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Am Fam Physician. 1998;57(11):2857

Oropharyngeal candidiasis (also called oral thrush) and candidal diaper dermatitis are annoying problems that resolve spontaneously in most healthy infants. In some cases, however, the symptoms may be persistent, causing pain, anorexia and discomfort. For these reasons, rapid control is often desirable. Hoppe reviews the management of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants.

Oropharyngeal candidiasis is rare in the first week of life. The peak prevalence of this disorder occurs at four weeks of age. Nonabsorbed agents should be used to treat neonates and infants without major underlying considerations. Gentian violet is moderately effective but may cause irritation and ulceration of the mucosa with prolonged use. Topical nystatin is virtually free of harmful reactions, although high doses of the oral preparation can cause nausea and vomiting. Nystatin suspension has suboptimal efficacy, because its antifungal activity is only moderate. Amphotericin B suspension appears to have slightly better efficacy than nystatin. Neither gentian violet, nystatin nor amphotericin has a clinical cure rate of greater than 80 percent. Miconazole gel and topical clotrimazole appear to be more effective, but miconazole oral gel is not available in the United States, and oral clotrimazole can raise liver enzyme levels and cause gastrointestinal side effects in infants. This lack of an efficacious treatment preparation has led to the unconventional oral administration of topical or vaginal antifungal agents. When miconazole is used, it is probably not necessary to administer the medication beyond the day of clinical cure.

Candidal diaper rash starts in the perianal area and spreads to adjacent areas. Treatment includes aerating the diaper area and keeping the infant dry. Zinc oxide paste may be soothing and protective when the acute phase of the eruption has subsided. Baby powder application also may be useful. Antifungal therapy is mandatory to achieve resolution. Nystatin, amphotericin, miconazole and clotrimazole are all useful, although cure rates are higher with use of miconazole and clotrimazole. Oral treatment of candidal diaper dermatitis and the possible accompanying intestinal infection is recommended by many experts.

The author concludes that for treatment of oropharyngeal candidiasis, miconazole oral gel is clearly superior to nystatin suspension. If nystatin suspension must be used, dosages higher than those conventionally administered might improve the outcome. For topical therapy of candidal diaper dermatitis, several agents appear to be equivalent. The addition of an oral agent to the topical treatment is probably appropriate. Nystatin suspension may be used for this purpose.

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