Sporotrichosis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
nonpregnant: lymphocutaneous/cutaneous
antifungal therapy
Spontaneous resolution of sporotrichosis is rare and treatment is necessary.
Itraconazole is the treatment of choice. Prognosis is excellent with cure rates of 90% to 100%.[37]Sharkey-Mathis PK, Kauffman CA, Graybill JR, et al. Treatment of sporotrichosis with itraconazole. NIAID Mycoses Study Group. Am J Med. 1993 Sep;95(3):279-85. http://www.ncbi.nlm.nih.gov/pubmed/8396321?tool=bestpractice.com [38]Restrepo A, Robledo J, Gómez I, et al. Itraconazole therapy in lymphangitic and cutaneous sporotrichosis. Arch Dermatol. 1986 Apr;122(4):413-7. http://www.ncbi.nlm.nih.gov/pubmed/3006602?tool=bestpractice.com [39]Conti Díaz IA, Civila E, Gezuele E, et al. Treatment of human cutaneous sporotrichosis with itraconazole. Mycoses. 1992 May-Jun;35(5-6):153-6. http://www.ncbi.nlm.nih.gov/pubmed/1335550?tool=bestpractice.com Oral solution is the preferred formulation to treat sporotrichosis because of its favorable absorption characteristics.
Higher doses of itraconazole (e.g., 200 mg twice daily rather than once daily), terbinafine, or saturated solution of potassium iodide are recommended for patients who do not respond to initial itraconazole therapy.[10]da Rosa AC, Scroferneker ML, Vettorato R, et al. Epidemiology of sporotrichosis: a study of 304 cases in Brazil. J Am Acad Dermatol. 2005 Mar;52(3 Pt 1):451-9. http://www.ncbi.nlm.nih.gov/pubmed/15761423?tool=bestpractice.com [41]Cabezas C, Bustamante B, Holgado W, et al. Treatment of cutaneous sporotrichosis with one daily dose of potassium iodide. Pediatr Infect Dis J. 1996 Apr;15(4):352-4. http://www.ncbi.nlm.nih.gov/pubmed/8866807?tool=bestpractice.com [42]Itoh M, Okamoto S, Kariya H. Survey of 200 cases of sporotrichosis. Dermatologica. 1986;172(4):209-13. http://www.ncbi.nlm.nih.gov/pubmed/3709907?tool=bestpractice.com [44]Chapman SW, Pappas P, Kauffmann C, et al. Comparative evaluation of the efficacy and safety of two doses of terbinafine (500 and 1000 mg day(-1)) in the treatment of cutaneous or lymphocutaneous sporotrichosis. Mycoses. 2004 Feb;47(1-2):62-8. http://www.ncbi.nlm.nih.gov/pubmed/14998402?tool=bestpractice.com
Fluconazole should be used only if other antifungal agents are not tolerated. Fluconazole and terbinafine should not be used in children.
Treatment course: 3 to 6 months (i.e., for 2 to 4 weeks after resolution of all lesions).
Primary options
itraconazole: children: 6-10 mg/kg orally once daily, maximum 400 mg/day; adults: 200 mg orally twice daily for 3 days, followed by 200 mg once daily
Secondary options
potassium iodide: children and adults: consult specialist for guidance on dose
OR
terbinafine: adults: 500 mg orally twice daily
Tertiary options
fluconazole: adults: 400-800 mg orally once daily
nonpregnant: extracutaneous mild/moderate disease
itraconazole
Itraconazole is the treatment of choice in patients with less-severe osteoarticular and pulmonary disease for at least 3 to 6 months, and for up to 12 months of total treatment duration depending on clinical response.
Serum levels of itraconazole should be monitored in patients who have received at least 2 weeks of therapy, to ensure adequate drug levels (target level: >1 microgram/mL).
Primary options
itraconazole: children: 6-10 mg/kg orally once daily, maximum 400 mg/day; adults: 200 mg orally twice daily
surgical debridement of osteoarticular disease
Treatment recommended for SOME patients in selected patient group
Adjunctive surgical debridement may be helpful in certain occasions such as in drainage of septic joint, sequestrum resection, or synovectomy.
resection of affected lung tissue
Treatment recommended for SOME patients in selected patient group
Adjunctive surgical resection of affected lung tissue, whenever feasible, is recommended for localized pulmonary disease in combination with amphotericin B. However, many patients who develop pulmonary sporotrichosis have underlying COPD and cannot tolerate surgery.
nonpregnant: extracutaneous severe/life-threatening disease
amphotericin B followed by intraconazole
For severe or life-threatening osteoarticular and pulmonary disease, all patients with meningeal and disseminated disease, or in patients who are unresponsive to itraconazole, amphotericin B should be given, followed by at least 3 to 6 months and up to 12 months step down therapy with itraconazole once a favorable response is seen.
Serum levels of itraconazole should be monitored in patients who have received at least 2 weeks of therapy to ensure adequate drug levels (target level: >1 microgram/mL).
Lipid formulations of amphotericin B are associated with lower incidence of renal toxicity compared with amphotericin B deoxycholate.
Primary options
amphotericin B lipid complex: children and adults: 3-5 mg/kg intravenously once daily
OR
amphotericin B deoxycholate: children and adults: 0.7 to 1 mg/kg intravenously once daily
OR
itraconazole: children: 6-10 mg/kg orally once daily, maximum 400 mg/day; adults: 200 mg orally twice daily
surgical debridement of osteoarticular disease
Treatment recommended for SOME patients in selected patient group
Adjunctive surgical debridement may be helpful in certain occasions such as in drainage of septic joint, sequestrum resection, or synovectomy.
resection of affected lung tissue
Treatment recommended for SOME patients in selected patient group
Adjunctive surgical resection of affected lung tissue, whenever feasible, is recommended for localized pulmonary disease in combination with amphotericin B. However, many patients who develop pulmonary sporotrichosis have underlying COPD and cannot tolerate surgery.
chronic suppressive therapy
Treatment recommended for ALL patients in selected patient group
In patients with HIV and other immunocompromised patients, chronic suppressive therapy with itraconazole is recommended to prevent relapse after initial treatment is complete.
In patients with meningeal sporotrichosis, lifelong suppression is necessary.
In patients with disseminated sporotrichosis, discontinuation of suppressive treatment can be considered if their CD4 count remains above 200 cells/mm³ for >1 year and the patient has received >1 year of itraconazole therapy.
Primary options
itraconazole: children: 100 mg orally once daily; adults: 200 mg orally once daily
pregnant: cutaneous
local hyperthermia
It is preferable to wait until delivery to treat lymphocutaneous sporotrichosis with antifungal agents.
Local hyperthermia can be used for fixed cutaneous sporotrichosis.
Daily application (about 1 hour/day) of heat by pocket warmer or infrared heater to achieve temperatures of 107.6°F to 109.4°F (42°C to 43°C) for about 3 to 6 months should be done.
terbinafine
It is preferable to wait until delivery to treat lymphocutaneous sporotrichosis with antifungal agents.
Terbinafine should not cause fetal toxicity, but because it passes to breast milk it could have an effect on nursing babies. The risks and benefits of using terbinafine in pregnant and nursing women should be discussed with each patient and decisions should be individualized.
Treatment course: 3 to 6 months.
Primary options
terbinafine: adults: 500 mg orally twice daily
pregnant: lymphocutaneous
observation until delivery
It is preferable to wait until delivery to treat lymphocutaneous sporotrichosis with antifungal agents.
terbinafine
It is preferable to wait until delivery to treat lymphocutaneous sporotrichosis with antifungal agents.
Terbinafine should not cause fetal toxicity, but because it passes to breast milk it could have an effect on nursing babies. The risks and benefits of using terbinafine in pregnant and nursing women should be discussed with each patient and decisions should be individualized.
Treatment course: 3 to 6 months.
Primary options
terbinafine: adults: 500 mg orally twice daily
pregnant: extracutaneous
amphotericin B
Amphotericin B can be used for severe extracutaneous sporotrichosis. It is given until a favorable response is seen.
Azole antifungals are contraindicated due to their teratogenic potential.
Primary options
amphotericin B lipid complex: adults: 3-5 mg/kg intravenously once daily
OR
amphotericin B deoxycholate: adults: 0.7 to 1 mg/kg intravenously once daily
chronic suppressive therapy
Treatment recommended for ALL patients in selected patient group
In patients with HIV and other patients who are immunocompromised, chronic suppressive therapy with itraconazole is recommended to prevent relapse after initial treatment is complete.
In patients with meningeal sporotrichosis, lifelong suppression is necessary.
In patients with disseminated sporotrichosis, discontinuation of suppressive treatment can be considered if their CD4 count remains above 200 cells/mm³ for >1 year and the patient has received >1 year of itraconazole therapy.
Primary options
itraconazole: adults: 200 mg orally once daily
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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