Candida is a yeast that commonly superinfects inflamed, warm, moist skin The typical clinical appearance is erythema in skin folds with pustules and peeling in the periphery (satellite pustules) ( Fig 66.14 ) Candidal infection of the oropharynx (“thrush”) presents with white papules and plaques that cannot be easily wiped off Feeding may be painful Thrush is common in young infants or after use of systemic antibiotics or steroids In older children with no steroid or antibiotic exposure, thrush may be a marker of immunosuppression Diagnosis is usually clinical but the white discharge can be cultured to prove the diagnosis Therapy is with topical nystatin or clotrimazole troches (in older children) or oral fluconazole if severe Neonatal candida infections can be mild or severe depending on the age and weight of the child and the mode of infection If there is premature rupture of membranes and an ascending candida infection, the child is surrounded by candida in the amniotic fluid Infants may be born with broad redness that looks like a sunburn and then often develops superimposed pustules and then peels within a few days This type of candida infection is severe and can be life threatening, especially in children under 1,000 g All children with congenital candidiasis should be evaluated for clinical signs of systemic infection and treated under the guidance of an infectious disease specialist Those under 1,000 g should be treated systemically and evaluated for more widespread infection FIGURE 66.14 Candida infection Note the intense confluent area of inflammation surrounded by discrete satellite lesions (Reprinted with permission from Sauer GC, Hall JC Manual of Skin Diseases 7th ed Philadelphia, PA: Lippincott-Raven; 1996.) Localized candidal infections in healthy full-term infants often present in diaper, axillary, or other warm moist environments In addition to therapy with topical antifungal agents, allowing the folds to dry is important to prevent reinfection Opportunistic Fungal Infections There are some fungi and yeasts that should not grow in patients with normal immunity under normal circumstances Therefore, infection with these opportunistic pathogens should warrant a workup for immunosuppression Fungi such as Aspergillus species, and molds such as mucormycosis (including Rhizopus species), Fusarium species, alternaria , and others can either cause infection by direct inoculation of the skin or by dissemination to the skin from a distant systemic infection in immunosuppressed patients Infection through direct cutaneous inoculation presents with an eschar or deep purple nodule The purple color is caused by vascular invasion or infarction and can simulate a bruise Infection is often at the site of trauma (including IV or surgical site) Localized infection with opportunistic fungi can also present as a pustular eruption if the fungus is present under occlusion such as tape or an arm board It is vital to identify localized opportunistic fungal infections immediately to prevent dissemination A biopsy with histopathologic evaluation and tissue culture can establish the diagnosis and fungal sensitivities Since the cause of an erythematous or necrotic skin lesion in an immunosuppressed patient can be bacterial, viral, or fungal, a tissue Gram stain or frozen section from tissue biopsy can help make a rapid diagnosis Patients with suspected opportunistic fungal infections should be treated with antifungals under the guidance of an infectious disease specialist Deep Fungal Infections Deep fungal infections are typically acquired as pulmonary infection through inhalation of the spores when the soil is disrupted and the spores are aerosolized Cryptococcosis, histoplasmosis, blastomycosis, coccidioidomycosis, and paracoccidioidomycosis are common causes of deep fungal pulmonary infection in normal hosts in North America This pulmonary infection can disseminate, or some of the spores can cause primary infection around the mouth Primary infection is uncommon but presents with inflamed papules or nodules, often with crusting or erosion typically perioral, perinasal, or involving the oral mucosa There also can be secondary reactive skin changes such as erythema nodosum (EN) EN is characterized by red, painful subcutaneous nodules, most specifically on the anterior shins The nodules seem to be reactive and not truly infectious and there are many other causes of EN Deep fungal infections can also manifest as nodules or verrucous plaques when directly inoculated into the skin Sporotrichosis often presents this way after direct inoculation of the fungus into the skin The fungus Sporothrix schenckii lives on various plants and vegetation, including rose thorns, sphagnum moss, and carnations Once inoculated into the skin, the fungus spreads along the lymphatic drainage (sporotrichoid pattern) up the affected arm or leg Diagnosis of cutaneous deep fungal infections is best proven with biopsy for histopathology and fungal culture The specimen should also be sent for bacterial and mycobacterial culture since these can mimic deep fungal infections Therapy is with systemic antifungals and should be guided by culture and infectious disease consultation depending on the specific fungus, extent of infection, and host factors such as immunosuppression Suggested Readings and Key References Buckingham SC Rocky Mountain spotted fever: a review for the pediatrician Pediatr Ann 2002;31(3):163–168 Demos M, McLeod MP, Nouri K Recurrent furunculosis: a review of the literature Br J Dermatol 2012;167(4):725–732 Fritz SA, Camins BC, Eisenstein KA, et al Effectiveness of measures to eradicate Staphylococcus aureus carriage in patients with communityassociated skin and soft-tissue infections: a randomized trial Infect Control Hosp Epidemiol 2011;32(9):872–880 Hawkins DM, Smidt AC Superficial fungal infections in children Pediatr Clin North Am 2014;61(2):443–455 Hussain S, Venepally M, Treat JR Vesicles and pustules in the neonate Semin Perinatol 2013;37(1):8–15 Kress DW Pediatric dermatology emergencies Curr Opin Pediatr 2011;23(4):403–406 Llera JL, Levy RC Treatment of cutaneous abscess: a double-blind clinical study Ann Emerg Med 1985;14(1):15–19 Rivitti EA, Aoki V Deep fungal infections in tropical countries Clin Dermatol 1999;17(2):171–190 ... Suggested Readings and Key References Buckingham SC Rocky Mountain spotted fever: a review for the pediatrician Pediatr Ann 2002;31(3):163–168 Demos M, McLeod MP, Nouri K Recurrent furunculosis:... Venepally M, Treat JR Vesicles and pustules in the neonate Semin Perinatol 2013;37(1):8–15 Kress DW Pediatric dermatology emergencies Curr Opin Pediatr 2011;23(4):403–406 Llera JL, Levy RC Treatment