Sporotrichosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Treatment

Treatment of sporotrichosis depends on the severity and location of the disease. The following are treatment options for this condition:

• Saturated potassium iodide solution

Although its mechanism is unknown, application of potassium iodide in droplet form can cure cutaneous sporotrichosis. This usually requires 3 to 6 months of treatment.

• Itraconazole (Sporanox) and fluconazole

These are antifungal drugs. Itraconazole is currently the drug of choice and is significantly more effective than fluconazole. Fluconazole should be reserved for patients who cannot tolerate itraconazole.

• Amphotericin B

This antifungal medication is delivered intravenously. Many patients, however, cannot tolerate Amphotericin B due to its potential side effects of fever, nausea, and vomiting.

Lipid formulations of amphotericin B are usually recommended instead of amphotericin B deoxycholate because of a better adverse-effect profile. Amphotericin B can be used for severe infection during pregnancy. For children with disseminated or severe disease, amphotericin B deoxycholate can be used initially, followed by itraconazole.

In case of sporotrichosis meningitis, the patient may be given a combination of Amphotericin B and 5-fluorocytosine/Flucytosine.

• Newer triazoles

Several studies have shown that posaconazole has in vitro activity similar to that of amphotericin B and itraconazole; therefore, it shows promise as an alternative therapy. However, voriconazole susceptibility varies. Because the correlation between in vitro data and clinical response has not been demonstrated, there is insufficient evidence to recommend either posaconazole or voriconazole for treatment of sporotrichosis at this time.

• Surgery

In cases of bone infection and cavitatory nodules in the lungs, surgery may be necessary.

Antimicrobial Regimen

• Sporotrichosis:

• 1.Lymphocutaneous/cutaneous

• Preferred regimen: Itraconazole 200mg PO qd
• Alternative regimen (1): Itraconazole 200 mg PO bid

• Alternative regimen (2): Terbinafine 500 mg bid

• Alternative regimen (3): Saturated solution potassium iodide(SSKI) with increasing doses

• Alternative regimen (4): Fluconazole 400–800 mg qd

• Alternative regimen (5): local hyperthermia
• Note(1): Treat for 2–4 weeks after lesions resolved
• Note(2): SSKI initiated at a dosage of 5 drops (using a standard eyedropper) 3 times daily, increasing as tolerated to 40–50 drops 3 times daily

• 2.Osteoarticular

• Preferred regimen: Itraconazole 200mg PO bid for 12 months
• Alternative regimen (1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day

• Alternative regimen (2): Amphotericin B deoxycholate 0.7–1 mg/kg/day
• Note(1): Switch to Itraconazole after favorable response if AmB used
• Note(2): Treat for a total of at least 12 months

• 3.Pulmonary

• Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day for severe or life-threatening pulmonary sporotrichosis, then Itraconazole 200 mg PO bid
• Preferred regimen(2): Itraconazole 200 mg PO bid for 12 months for less severe disease
• Alternative regimen: Amphotericin B deoxycholate 0.7–1 mg/kg/d, then Itraconazole 200 mg PO bid OR surgical removal
• Note(1): Treat severe disease with an AmB formulation followed by Itraconazole
• Note(2): Treat less severe disease with Itraconazole
• Note(3): Treat for a total of at least 12 monthsSurgery combined with amphotericin B therapy is rec- ommended for localized pulmonary disease

• 4.Meningitis

• Preferred regimen: Lipid amphotericin B (Lipid AmB) 5 mg/kg daily for 4–6 weeks, then Itraconazole 200 mg PO bid
• Alternative regimen: Amphotericin B deoxycholate 0.7–1 mg/kg/d, then Itraconazole 200 mg PO bid
• Note(1): Length of therapy with AmB not established, but therapy for at least 4–6 weeks is recommended.
• Note(2): Treat for a total of at least 12 months.
• Note(3): May require long-term suppression with Itraconazole.

• 5.Disseminated

• Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day, then Itraconazole 200 mg PO bid
• Alternative regimen: Amphotericin B deoxycholate 0.7–1 mg/kg/day, then Itraconazole 200 mg PO bid
• Note(1): Therapy with AmB should be continued until the patient shows objective evidence of improvement.
• Note(2): Treat for a total of at least 12 months.
• Note(3): May require long-term suppression with Itraconazole.

• 6.Pregnant women

• Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day OR Amphotericin B deoxycholate 0.7–1 mg/kg/day for severe sporotrichosis
• Preferred regimen(2): Local hyperthermia for cutaneous disease.
• Note(1): It is preferable to wait until after delivery to treat non–life-threatening forms of sporotrichosis.
• Note(2): Azoles should be avoided.

• 7.Children

• Preferred regimen:

• Mild disease: Itraconazole 6–10 mg/kg/day (400 mg/day maximum)
• Severe disease: Amphotericin B deoxycholate 0.7 mg/kg/day followed by Itraconazole 6–10 mg/kg up to a maximum of 400 mg PO daily, as step-down therapy

• Alternative regimen: Saturated solution potassium iodide(SSKI) with increasing doses for mild disease initiated at a dosage of 1 drop (using a standard eyedropper) 3 times daily and increased as tolerated up to a maximum of 1 drop/kg or 40–50 drops 3 times daily, whichever is lowest