From the Guidelines
For a patient with cutaneous candidiasis who has failed fluconazole treatment, the next step should be to switch to itraconazole solution at a dosage of 200 mg daily. This recommendation is based on the clinical practice guidelines for the management of candidiasis: 2009 update by the infectious diseases society of America 1. The guidelines suggest that for fluconazole-refractory disease, either itraconazole solution or posaconazole suspension can be used as an alternative treatment. However, considering the available options, itraconazole solution at a dosage of 200 mg daily is a suitable choice for patients who have failed fluconazole treatment. Some key points to consider when treating a patient with cutaneous candidiasis who has failed fluconazole treatment include:
- Identifying and addressing underlying factors contributing to treatment failure, such as immunosuppression or continued exposure to moist environments
- Keeping affected areas clean and dry, avoiding tight clothing, and changing out of wet clothes promptly
- Considering alternative antifungal agents, such as posaconazole suspension or voriconazole, if treatment with itraconazole fails
- Obtaining fungal cultures with susceptibility testing if the infection persists despite treatment, to guide targeted therapy, as recommended by the guidelines 1.
From the Research
Next Steps for Patients with Cutaneous Candidiasis Who Have Failed Fluconazole Treatment
- If a patient with cutaneous candidiasis has failed fluconazole treatment, second-line therapy with a wider spectrum antifungal, such as itraconazole, should be considered 2.
- Itraconazole has proven efficacy in treating cutaneous and mucosal Candida infections, and it may have increased efficacy and an excellent safety profile when administered in a pulse-dose, or intermittent fashion, for superficial mycotic infections 3.
- Other treatment options for cutaneous candidiasis include topical therapies such as clotrimazole, nystatin, and miconazole, which have demonstrated similar efficacy with complete cure rates of 73%-100% 4.
- Oral fluconazole has been shown to be as effective as topical clotrimazole and is a commercially available evidence-based option for systemic treatment of cutaneous candidiasis 4.
- In cases where fluconazole is not effective, itraconazole solution can be an effective alternative, although it may be less well tolerated as first-line therapy 2.
Considerations for Treatment
- The choice of treatment should take into account the severity of the infection, the patient's immune status, and the potential for resistance to antifungal agents 5.
- Fluconazole is still a major drug for antifungal prophylaxis in certain settings, such as transplantation, intensive care unit, and in neutropenic patients, but its use should be limited to selected high-risk patients to minimize the risk of emergence of azole-resistant strains 5.
- Itraconazole has been shown to be effective in treating Candida infections that are non-responsive to fluconazole, and it may be a suitable alternative for patients who have failed fluconazole treatment 2, 3.