5. 5 Candida (thrush) and skin problems
Type of infection
Candida is a fungal yeast infection.
It can affect the mouth (oral candida), throat (oesophageal candida), sinuses, bowels and genitals. especially the vagina. In rare cases the brain.
Candida is also called thrush. It is very common in people with CD4 counts under 300 cells/mm3, and it becomes more common the lower the CD4 count drops. Genital thrush can occur at any CD4 count and does not need to be linked to HIV.
- Oral thrush appears as white or red patches (especially in the mouth). These patches can sometimes be scraped off. Another symptom can be cracks at the corners of the mouth.
- In the sinuses, thrush can cause headaches, difficulty breathing and a build up of mucus.
- In the throat it can make eating and swallowing painful and difficult, making it difficult to hold food down.
Visual examination for oral candida, swab sample for candida in other areas.
- Diet changes – cutting down on foods that contain refined sugars and wheat.
- Including live, unpasteurised yoghurt that contains lactobacillus bacteria in your diet might help oral or vaginal thrush. Anecdotally, yogurt can be applied directly to the vagina for vaginal thrush, although the evidence for this benefit is unclear.
- Antifungal medications: fluconazole tablets, oral solution or topical cream is the first line treatment for candida.
Other options can include: co-trimoxazole lozenges, nystatin or itraconazole syrup, miconazole patch (for the inside of the mouth), ketaconazole and itraconazole tablets (fluconazole may be better if using rifampicin for TB treatment).
- Echinocandins, including caspofungin, micafungin and anidulafungin are first-line treatment, for invasive (internal) Candida and are given by infusion.
- More recent drugs including ibrexafungerp can be active against drug resistant candida.
If the CD4 counts increase in response to HIV treatment (ART), thrush should occur less often – and can stop completely.
Prophylaxis drugs are rarely used in people who have no symptoms. This is because the risks of side effects and drug resistance usually outweigh the benefits of protection. It is easier just to treat when needed.
There are several experimental treatments that may help people who develop resistance to existing antifungals. Most research into candida is not directly related to HIV.
Other skin problems
Minor skin problems can be one of the first symptoms of HIV and are an indication that CD4 count is less than 350 cells/mm3.
Often these are relatively minor, like dry skin. But they can also be from an infection that your immune system is no longer strong enough to 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.