Although it most often manifests as a cutaneous infection that is not life-threatening, sporotrichosis usually requires treatment to resolve. The Infectious Diseases Society of America first published treatment guidelines for this disease in 2000.7 Because few randomized controlled treatment trials have been done, the guidelines committee put the most emphasis on multicenter trials of specific treatments. Several changes were made when these guidelines were updated in 2007 (Table).8
Available Agents for Treatment
There are several agents available for treatment of sporotrichosis. They include itraconazole(Drug information on itraconazole), fluconazole, amphotericin B(Drug information on amphotericin b) (AmB), saturated solution of potassium iodide(Drug information on potassium iodide) (SSKI), and terbinafine(Drug information on terbinafine). In addition, local application of heat has been used for cutaneous disease.
Itraconazole. This has become the preferred agent to treat many forms of sporotrichosis because of its effectiveness and tolerability. Several studies and many small series now support its use for the various manifestations of sporotrichosis.9
Itraconazole is available in 2 oral formulations, solution and capsule.9
Obtaining drug levels is recommended when treating more severe disease and when treatment failure is suspected. A random level of 1 mg/mL or greater indicates adequate absorption.8
Other azoles. Fluconazole(Drug information on fluconazole) and ketoconazole(Drug information on ketoconazole) are other azoles that have been clinically evaluated. Fluconazole has a more favorable toxicity profile and does not have the same issues of absorption that itraconazole does, but it is less effective. Kauffman and colleagues4 reported cure rates with fluconazole of 71% for lymphocutaneous disease and 31% for osteoarticular or visceral disease.
This finding is reflected in the updated guidelines, and fluconazole is no longer specifically recommended, except as an alternative treatment for cutaneous and lymphocutaneous disease. Ketoconazole is no longer recommended because of its inferior effectiveness and less favorable toxicity profile.8
Several studies have examined the newer azoles, posaconazole and voriconazole(Drug information on voriconazole). Posaconazole has been shown to have in vitro activity comparable to that of AmB and itraconazole, and therefore is a promising alternative treatment. Susceptibility to voriconazole, however, varies.10,11 The correlation between in vitro data and clinical response has not been demonstrated, and there is insufficient clinical evidence to recommend either agent for use at this time.
AmB. This agent remains the treatment of choice for severe or life-threatening sporotrichosis. It is indicated for disseminated, meningeal, and severe pulmonary infections. In addition, it can be used for severe infection during pregnancy when other agents cannot be used.8
It should be noted that both clinical response5 and in vitro susceptibility12 to AmB can vary depending on the strain. Several formulations of AmB are available. Lipid formulations of AmB at a dosage of 3 to 5 mg/kg/d are recommended in the guidelines because of their more favorable toxicity profile. AmB deoxycholate at a dosage of 0.7 to 1 mg/kg/d is now listed as an alternative treatment.8