, topical azole or ciclopirox + topical steroid for inflammation; systemic fluconazole or itraconazole for refractory
— Perlèche: topical nystatin/azole + treat denture stomatitis with antifungal soak; address vitamin/iron deficiency
— Nipple candidiasis in lactation: topical miconazole or nystatin to nipples, treat infant oral thrush concurrently with oral nystatin suspension
— Balanitis: topical clotrimazole BID × 1–2 weeks; treat partner if symptomatic
— Cephalexin or dicloxacillin for MSSA; TMP-SMX, doxycycline, or clindamycin for suspected MRSA
Board pearl: Combination clotrimazole-betamethasone dipropionate is the most commonly missed wrong answer—mid-potent steroid in intertriginous skin causes atrophy and treatment failure. Choose plain clotrimazole or nystatin instead.
— Fluconazole: highly water-soluble, renally cleared, excellent oral bioavailability; minimal CYP3A4 inhibition at low doses
— Itraconazole: lipophilic, requires gastric acid for capsule absorption (take with cola/food); solution is better absorbed on empty stomach; negative inotrope—contraindicated in CHF
— Voriconazole, posaconazole, isavuconazole: reserved for invasive or azole-resistant disease, ID consult
— Ketoconazole systemic: avoid—hepatotoxicity and adrenal suppression; topical is fine
— Azoles + warfarin → ↑ INR
— Azoles + statins (especially simvastatin, lovastatin) → rhabdomyolysis risk
— Azoles + sulfonylureas → hypoglycemia
— Azoles + QT-prolonging drugs (ondansetron, methadone, fluoroquinolones) → torsades risk—check baseline ECG if combined
— Itraconazole + direct oral anticoagulants → bleeding; calcineurin inhibitors → toxicity
— Suppressive fluconazole 150 mg PO weekly for chronic recurrent candidal intertrigo in obese/diabetic patients
— Reassess every 3 months; check LFTs at baseline and periodically
— Address underlying drivers concurrently
— C. glabrata: often dose-dependent fluconazole; consider micafungin or amphotericin B for severe disease
— C. krusei: intrinsically fluconazole-resistant; use echinocandin or voriconazole
— C. auris: echinocandin first-line; contact precautions and public health notification
— Antibacterial soaks (dilute bleach baths, acetic acid for paronychia, Burow's solution for weeping intertrigo)
— Antiperspirants with aluminum chloride for hyperhidrosis-driven recurrence
— Topical tacrolimus 0.1% for steroid-sparing inflammation in chronic intertrigo (off-label)
CCS pearl: In a hospitalized diabetic with extensive intertriginous candidiasis: order fluconazole 150 mg PO, schedule glucose checks, consult diabetes educator, order HbA1c, place barrier dressings in folds, and schedule follow-up in 2 weeks—virtual time advance, then reassess rash and glycemic targets.
— Intertrigo is common in bedbound, incontinent, demented, or frail elderly with panniculus, mobility limitation, and inability to self-inspect
— Pressure injuries and moisture-associated skin damage (MASD) often coexist with candidiasis
— Polypharmacy increases drug-interaction risk with systemic azoles (warfarin, statins, sulfonylureas, amiodarone)
— Cognitive impairment limits self-care; involve caregivers explicitly in treatment plan
— Fluconazole: dose adjust if CrCl <50 mL/min — usual loading dose, then 50% maintenance dose
— Topical agents: negligible systemic absorption, safe in CKD
— Avoid systemic agents in dialysis patients without ID input
— Monitor for QT prolongation in CKD patients with electrolyte derangements
— Itraconazole, ketoconazole, voriconazole: hepatotoxic — avoid or use with caution; obtain baseline LFTs, repeat at 2–4 weeks
— Fluconazole has lowest hepatotoxicity among azoles but still requires LFT monitoring with prolonged courses
— Discontinue systemic azole if ALT/AST >3× ULN with symptoms or >5× ULN asymptomatic
— Avoid combination steroid-antifungal preparations in elderly fold skin — atrophy is rapid
— Use InterDry or absorbent fabric between folds; reposition every 2 hours in bedbound
— Treat incontinence aggressively: scheduled toileting, condom catheter (selectively), barrier creams (zinc, dimethicone)
— Hospital → SNF: include explicit skin/fold inspection orders and antifungal continuation in transfer note
— Home health: nursing visits for wound and fold care in obese or post-op patients
— Reconciliation of antifungals at every transition—missed doses drive recurrence
Step 3 management: For an elderly diabetic on warfarin started on fluconazole for extensive intertrigo, reduce warfarin dose by 25–50% and recheck INR in 3–5 days, or choose a topical-only regimen if feasible. This drug-interaction pearl recurs on Step 3.
— Cutaneous candidiasis incidence rises due to immune modulation, hyperglycemia (especially gestational diabetes), and hyperhidrosis
— Topical azoles (clotrimazole, miconazole) and nystatin are first-line and safe in all trimesters
— Avoid oral fluconazole in the first trimester — associated with spontaneous abortion at high doses and possible teratogenicity (skeletal/cardiac); single 150 mg dose has been used but topical is preferred
— Manage gestational diabetes per ADA/ACOG; screen at 24–28 weeks
— Postpartum lactational nipple candidiasis: topical miconazole/nystatin to nipples after each feed; treat infant simultaneously
— Congenital cutaneous candidiasis (in-utero acquisition): generalized maculopapular eruption at birth; preterm infants risk systemic disease — evaluate with blood culture, LP, consider IV antifungal
— Diaper candidiasis: nystatin or clotrimazole cream with each diaper change; oral nystatin if oral thrush coexists
— Avoid potent topical steroids in diaper area — risk of striae, adrenal suppression
— Frequent diaper changes, air time, zinc oxide barrier
— Persistent or recurrent infection of skin/nails/mucosa from infancy
— Evaluate for APECED (AIRE mutation) — also features hypoparathyroidism and adrenal insufficiency
— STAT1 gain-of-function, IL-17/IL-22 pathway defects, CARD9 deficiency
— Refer to pediatric immunology; long-term oral azole suppression
— HIV with CD4 <200, transplant recipients, chemotherapy patients, biologics (anti-IL-17, anti-IL-23)
— Lower threshold for systemic therapy and species identification
— Monitor for invasive disease
— Wrestlers, swimmers, dishwashers, healthcare workers with chronic glove use
— Education on drying, glove rotation, cotton liners, post-shower fold care
Board pearl: Oral fluconazole in the first trimester is the classic wrong answer for vulvovaginal or cutaneous candidiasis in pregnancy—topical clotrimazole or miconazole is the right choice. ACOG and FDA labeling support this.
— Bacterial superinfection: Staph aureus (including MRSA), Strep pyogenes, Pseudomonas (especially in toe webs and chronic paronychia)
— Cellulitis and erysipelas spreading from macerated fold skin — common portal of entry for lower-extremity cellulitis in obese patients
— Abscess formation in intergluteal or perianal disease
— Necrotizing soft tissue infection — rare, but consider in diabetics with rapidly spreading pain out of proportion, crepitus, or systemic toxicity
— Chronic fissuring and lichenification of fold skin from prolonged disease
— Candidemia and invasive candidiasis: rare from intact skin but possible in neutropenic patients, burn patients, or with indwelling lines
— Endophthalmitis, endocarditis, hepatosplenic candidiasis as downstream invasive complications
— In neonates with congenital cutaneous candidiasis, risk of systemic involvement is high
— Topical steroid misuse → atrophy, striae, telangiectasia, steroid rosacea, tinea/candida incognito
— Systemic azole hepatotoxicity: monitor LFTs in prolonged courses
— QT prolongation and torsades de pointes with fluconazole, especially with other QT-prolonging agents or electrolyte disturbance
— Adrenal suppression with ketoconazole (systemic)
— Drug interactions causing INR elevation, statin myopathy, hypoglycemia
— Pain, pruritus, sleep disruption, sexual dysfunction (genital sites)
— Embarrassment, depression — particularly with chronic, visible, malodorous disease
— Lost workdays in occupational hand and foot involvement
— Recurrent disease becomes a marker of uncontrolled diabetes or HIV—missed opportunity for chronic disease management
— Untreated intertrigo predisposes to catheter-associated bloodstream infections, pressure injury infections, surgical site infections
— Inframammary candidiasis in cardiac surgery patients can compromise sternal wound healing
Key distinction: Cellulitis from intertriginous skin breakdown is treated with anti-streptococcal/staphylococcal antibiotics, while the underlying candidiasis still requires antifungal therapy—both are needed concurrently. Treating only the bacterial infection guarantees rapid recurrence of cellulitis.
— Failure of 2–4 weeks of appropriate topical therapy
— Recurrent disease (≥3 episodes per year) despite optimization
— Suspected non-albicans species or azole resistance
— Atypical morphology requiring biopsy
— Suspected underlying immunodeficiency, particularly in pediatrics
— Dermatology: refractory, atypical, or biopsy-needed cases; consider Hailey-Hailey, inverse psoriasis, extramammary Paget, CTCL, glucagonoma
— Endocrinology: newly diagnosed difficult-to-control diabetes
— Infectious disease: non-albicans, multidrug-resistant C. auris, invasive candidiasis, HIV with recurrent mucocutaneous candidiasis
— Immunology: suspected CMC, APECED, STAT1 GOF
— Surgery/Wound care: pannus management, panniculectomy for refractory disease, abscess drainage
— OB/lactation consultant: nipple candidiasis interfering with breastfeeding
— Systemic toxicity: fever, tachycardia, hypotension
— Necrotizing soft tissue infection (surgical emergency)
— Cellulitis failing oral antibiotics
— Candidemia or invasive candidiasis
— Immunocompromised host with extensive disease and failure to thrive
— Neonatal congenital cutaneous candidiasis with systemic features
— Septic shock from soft tissue source
— Candidemia with hemodynamic instability
— Neutropenic patient with invasive candidiasis
— Need for surgical debridement of necrotizing infection
— PCP, dermatology, nutrition, behavioral health, bariatric surgery referral, physical therapy
— Diabetes educator and certified diabetes care specialist
— Home health for wound and skin fold care
CCS pearl: On a CCS case of "recurrent inframammary rash in diabetic": don't stop at antifungal — order HbA1c, fasting lipids, urine microalbumin, dilated eye exam referral, diabetes education consult, and weight management counseling. Step 3 rewards the longitudinal, system-level orders alongside the acute treatment.
— Spares the scrotum, central clearing, raised scaly active border, no satellites
— Caused by Trichophyton rubrum, Epidermophyton floccosum
— KOH: septate hyphae without budding
— Treat with topical terbinafine or azole
— Toe web maceration, especially lateral webs; chronic dry scaly moccasin distribution on soles
— May coexist with candidiasis; KOH and culture distinguish
— Treat with topical antifungal; systemic terbinafine for extensive disease
— Corynebacterium minutissimum; well-demarcated brown-red patches in folds
— Coral-red fluorescence with Wood's lamp — pathognomonic
— Treat with topical erythromycin/clindamycin or oral erythromycin or clarithromycin
— Shiny, well-demarcated, non-scaly plaques in folds; classic plaque psoriasis elsewhere
— No satellites or pustules
— Treat with low-potency topical steroid, calcineurin inhibitors, vitamin D analogs
— Greasy yellow scale, scalp/face involvement; Malassezia-driven
— Treat with ketoconazole shampoo/cream, low-potency steroid
— Pattern matches contactant (waistband, deodorant, fabric softener); itching predominates
— Patch testing for allergic contact; avoidance + topical steroid
— Discrete pustules at hair follicles; treat with antibacterial wash, topical clindamycin
— Recurrent nodules, sinus tracts, scarring in axillae, groin, inframammary, perianal
— Often misdiagnosed as recurrent abscess or candidiasis
— Treat per Hurley stage: topical/oral clindamycin, hormonal therapy, adalimumab, surgery
— Burrows, intense nocturnal itch, web-space and waistline involvement; treat with permethrin
Key distinction: Tinea cruris spares the scrotum; candidal intertrigo involves it. This single anatomic finding is high-yield. Also remember: dermatophytes cause annular lesions with central clearing and active border, candida causes confluent erythema with satellites.
— Autosomal dominant ATP2C1 mutation; flaccid vesicles and erosions in folds, often with fissures
— Biopsy: suprabasal acantholysis ("dilapidated brick wall")
— Often misdiagnosed as recurrent candidiasis; refractory to antifungals
— Treat with topical steroids, antiseptics, laser, botulinum toxin for hyperhidrosis
— Persistent, unilateral, well-demarcated erythematous plaque in vulvar, perianal, scrotal, or axillary skin in older adults
— Refractory to topical therapy → biopsy
— Underlying GU or GI malignancy in a subset — workup with imaging, endoscopy
— Treat with wide local excision, imiquimod, Mohs
— Patch/plaque/tumor stage; can mimic intertrigo or eczema in early stages
— Biopsy with T-cell clonality studies
— Persistent rash >6 months despite appropriate therapy should prompt biopsy
— Annular, erosive erythema in intertriginous areas; weight loss, diabetes, anemia, stomatitis
— Elevated glucagon, pancreatic NET imaging
— Periorificial and intertriginous erosive dermatitis in infants; alopecia, diarrhea
— Serum zinc low; replete
— Autoimmune blistering; biopsy with DIF
— Violaceous, well-demarcated plaques; Wickham striae elsewhere
— Hyperkeratotic red-brown papules/plaques in axilla/groin; biopsy with retained keratohyalin granules
— Often linked to antiperspirant use
Board pearl: A persistent, unilateral, well-demarcated erythematous patch in the vulva or perianal area of an older adult that has failed topical antifungals/steroids is extramammary Paget until proven otherwise—biopsy is mandatory. Do not continue empirically treating as candidiasis.
— Weight management: refer for medical or surgical weight loss in BMI ≥30 with comorbidities; document counseling at every visit
— Glycemic control: target HbA1c <7% (individualized); recurrent candidiasis is a clinical marker of inadequate control
— Continence optimization: scheduled toileting, treat UTIs, pelvic floor PT, condom catheters or external female catheters where appropriate
— Hyperhidrosis: aluminum chloride topical, iontophoresis, botulinum toxin (axillary)
— Daily fold inspection (or by caregiver) with mirror or partner
— Gentle cleansing with pH-balanced cleanser; pat dry; air-dry folds with cool hair dryer
— Apply miconazole powder or absorbent fabric (InterDry with silver) in chronic folds
— Loose, breathable cotton clothing; moisture-wicking athletic wear
— Change out of sweaty clothes promptly
— For recurrent disease (≥3–4 episodes/year): fluconazole 150 mg PO weekly or twice monthly × 3–6 months
— Topical antifungal twice weekly maintenance after clearance
— Monitor LFTs at baseline and every 3 months
— Reassess broad-spectrum antibiotics, inhaled steroids (rinse mouth, use spacer), and SGLT2 inhibitors (consider switching class if recurrent genital candidiasis)
— Reconcile drug interactions with chronic azoles
— HIV: optimize ART, achieve undetectable viral load
— Iron, B12, zinc deficiency for perlèche
— Chronic mucocutaneous candidiasis: immunology follow-up
— Written instructions on fold care, signs of recurrence, when to call
— Phone or portal access for early flare management
Step 3 management: For a patient with recurrent diabetic intertrigo, the discharge/follow-up bundle includes: (1) topical antifungal × 4 weeks, (2) HbA1c-driven diabetes intensification, (3) weight management referral, (4) miconazole powder maintenance, (5) follow-up in 4 weeks, (6) annual eye exam, (7) foot exam every visit. Step 3 rewards bundled longitudinal orders.
— 2 weeks after initiating topical therapy: assess response; if no improvement, re-examine, KOH/culture, reconsider diagnosis
— 4 weeks: confirm clearance, transition to maintenance regimen
— 3 months: for chronic suppressive therapy patients, reassess LFTs and adherence
— Annual: comprehensive skin and fold inspection in high-risk patients (obese, diabetic, immunosuppressed)
— Clinical: erythema, satellites, maceration, symptom diary
— Laboratory: HbA1c every 3–6 months; LFTs with prolonged azoles; CBC if cytopenias suspected
— ECG: baseline and follow-up if combining systemic azoles with QT-prolonging meds
— INR: 3–5 days after starting/stopping azoles in warfarin patients
— Glucose: home monitoring in diabetics
— Adherence: continue topical therapy 1–2 weeks beyond visible clearance to prevent relapse
— Avoid OTC combination steroid-antifungals in folds
— Hygiene without overwashing: harsh soaps disrupt skin barrier
— Sexual partners: treat symptomatic partners of patients with genital candidiasis; reassure that uncomplicated candida is not classified as STI
— Pregnancy: counsel on safe topical agents
— Lactation: simultaneous treatment of infant and mother
— Teach-back method for application technique
— Smartphone photos to track progress
— Written action plan for early recurrence: restart topical at first symptom
— Physical therapy for mobility-related self-care barriers
— Occupational therapy for hand candidiasis in dishwashers, healthcare workers (glove discipline, cotton liners)
— Nutrition counseling: weight loss, glycemic-friendly diet, micronutrient repletion
— Communicate with home health, SNF, caregivers on fold care protocol
— Update problem list with "recurrent cutaneous candidiasis" — drives chronic-care payments and triggers reminders
Board pearl: Treatment "until clear plus 1–2 weeks" is the rule for superficial fungal infections—early discontinuation is the #1 cause of recurrence and a frequent Step 3 distractor (the wrong answer is always "stop when the rash resolves").
— Discuss risks/benefits of systemic azoles, especially in pregnancy (first-trimester fluconazole), elderly on warfarin, and patients with hepatic disease
— Document teratogenicity counseling and contraception plans when prescribing oral antifungals to reproductive-age patients
— In chronic suppressive therapy, document understanding of LFT monitoring requirements
— Candida auris is reportable to state and CDC in many jurisdictions due to multidrug resistance and outbreak potential — initiate contact precautions and notify infection prevention
— Suspected child neglect: severe diaper candidiasis with associated failure to thrive, malnutrition, or untreated diaper dermatitis may warrant CPS evaluation
— Elder neglect: untreated chronic intertrigo in bedbound patients in facility settings may trigger adult protective services reporting
— Topical antifungals are inexpensive and OTC, but combination products and brand-name systemic azoles can be costly — use generic clotrimazole/nystatin and generic fluconazole
— Counsel on cost transparency; check formulary
— Recognize that obesity and diabetes—major drivers of intertrigo—disproportionately affect underserved populations; address social determinants (food access, mobility aids, caregiving)
— Hospital discharge: explicit skin/fold care orders in transfer summary
— Medication reconciliation: ensure antifungal continuation and flag azole-warfarin or azole-statin interactions
— Home health handoff: provide written fold-care protocol and follow-up plan
— Pediatric handoff: ensure infant and lactating mother both receive coordinated treatment
— Pressure injury prevention bundles must include fold inspection
— Avoid restraints that prevent fold separation and air circulation
— Caregiver education on incontinence care to prevent recurrence
— Distinguish candidiasis from contact dermatitis and pressure injury for accurate coding and quality metrics
— In nursing homes, intertrigo with breakdown can be miscoded as pressure injury, affecting facility quality scores
Step 3 management: When prescribing oral fluconazole to a sexually active reproductive-age patient, always document pregnancy status, contraception plan, and counseling on first-trimester risk—a recurring Step 3 ethics/safety stem.
— "Beefy-red plaques with satellite pustules in folds" → cutaneous candidiasis
— "Spares the scrotum, central clearing" → tinea cruris (not candida)
— "Coral-red fluorescence under Wood's lamp" → erythrasma
— "Dilapidated brick wall on biopsy" → Hailey-Hailey
— "Persistent unilateral vulvar/perianal red patch in elderly" → extramammary Paget
— "Necrolytic migratory erythema + diabetes + weight loss" → glucagonoma
— "Periorificial dermatitis + diarrhea + alopecia in infant" → acrodermatitis enteropathica (zinc deficiency)
— "Web-space maceration in dishwasher" → erosio interdigitalis blastomycetica
— Topical clotrimazole/miconazole = first-line
— Nystatin = Candida only, no dermatophyte coverage
— Terbinafine = great for dermatophytes, weak vs Candida
— Combination clotrimazole-betamethasone in folds = wrong answer
— Fluconazole + warfarin → ↑ INR; reduce warfarin
— Fluconazole first trimester pregnancy → avoid; use topical
— Itraconazole + CHF → contraindicated (negative inotrope)
— Ketoconazole systemic → hepatotoxic, adrenal suppression; avoid
— New cutaneous candidiasis → check glucose/HbA1c
— Recurrent mucocutaneous candidiasis in adult → check HIV
— Childhood-onset chronic mucocutaneous candidiasis → APECED, STAT1 GOF
— SGLT2 inhibitors → genital candidiasis
— Inhaled steroids without spacer → oral and perioral candida
— Inframammary, abdominal pannus, inguinal, axillary, intergluteal, web spaces, nipple, glans, oral commissures, nail folds
— Topical: until clear + 1–2 weeks
— Systemic: 1–2 weeks for cutaneous, longer for chronic paronychia
— Suppressive: 3–6 months for recurrent disease
Board pearl: The "newly diagnosed diabetic with extensive candidal intertrigo" stem is one of the most reliable Step 3 vignettes—correct management is topical antifungal + glycemic control + diabetes workup, not systemic antifungal alone.
— "62-year-old obese woman with poorly controlled diabetes presents with a beefy-red rash in inframammary and inguinal folds with surrounding small pustules. KOH shows pseudohyphae." → Diagnosis: cutaneous candidiasis; treatment: topical clotrimazole + glycemic control
— Patient with intertrigo treated with clotrimazole-betamethasone developing atrophy and worsening rash → recognize steroid as the culprit; switch to plain topical antifungal
— Lean adult with recurrent oral and cutaneous candidiasis → next step: HIV test
— Adult with new-onset extensive candidal intertrigo → next step: HbA1c
— Infant with persistent diaper candidiasis, hypoparathyroidism, adrenal insufficiency → APECED workup
— Groin rash that spares the scrotum with active raised border → tinea cruris, treat with terbinafine
— Brown-red patches in axilla with coral-red Wood's lamp → erythrasma, treat with erythromycin
— Unilateral persistent vulvar plaque in 70-year-old → biopsy for extramammary Paget
— Pregnant patient with vulvar/cutaneous candidiasis → topical azole; avoid first-trimester oral fluconazole
— Patient on warfarin started on fluconazole develops elevated INR → reduce warfarin and recheck in 3–5 days
— Patient on simvastatin + itraconazole → rhabdomyolysis risk; switch statin or antifungal
— Recurrent intertrigo despite topical therapy → identify uncontrolled diabetes; order HbA1c, intensify diabetes regimen, refer for weight management, schedule follow-up
— Obese diabetic with intertrigo and expanding leg erythema, fever → cellulitis arising from fold; treat with anti-staph/strep antibiotics + antifungal
— Diaper rash involving creases with satellites → candidiasis; nystatin cream + barrier
— Diaper rash sparing creases → irritant; barrier cream only
Key distinction: Step 3 stems often pivot on the next best step in longitudinal management rather than acute diagnosis—choose answers that address the systemic driver (diabetes, HIV, weight, drug interactions) alongside the topical treatment.
Cutaneous candidiasis and intertrigo are clinical diagnoses of beefy-red, satellite-studded fold rashes driven by moisture, friction, and host susceptibility (especially diabetes, obesity, and immunosuppression), treated with topical azoles or nystatin plus aggressive moisture control and longitudinal management of the underlying driver.
— Beefy-red plaques with satellite pustules in folds; KOH shows pseudohyphae and budding yeast
— Tinea cruris spares scrotum and shows central clearing; erythrasma fluoresces coral-red; inverse psoriasis is non-scaly and satellite-free
— Persistent, unilateral, refractory fold plaque in an older adult demands biopsy to exclude extramammary Paget
— First-line: topical clotrimazole, miconazole, or nystatin × 2–4 weeks, continued 1–2 weeks beyond clearance
— Avoid combination clotrimazole-betamethasone in intertriginous skin
— Reserve oral fluconazole for extensive, recurrent, or refractory disease; avoid first-trimester pregnancy and watch drug interactions (warfarin, statins, sulfonylureas, QT-prolonging agents)
— New or recurrent candidal intertrigo → screen for diabetes (HbA1c) and consider HIV testing
— Optimize glycemic control, weight, continence, and moisture management—these prevent recurrence more reliably than any drug
— Bundle follow-up at 2 and 4 weeks; transition to maintenance topical or suppressive weekly fluconazole for chronic recurrent disease
— Document patient education, drug-interaction review, and pregnancy counseling for safety and exam credit
Board pearl: On Step 3, the right answer almost always pairs the antifungal with a systemic, longitudinal intervention—glycemic control, weight management, drug reconciliation, or HIV screening. Treat the rash, then treat the patient.