• Opportunistic yeasts of the genus Candida (major C. albicans; too C. glabrata, C. parapsilosis, etc.).
• Local dysbiosis + maceration/humidity, antibiotics, corticosteroids (inhaled/topical/oral)
• DM, pregnancy, immunosuppression (HIV, chemotherapy), and IL-17/STAT1 defects in CMC.

Elementary lesion: Erythematous-macerated plaques with satellite pustular lesions (skin/folds); satellite papules/pustules; detachable whitish plaques (thrush); vulvar erythema and pruritus with lumpy exudate. In nail lesions, chronic paronychia with swelling of the nail fold and loss of cuticle.
Zones: folds (submammary, inguinal, intergluteal, axillary, interdigital), diaper area; oral mucosa; vulva/vagina; nail folds.
Prototype: bright “bright red” intertrigo with satellite pustules; VVC with intense itching, dyspareunia, thick “cottage cheese” discharge; thrush with whitish plaques that are removed leaving erythema.
Specific clinical findings: angular cheilitis; “erosio interdigitalis blastomycetica”; median rhomboidal glossitis (chronic, posterior) and oral hyperplastic candidiasis (adherent white plaques, possible transformation).
Evolution: Acute course with response to local measures/azoles; recurrences in VVC (≥3/year = RVVC); chronicity in paronychia; CMC = persistent/recurrent infections since childhood.
Atypical forms: Oral hyperplastic candidiasis (risk of transformation), median rhomboid glossitis, balanoposthitis due to Candidaonychomycosis due to Candida (less frequent than dermatophytes).

• Dermatophytic intertrigo (tinea cruris)
• Erythrasma (coral-red with Wood's lamp)
• Psoriasis inversa
• Seborrheic dermatitis
• Impetigo
• Irritant diaper rash
• In the oral cavity: leukoplakia, lichen planus, geographic/wet tongue, hairy leukoplakia (EBV)
• In vulva/vagina: bacterial vaginosis, trichomoniasis, contact dermatitis, chronic lichen simplex

Pattern: superficial dermatitis with neutrophilic microabscesses in the stratum corneum y yeasts/pseudohyphae in the stratum corneum.
Description: Hyper/parakeratosis, variable spongiosis; PAS and GMS positives evidence of yeasts and pseudohyphae; C. glabrata It can be seen as blastoconidia without pseudohyphae.
Special stains: Administrative staff, Grocott-GMS (of choice). Calcofluor (direct mycology). IF/IHC are not usually necessary.
Molecular tests: non-routine for skin/mucosal disease; in CMC: panel of immunodeficiencies with genes STAT1 (GOF), IL17RA/IL17F, ACT1/TRAF3IP2, CARD9, among others.

• Dermatophytosis (thin septate hyphae only in the stratum corneum; different clinical presentation)
• malassezia (yeasts in “string of pearls”)
• Impetigo (without fungus)
• Inverse psoriasis (Munro microabscesses but without fungus)
• Erythrasma (coryneform bacilli; without fungi).

Direct: KOH/Calcofluor of scales, exudate or flow; Gram stain on mucosa.
Cultivation: Sabouraud/CHROMagar (identifies species); consider MALDI-TOF.
Sensitivity: in recurrences/failure or at-risk population (non-species)albicans, azol-R).
VVC: microscopy (KOH) and culture in complicated/recurrent cases.
Oropharyngeal: if dysphagia/odynophagia → consider endoscopy for esophagitis.
HIV/DM testing and other states of immunosuppression when the pattern is severe/recurrent

Biopsy:

• Recommended type (when diagnosis is uncertain or refractory): active edge punch/shaving on skin; mucous membraneIncisional plaque/pseudomembrane. Include complete epidermis/superficial dermis.
• Considerations: Discontinue topical antifungals for 48–72 hours if possible; choose an area with active pustules/scales
• Contraindications: relative (uncontrolled anticoagulation, deep undrained infection).
• Fixation: 10% formalin for histology

First line (measures + drugs):
• Universal measures: Dry skin folds, apply zinc oxide barrier to diaper, avoid maceration/tight clothing, monitor blood glucose, check inhalers (rinse).
• Cutaneous/intertrigo: nystatin o topical azoles (clotrimazole, miconazole, ketoconazole) 1–2 times/day for 1–2 weeks; extensive cases or obesity: fluconazole 100–200 mg/d × 7–14 d.
• Mild oropharyngeal: clotrimazole 10 mg 5x/day 7–14 do nystatin suspension; moderate-severe: fluconazole 100–200 mg/d 7–14 d.
• Uncomplicated VVC: fluconazole 150 mg PO single dose or short-course intravaginal azoles; in pregnancy: Topical azoles only for 7 days.
• Chronic paronychia: Avoid irritants/moisture; topical azole + mild steroidrefractory: short course of systemic azole.

9b Second/third line and special situations:
• RVVC: induction (azole 10–14 d) followed by Suppression with fluconazole 150 mg/week for 6 monthsnew options oteseconazole (specific RVVC in women not of reproductive age) and ibrexafungerp (oral, effective in VVC and RVVC).
• non-speciesalbicans or azol-R (e.g., C. glabrata): prolonged regimens of topical azoles; boric acid 600 mg intravaginal/d 14 d (not during pregnancy).
• CMC (STAT1-GOF/IL-17 defects): prolonged azoles + background management; JAK inhibitors (ruxolitinib/baricitinib) They have shown benefit in series and reports.

Care and safety:
• Systemic azoles: hepatotoxicity, QT and interactions (CYP); adjust dose in CKD (fluconazole).
• Oteseconazole: Avoid in pregnant women and women of reproductive potential; indicated in postmenopausal or infertile women (according to trials).

Key Contraindications:
• Pregnancy: avoid oral fluconazole; prefer topical azoles 7 d.
• Prolonged QT syndrome / polypharmacyCaution with systemic azoles.

• Adult with thrush/esophagitis or extensive cutaneous candidiasis → rule out HIV and immunosuppression, uncontrolled diabetes.
• Recurrent VVC (≥3/year) → assess cultivation/speciation and suppression; avoid repeated self-management.
• Pregnancy → No. oral fluconazole; use topical azoles for 7 days.
• Therapeutic failure → consider C. glabrata/No-albicans or resistance; cultivation + sensitivity.
• Systemic azoles → Monitor for hepatotoxicity and interactions (warfarin, statins, QT).
• Mucocutaneous candidiasis with persistent fungal infections since childhood → genetic study (STAT1, IL-17 pathway).

• Satellite pustules and commitment to folds suggest candidiasis.
• Erythrasm fluoresce coral-red with Wood (useful for differentiating in folds).
• In complicated VVC o recurrent, Do KOH/culture; C. glabrata may not form pseudohyphae.
• In chronic paronychia, to combine topical azole + mild steroid and anti-humidity measures.

• Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1–e50. DOI: 10.1093/cid/civ933. PMID: 26679628.
  Summary: IDSA Broad Spectrum Guidelines (Mucosal and Cutaneous Candidiasis): Diagnostic Criteria, Antifungal Choice (Azole vs. Polyene vs. Echinocandin), Duration, and Adjustments for Comorbidities.

• Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1–187. DOI: 10.15585/mmwr.rr7004a1. PMID: 34292926.
  Summary: Recommendations for vaginitis: practical schemes for vulvovaginal candidiasis (VVC), management in pregnancy and recurrence; coordination with STI testing.

• Nyirjesy P, Ghannoum M, Sobel JD. Vulvovaginal candidiasis and antifungal resistance: an emerging problem. Clin Infect Dis. 2022;(suppl.). DOI: 10.1093/cid/ciac064. PMID: 35416967.
  Summary: Resistance review in Candida (No-albicans, C. glabrata) and clinical failures; strategies when there is failure with azoles.

• Sobel R, Nyirjesy P, Ghannoum MA, et al. VANISH-306: ibrexafungerp vs placebo in acute VVC (phase 3). BJOG.2022;129(3):412–420. DOI: 10.1111 / 1471-0528.16972. PMID: 34676663.
  Summary: Pivotal trial demonstrating clinical superiority of oral ibrexafungerp in moderate-to-severe VVC, primarily GI safety profile.

• Goje O, Sobel R, Nyirjesy P, et al. Oral ibrexafungerp for VVC: pooled analysis VANISH 303/306. J Womens Health (Larchmt). 2023;32(3):ePub. DOI: 10.1089/jwh.2022.0132. PMID: 36255448.
  Summary: Combined analysis confirming sustained efficacy/symptomatic in subgroups (high pH, ​​recent relapse).

• Martens MG, Bornstein J, Mert I, et al. Oteseconazole for recurrent VVC (CL-011/CL-012, phase 3). Am J Obstet Gynecol. 2022;227(5):739.e1–739.e13. DOI: 10.1016/j.ajog.2022.05.009. PMID: 35597652.
  Summary: In RVVC, oteseconazole significantly reduces recurrences vs. maintenance fluconazole; noteworthy is lower cross-activity with classic azoles.

• Sobel JD, Nyirjesy P, Danna RP, et al. Oteseconazole in recurrent vulvovaginal candidiasis. NEJM Evidence.2022;1(5):EVIDoa2100055. DOI: 10.1056/EVIDoa2100055. PMID: 38319878.
  Summary: Clinical program review/update: rationale for use in RVVC, sustained efficacy, and safety considerations.

• Okada S, Puel A, Casanova JL, Kobayashi M. Chronic mucocutaneous candidiasis disease associated with inborn errors of IL-17 immunity. Clin Transl Immunol. 2016, 5 (12): e114. DOI: 10.1038/cti.2016.71. PMID: 28090315.
  Summary: Review of IL-17/Th17 immunity, congenital errors (IL-17RA/F, ACT1) and CMC phenotype.

• Higgins E, Al Shehri T, McAleer MA, et al. Use of ruxolitinib to successfully treat CMC caused by STAT1 GOF. J Allergy Clin Immunol. 2015;135(2):551–553. DOI: 10.1016/j.jaci.2014.12.1867. PMID: 25662309.
  Summary: Letter with first use of ruxolitinib (JAK1/2) in CMC by STAT1-GOF, with clinical improvement.

• Mössner R, Diering N, Bader O, et al. Ruxolitinib induces IL-17 and ameliorates CMC caused by STAT1 GOF. Clin Infect Dis. 2016;62(7):951–953. DOI: 10.1093/cid/ciw020. PMID: 26768354.
  Summary: Case series documenting Th17 axis “repolarization” with ruxolitinib and clinical control of CMC.

• Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev.2011;24(2):247–280. DOI: 10.1128/CMR.00053-10. PMID: 21482725.
  Summary: Review of histological patterns (PAS, GMS, mucicarmine), diagnostic pitfalls and the role of IHC/ISH/PCR in mycoses.

• Howell SA. Dermatopathology and the Diagnosis of Fungal Infections. Br J Biomed Sci. 2023; 80: 11314. DOI:10.3389/bjbs.2023.11314. PMID: 37351018.
  Summary: Practical dermatopathological view from skin/nail/mucosa biopsies; when to biopsy, usefulness of histology vs culture.

• Lu SY. Oral Candidiasis: Pathophysiology and Best Practice for Diagnosis, Classification, and Successful Management. J Fungi (Basel). 2021, 7 (7): 555. DOI: 10.3390/jof7070555. PMID: 34356934.
  Summary: Comprehensive review of oral candidiasis: clinical forms (pseudomembranous, erythematous, angular cheilitis), predisposing factors and management.

• Metin A, Dilek N, Bilgili SG. Recurrent candidal intertrigo: challenges and solutions. Clin Cosmet Investigate Dermatol.2018; 11: 175-185. DOI: 10.2147/CCID.S127841. PMID: 29713190.
  Summary: Review focused on recurrent candidal intertrigo: predisposing factors (obesity, DM), barrier/drying measures and topical/systemic therapy.

• Taverne-Ghadwal L, Kuhns M, Buhl T, et al. Epidemiology and Prevalence of Oral Candidiasis in HIV Patients From Chad in the Post-HAART Era. Front Microbiol. 2022; 13: 844069. DOI: 10.3389/fmicb.2022.844069. PMID:35250957.
  Summary: Field study (n=589) on HIV: prevalence, species (MALDI-TOF), relationship with CD4<200, effect of HAART and antifungal susceptibility.

• Puel A, Cypowyj S, Bustamante J, et al. Chronic mucocutaneous candidiasis in humans with inborn errors of interleukin-17 immunity. Science. 2011;332(6025):65–68. DOI: 10.1126/science.1200439. PMID: 21350122.
  Summary: Seminal work that causally links the IL-17 pathway (IL-17RA/IL-17F/ACT1) with human CMC; defines immunogenetic basis and phenotype.

• Okada S, Asano T, Moriya K, et al. Human STAT1 Gain-of-Function Heterozygous Mutations. J Clin Immunol.2020;40(1):82–95. DOI: 10.1007/s10875-020-00847-x. PMID: 32852681.
  Summary: Review of the STAT1-GOF spectrum: CMC, autoimmunity (thyroiditis), mechanisms (hyperphosphorylation/dephosphorylation defect) and targeted therapies.

• Huppler AR, Conti HR, Gaffen SL. Mucocutaneous candidiasis: the IL-17 pathway and implications for therapy. Expert Rev Anti Infect Ther. 2012;10(4):pp.. DOI: — (classic review with PMCID). PMID: 22838497.
  Summary: Classic review of the role of IL-17 in CMC and therapeutic consequences (potential targets).

• Barnes KN, Yancey AM, Forinash AB. Ibrexafungerp in the Treatment of Vulvovaginal Candidiasis. Ann Pharmacother. 2023;57(1):99–106. DOI: 10.1177/10600280221091301. PMID: 35502451.
  Summary: Pharmacological and clinical review of ibrexafungerp: mechanism (glucan synthase), phase 2–3 efficacy, adverse effects, evidence gaps vs. topical imidazoles.