Derm Cases · Dermatology / Infectious Diseases / Primary Care
OSCE — satellite pustules in moist folds: candidiasis management
An 8-minute OSCE station on cutaneous and mucosal candidiasis recognition, topical and systemic azole/nystatin regimens with doses, host-factor modification, pregnancy rules, and red flags for invasive or immunodeficiency-related disease.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on cutaneous and mucosal candidiasis recognition, topical and systemic azole/nystatin regimens with doses, host-factor modification, pregnancy rules, and red flags for invasive or immunodeficiency-related disease.
Brief (to candidate)
A 55-year-old woman with poorly controlled type 2 diabetes presents with pruritic, macerated erythema under the breasts and in the inguinal folds with satellite pustules. She also reports white plaques that wipe off the tongue. You have 8 minutes to diagnose the spectrum of candidiasis, treat skin and mucosa, modify host factors, and safety-net serious disease.
[1]Candidate instructions
- Recognise Candida intertrigo and oral thrush.
- Differentiate from dermatophyte, erythrasma, and irritant intertrigo.
- Prescribe topical therapy for skin folds with adjunct drying measures.
- Treat oral disease; state when systemic fluconazole is used.
- Address diabetes, occlusion, antibiotics/steroids as risk factors.
- Red flags: invasive candidiasis, chronic mucocutaneous disease, pregnancy dosing rules.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Moist fold erythema with satellite papules/pustules = cutaneous candidiasis; oral white plaques that wipe off = thrush (Candida albicans commonest)[1][3] |
| Differential | vs tinea cruris (often spares scrotum; annular edge), erythrasma (coral-red Wood's lamp), irritant napkin/intertrigo without satellites |
| Skin Rx | Topical azole (clotrimazole 1% or miconazole 2% BD) or nystatin for 2–4 weeks + dry the folds (absorbent powder, reduce occlusion, weight/diabetes control)[1][2] |
| Mucosal Rx | Mild thrush: nystatin suspension or miconazole oral gel / clotrimazole troches; moderate–severe/recurrent: fluconazole 100–200 mg daily × 7–14 days[3] |
| VVC notes (if asked) | Uncomplicated: fluconazole 150 mg single dose or topical azole; pregnancy → topical azoles only (avoid oral fluconazole especially first trimester); recurrent → culture, diabetes screen, possible weekly suppression[4] |
| Host factors | Optimise glycaemic control, stop unnecessary broad-spectrum antibiotics/steroids if possible, denture hygiene, keep skin dry |
| Red flags & disposition | Fever/neutropenia/catheter → invasive candidiasis pathway; chronic/refractory mucocutaneous → immunology (CMC); outpatient for uncomplicated intertrigo/thrush with early review if not improving |
Model key actions
- Diagnose Candida intertrigo + oral thrush in a diabetic host.[1][3]
- Topical azole/nystatin + drying for folds; fluconazole when thrush is moderate/severe or skin disease extensive/refractory.[2]
- Treat the host factors, not just the fungus.
Common errors
- Treating fold yeast with oral terbinafine (dermatophyte drug; poor Candida activity).
- Using fluconazole in pregnancy for VVC when topical azoles are preferred.
- Missing diabetes workup in recurrent candidiasis.
- Barrier cream alone without antifungal when satellites present.
- Ignoring dentures or inhaled steroid technique in thrush.
References4ShowHide
- [1]Taudorf EH, Jemec GBE, Hay RJ, et al. Cutaneous candidiasis - an evidence-based review of topical and systemic treatments to inform clinical practice. Journal of the European Academy of Dermatology and Venereology, 2019.PMID 31287594
- [2]Hay RJ. The management of superficial candidiasis. Journal of the American Academy of Dermatology, 1999.PMID 10367915
- [3]Millsop JW, Fazel N. Oral candidiasis. Clinics in Dermatology, 2016.PMID 27343964
- [4]Sobel JD. Recurrent vulvovaginal candidiasis. American journal of obstetrics and gynecology, 2016.PMID 26164695