History
A 46-year-old housewife with known multisystem sarcoidosis comes for a regular follow-up visit to the dermatology clinic. She complains of an increasing number of asymptomatic skin lesions on her limbs. She also mentions soreness between her fingers where the skin has started to break down. She had become increasingly breathless over the past two months and after consultation with the respiratory team she was commenced on a slowly reducing course of oral prednisolone and is currently taking 30 mg daily. Her past medical history includes hypothyroidism and idiopathic thrombocytopenic purpura.
Examination
She is slightly breathless at rest and looks mildly cushingoid. The skin between her fin-gers is erythematous with superficial white maceration (Fig. 81.1) and ulceration forming deep fissures (Fig. 81.2). In addition she has indurated, slightly hyperpigmented nodules and plaques on her limbs.
Questions
• What is the likely underlying cause of the skin changes in the finger webs?
• What is the cause of the cutaneous lesions on this patient’s limbs?
• How would you manage her skin?
Medicine
This patient has multiple, indurated, asymptomatic nodules and plaques of cutaneous sar-coidosis on her limbs. She had been taking systemic corticosteroids for her deteriorating respiratory sarcoid. This iatrogenic immunosuppression had left the patient vulnerable to infection. She developed a Candida albicans intertrigo in her finger webs (confirmed by yeast culture from her skin swab). This presentation is occasionally referred to as erosio interdigitalis blastomycetica (interdigital candidosis) and can be associated with occupations requiring frequent ‘wet work’ such as housework and gardening. Clinically, this superficial yeast infection is characterized by erythema, maceration and peeling of the flexural skin between the fingers. So-called ‘satellite lesions’ can often be seen as small erythematous papules/pustules at the periphery of the area of yeast-infected skin.
Candida prefers a warm moist environment and hence the most commonly affected skin sites include the groin, natal cleft, axillae, under the breasts and between the digits.
C. albicans yeast forms part of normal human flora, with reservoirs in the gastrointestinal tract and vagina. C. albicans is not part of the normal skin flora, however it can tran-siently colonize flexural areas. The fine balance between the patient’s immune system and nyeast numbers can be easily upset by minor changes in the local skin environment, use of antibiotics, raised serum glucose and immune compromise through disease or medica-tions leading to active candidiasis of the skin.
Management of Candida intertrigo includes trying to ensure the skin is kept as dry as possible to make the local skin environmentally hostile to the yeast. This can be achieved by using drying soaks such as potassium permanganate, antifungal powders and acetic acid. Antifungal treatments can be given orally or applied topically. Many dermatologists will try to manage localized disease with a topical combination antifungal cream plus anti-inflammatory steroid. Short courses of oral fluconazole or itraconazole may, how-ever, be required in patients who are immunosuppressed or who have recalcitrant disease.
This patient needed to remain on her systemic corticosteroids and therefore oral flucona-zole was given to try to help eliminate the Candida intertrigo over a few weeks. In addi-tion she was asked to wash her hands once daily in chlorhexidine and to apply Canestan cream twice daily. This type of infection can take several weeks to clear, particularly in patients who are diabetic or immunosuppressed.
KEY POINTS
• Cutaneous Candida infections should be suspected in flexural skin with erythema and maceration.
• Candida yeasts more frequently cause skin disease in patients who are vulnerable such as neonates, the immunocompromised and the elderly.
• Combination treatment with skin drying agents, antifungals and topical steroids are effective.
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