Cutaneous and Mucocutaneous Candidiasis
Nystatin is used topically as a cream, ointment, or powder for the treatment of cutaneous infections caused by Candida albicans, such as perleche, intertriginous candidiasis, paronychia, and diaper rash.
Topical nystatin also is used in conjunction with a topical corticosteroid (i.e., triamcinolone acetonide) for the treatment of cutaneous candidiasis as a commercially available fixed-combination cream or ointment that contains both drugs. Combined therapy with the drugs is more effective than nystatin alone for improving the clinical severity of cutaneous candidiasis, especially during the first few days of treatment; combined therapy generally provides earlier relief of signs and symptoms of this infection than does nystatin alone. Combinations of nystatin and corticosteroids may be of value in reducing local inflammation and pain that may accompany candidal infection. Nystatin creams and ointments were previously commercially available in combination with corticosteroids and antibacterial agents (e.g., gramicidin, neomycin) for the treatment of cutaneous candidiasis, other superficial infections, and various other dermatologic conditions complicated by candidal and/or bacterial infection, but these preparations have been reformulated and the indications for use narrowed because there was a lack of substantial evidence of efficacy for these combinations in the treatment of these conditions.
Candidal Diaper Dermatitis
Nystatin has been administered orally as a suspension in conjunction with local application of the drug for the treatment of candidal diaper dermatitis. The majority of infants with candidal diaper dermatitis harbor C. albicans in their intestines, and infected feces appear to be an important source of the cutaneous infection. Candidal diaper dermatitis usually is treated with topical antifungal agent therapy (e.g., topical nystatin, miconazole, clotrimazole). In addition, some clinicians recommend that an oral antifungal agent (e.g., oral nystatin) be administered concomitantly to treat the intestinal infection. Although results of 2 small studies have not provided evidence that concomitant oral and topical therapy is more effective than topical therapy alone, some clinicians suggest that such a strategy may be warranted.
Nystatin is used orally in the form of an oral suspension for the topical treatment of oropharyngeal candidiasis (thrush).
Topical therapy with oral nystatin oral suspension has been used in the treatment of oropharyngeal candidiasis in patients with human immunodeficiency virus (HIV) infection. Some clinicians consider oral topical therapy with clotrimazole lozenge or nystatin oral suspension the treatment of choice for uncomplicated oropharyngeal candidiasis in HIV-infected patients and recommend that systemic antifungals (e.g., oral fluconazole, oral itraconazole, oral ketoconazole) be reserved for the treatment of oropharyngeal candidiasis unresponsive to oral topical agents or for the treatment of severe oropharyngeal candidiasis with esophageal involvement. However, other clinicians prefer to use an oral azole antifungal agent for initial therapy of oropharyngeal candidiasis in HIV-infected individuals. Topical oral therapy with nystatin oral suspension is ineffective for the treatment of esophageal candidiasis in HIV-infected individuals.
Although oral nystatin has been used for prophylaxis against oropharyngeal candidiasis in HIV-infected individuals, the drug is no longer included in the prophylaxis guidelines of the Prevention of Opportunistic Infections Working Group of the US Public Health Service and Infectious Diseases Society of America (USPHS/IDSA). If prophylaxis of oropharyngeal candidiasis is indicated in HIV-infected individuals, the USPHS/IDSA recommends oral fluconazole or oral itraconazole solution.
Nystatin is used orally for the treatment of mucous membrane (nonesophageal) GI candidiasis. Oral nystatin also has been used in conjunction with an intravaginal antifungal agent to treat coexisting intestinal candidiasis and vulvovaginal candidiasis.
(See Uses: Vulvovaginal Candidiasis.)
Nystatin vaginal tablets are used for the treatment of uncomplicated vulvovaginal candidiasis. Prior to administration of intravaginal nystatin therapy, the diagnosis should be confirmed either by demonstrating yeast or pseudohyphae with direct microscopic examination of vaginal discharge (saline or 10% potassium hydroxide [KOH] wet mount or Gram stain) or by culture; identifying Candida by culture in the absence of symptoms is not an indication for antifungal treatment since approximately 10-20% of women harbor Candida or other yeasts in the vagina.
Up to 75% of women reportedly have at least one episode of vulvovaginal candidiasis and 40-45% have 2 or more episodes during their lifetime, but a small percentage of women (up to 5%) have recurrent vulvovaginal candidiasis (i.e., 4 or more episodes of symptomatic vulvovaginal candidiasis each year). While certain factors may precipitate a sporadic attack of vulvovaginal candidiasis and have been associated with an increased risk for recurrent vulvovaginal candidiasis (e.g., uncontrolled diabetes mellitus, pregnancy, oral contraceptive use, corticosteroid or other immunosuppressive therapy, immunodeficiency, use of intravaginal sponges or devices, repeated courses of topical or systemic antibacterial agents), these factors are not present in most women who have recurrent episodes.
Azole antifungals (imidazole and triazole derivatives) are considered the drugs of choice for the treatment of vulvovaginal candidiasis. The US Centers for Disease Control and Prevention (CDC) and other clinicians generally recommend that uncomplicated vulvovaginal candidiasis (defined as vulvovaginal candidiasis that is mild to moderate, sporadic or infrequent, most likely caused by Candida albicans, or occurring in immunocompetent women) should be treated with an intravaginal azole antifungal (e.g., butoconazole, clotrimazole, miconazole, terconazole, tioconazole) given in appropriate single-dose or short-course regimens or, alternatively, oral fluconazole given in a single-dose regimen. These regimens generally have been associated with clinical and mycologic cure rates of 80-90% in otherwise healthy, nonpregnant women with uncomplicated infections, and there is no clear evidence that any one intravaginal azole antifungal regimen is superior to other intravaginal azole regimens available for the treatment of these infections. While a 14-day regimen of intravaginal nystatin tablets also can be used for the treatment of uncomplicated vulvovaginal candidiasis, intravaginal nystatin generally is less effective than intravaginal azole antifungals.
Vulvovaginal candidiasis usually is not acquired through sexual activity, and treatment of sexual partner(s) is not recommended but may be considered in women who have recurrent infections. However, male sexual partners who have symptomatic balanitis or penile dermatitis may benefit from treatment with a topical antifungal agent to relieve symptoms.
In patients with coexisting intestinal candidiasis and vulvovaginal candidiasis, nystatin has been administered orally in conjunction with intravaginal application of an antifungal agent. While early studies provide some limited evidence that, by reducing intestinal candidal colonization, combined oral and intravaginal antifungal therapy possibly could improve the mycologic response and reduce the recurrence rate of vulvovaginal candidiasis, most evidence suggests that combined therapy does not substantially reduce the risk of recurrence compared with intravaginal therapy alone.
For additional information on treatment of uncomplicated vulvovaginal candidiasis and information on treatment of complicated and recurrent vulvovaginal candidiasis, see Uses: Vulvovaginal Candidiasis in Clotrimazole 84:04.08.08.
External ophthalmic candidal infections have been treated with local ophthalmic application of nystatin or with subconjunctival injection of the drug. However, nystatin preparations for ophthalmic application are not commercially available.
Nystatin is ineffective in and should not be used for the treatment of infections caused by dermatophytes such as species of Trichophyton, Microsporum, or Epidermophyton.
For information on use of oral nystatin for prophylaxis of candidal infections,