An 18-Year-Old Woman With Recurrent Skin, Nail, and Oral Mucosal Abnormalities

An 18-year-old woman presented to the dermatology clinic for evaluation of recurrent skin, nail, and oral mucosal abnormalities. At age 4 years, she developed white oral plaques that resolved with oral nystatin. Approximately 6 months later, the oral plaques recurred, her toenails became thickened and yellowed, and red plaques appeared on both feet and lower legs. After 3 months of daily oral itraconazole, her skin, nail, and oral mucosal abnormalities resolved for approximately 1 year. Over the following years, she received intermittent 3- to 6-month courses of daily itraconazole for recurrent skin, nail, and oral mucosal abnormalities, which typically recurred within 6 to 12 months of discontinuing itraconazole. Her last dose of itraconazole was approximately 2 years prior to presentation. On physical examination, the patient had white, moist, nonadherent plaques in the oral mucosa and moist red fissures at bilateral oral commissures (Figure, left panel). She also had thickened, yellowed toenails and scaly erythematous plaques on her lower legs and feet bilaterally (Figure, right panel). Results of complete blood cell count with differential were normal, as were results of measurement of serum IgG, IgA, IgM, and IgE levels and analysis of CD3, CD4, and CD8 T-cell subsets. Potassium hydroxide wet mount preparation of skin scrapings from the lower extremities demonstrated fungal elements. Fungal culture of the skin scrapings grew Candida albicans.