5. 5 Candida (thrush) and skin problems

Type of infection

Candida is a fungal yeast infection that is also called thrush.

It can affect the mouth (oral thrush), throat (oesophageal thrush), sinuses, bowels and genitals. In rare cases it can affect the brain.

Thrush is common when the CD4 count is under 200. It also becomes more common if the CD4 count drops lower. Genital thrush can occur at any CD4 count and is not linked to HIV.

Main symptoms

• Oral thrush usually appears as white patches, especially in the mouth. These can sometimes be scraped off. Thrush can also cause cracks at the corners of the mouth.
• In the sinuses, thrush can cause headaches and difficulty breathing. It can increase the amount of mucus.
• In the throat thrush can make eating and swallowing painful and difficult. This can make it difficult to hold down food.

Diagnosis

Thrush is often just diagnosed by sight, Swab samples are sometimes tested for other areas.

Treatment

• Diet changes can help. For example, cutting down on refined sugars and wheat.
• Eating live, unpasteurised yoghurt that contains lactobacillus bacteria might help oral or vaginal thrush. Some people use yogurt topically, although this is not generally recommended.
• First-line treatment includes fluconazole tablets, oral solution or topical cream.
  Other options can include co-trimoxazole lozenges, nystatin or itraconazole syrup. Miconazole patches can be used in the mouth. Ketaconazole and itraconazole tablets (or fluconazole if using rifampicin for TB).
• Caspofungin, micafungin and anidulafungin are first-line treatment, for invasive (internal) thrush. These are given by infusion.
• Ibrexafungerp can be active against drug resistant thrush.

If the CD4 count increases on ART, thrush should occur less often or stop completely.

Prophylaxis

Drugs are rarely used unless someone has symptoms. This is because of the risks of side effects and drug resistance. It is easier just to treat when needed.

Research

Ongoing research is looking at ways to treat drug resistant thrush. Most of this research is not directly related to HIV.

Other skin problems

Minor skin problems can be an early symptoms of a low CD4 count.

Often these are relatively minor, like dry skin. They can also be from infections that your immune system can no longer fight.

• BHIVA guidelines on the management of opportunistic infection in people living with HIV: The clinical management of candidiasis 2019 (2022 interim update)
• View non-technical summary
• BNF page on systemic antifungal drugs.
• US CDC guidelines for HIV-related candida (from the US guidelines on Opportunistic Infections).
• US CDC guidelines for vaginal thrush (not HIV-specific)

Last updated: 1 January 2023.