Anti-fungal agents: Therapy for specific diseases

Mild skin infections

Mainly use a topical preparation including some of the following

• Azoles
• Allylamines

Or over the counter stuff

• Tolnaftate (Tinactin)
• Clotrimazole
• Miconazole
• Terbinafine (Lamisil)

Severe skin infections

• Oral antifungal agents, mainly itraconazole

Tinea Capitis (ringworm of the scalp)

• Oral therapy with Griseofulvin
• Could also use azoles if Griseofulvin fails

Onychomycosis (infection of the nails)

• Griseofulvin for 6-12 months
• Or itraconazole and terbinafine for 3 months
• Topical preparations like Ciclopirox are easy to use, but have a low cure rate

Tinea Versicolor (sun spots)

• Topical ketoconazole for small spots
• For larger areas, use oral itraconazole or fluconazole for a short time

Chromomycosis (infections of the skin and sub-cutaneous)

• Surgical excision when possible
• In conjunction with itraconazole for 12-36 months
• When surgery is not possible, Amphotericin B may be necessary

Mycetoma (a tumor caused by filamentous bacteria or filamentous fungi)

• Surgical excision, maybe even amputation
• In combination with an Azole for 1 to 3 years

Zygomycosis (mucormycosis, phycomycosis) (opportunistic infections)

• Quickly initiate therapy with Amphotericin B
• (Azoles are not effective against mucormycosis)
• In diabetic patients, control the acidosis, then surgically debride the tissue

Aspergillosis

Allergic bronchopulmonary aspergillosis

• Desensitization protocols
• Along with oral corticosteroids

Aspergillomas

• Surgically excise
• Along with oral itraconazole
• Or IV amphotericin B

Invasive aspergillosis

• Amphotericin B, but the outlook is still poor

Candidiasis

Superficial candidiasis

• Creams or ointments containing an Azole or Nystatin

Oropharyngeal candidiasis

• Nystatin swish and swallow
• Or an Azole troche formulation

Esophageal candidiasis

• Treat with an oral Azole
• In AIDS pt’s, use Fluconazole, b/c the absorbtion of itraconazole and ketoconazole depends on gastric acid secretion, which may be depressed (achlorohydric) in a pt with AIDS

Vaginal Candidiasis

• One dose of 150mg of Fluconazole
• Or two doses of 200mg itraconazole given 8 hours apart
• Also vaginal creams and suppositories

Systemic Candidiasis

• Amphotericin B
• Removal of the artificial heart valve or indwelling catheter, if that is the cause

Cryptococcosis (CNS and disseminated infection)

• Treat with a combination of Amphotericin B and 5-fluorocytosine
• This combination allows for synergism and a reduction in the dose of Amp B

Blastomycosis (cutaneous, pulmonary and disseminated)

• For mild cases, treat with Itraconazole for at least 6 months
• For severe cases, treat with Amphotericin B for several weeks

Histoplasmosis (a disease of the reticuloendothelial system RES)

• Pulmonary, disseminated or ocular
• For mild cases, treat with Itraconazole
• For severe cases, treat with Amphotericin B

Coccidioidomycosis (cutaneous, pulmonary, ocular, disseminated, and Valley Fever)

• Amphotericin B for life-threatening infections
• Itraconazole or fluconazole for milder cases
• Itraconazole is primarily used, but Fluconazole has better BBB penetration, so
• Extended therapy with Fluconazole is indicated with CNS involvement
• Could require lifetime administration

Paracoccidioidomycosis (South American Blastomycosis)

• Mucocutaneous, pulmonary, lymphatic, and visceral
• Treat with Itraconazole for many months

Sporotrichosis (cutaneous and visceral)

• Cutaneous sporotrichosis, use Itraconazole
• Lymphatic sporotrichosis, use Itraconazole
• For systemic infection, treat with Amphotericin B

Unusual Opportunistic Organisims

• Rule of thumb, treat with Amphotericin B

Category: Pharmacology Notes