SSKI. The classic treatment for cutaneous and lymphocutaneous sporotrichosis is SSKI. It is clinically effective and has a low cost.
Typically, treatment is started at 5 drops 3 times daily, and this is increased to 40 to 50 drops 3 times daily as tolerated. Multiple daily dosing and mild but frequent adverse effects, including headache, GI disturbance, and taste disturbance, probably contribute to decreased adherence. It is still used commonly in developing nations, where cost prohibits the use of more expensive treatments.13
Terbinafine. Clinical experience with terbinafine(Drug information on terbinafine) is limited, but a randomized controlled trial showed this treatment to be both effective and well-tolerated in patients with cutaneous and lymphocutaneous sporotrichosis. Recommended dosing for sporotrichosis is 500 mg twice daily.14
Cutaneous and lymphocutaneous sporotrichosis. Patients with cutaneous and lymphocutaneous sporotrichosis should be treated with itraconazole(Drug information on itraconazole) 200 mg daily until 2 to 4 weeks after lesions have resolved. Several series have demonstrated response rates greater than 90% with this regimen.8
Sharkey-Mathis and colleagues3 reported on a series 27 patients with various forms of sporotrichosis. All 9 patients with lymphocutaneous disease in their series responded to itraconazole. For patients who do not respond to itraconazole 200 mg daily, alternative treatments include itraconazole 200 mg twice daily, terbinafine, or SSKI. Fluconazole(Drug information on fluconazole) should be used only when these other agents cannot be tolerated.8
Terbinafine has been the focus of one of the few randomized controlled trials for sporotrichosis treatment. In a multicenter, randomized, double-blind trial in 2004, Chapman and colleagues15 compared patients with cutaneous or lymphocutaneous sporotrichosis treated with terbinafine 500 or 1000 mg daily. Treatment response was dose-dependent; there was a significantly higher clinical cure rate with the 1000-mg dose (87% vs 52%; P = .004). No relapses were noted after 24 weeks of follow-up in the 1000-mg daily group.
Another study examined the effects of SSKI in the treatment of cutaneous sporotrichosis. Cabezas and colleagues13 performed a randomized nonblind study in Peruvian children to compare a once-daily dose of SSKI with the traditional 3-times-daily dosing. Clinical response was 89% in both groups with no relapses at 45 days. Adverse effects were common but did not result in treatment discontinuation. This study was too small to recommend a once-daily dosing regimen but highlights the likely niche that the drug currently fills. Other studies also support its use for cutaneous disease, particularly in developing nations.16,17
Local application of heat is also an alternative treatment for pregnant patients with cutaneous sporotrichosis, although this treatment does require further study.8 AmB is not usually used as a treatment, given the low morbidity of this form of disease and the adverse effects of this medication.
Osteoarticular sporotrichosis. This form of the disease requires higher doses of itraconazole for a longer duration. Itraconazole 200 mg twice daily is recommended for at least 12 months. AmB can be used initially; when a favorable response is noted, itraconazole can then be substituted.
In the series published by Sharkey-Mathis and colleagues,3 11 of 15 patients with osteoarticular sporotrichosis responded to treatment with itraconazole. Four of these patients then relapsed within 6 months, and they had only received treatment for 6 months or less.