What is the treatment for penile candidiasis (fungal infection) secondary to Sodium-Glucose Linked Transporter 2 Inhibitors (SGLT2i) use?

Treatment of Penile Candidiasis Secondary to SGLT2i Use

For penile candidiasis secondary to SGLT2 inhibitor use, topical antifungal agents such as clotrimazole or miconazole applied twice daily for 7-14 days are the first-line treatment, with oral fluconazole 150 mg as a single dose recommended for moderate to severe cases. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis by:

• Looking for characteristic signs: erythema, pruritus, and white patches on the penis
• Performing a potassium hydroxide (KOH) preparation to visualize yeast or hyphae
• Consider fungal culture in recurrent or resistant cases to identify non-albicans species

Treatment Algorithm

First-line Treatment (Mild to Moderate Cases)

• Topical antifungal agents applied twice daily for 7-14 days 1, 2:
  • Clotrimazole 1% cream
  • Miconazole 2% cream
  • Nystatin cream

Moderate to Severe Cases

• Oral fluconazole 150 mg as a single dose 1, 2
  • Can be combined with topical therapy for faster symptom relief
  • For fluconazole-refractory disease, consider itraconazole solution or posaconazole 1

Recurrent Infections

• For patients with recurrent infections (defined as ≥4 episodes per year):
  • Consider maintenance therapy with weekly application of topical antifungal for 1-2 months
  • Or fluconazole 150 mg weekly for 6 months 2
  • Evaluate for underlying conditions contributing to recurrence

SGLT2i Management Considerations

The decision to continue or discontinue the SGLT2i depends on infection severity and recurrence:

1. For first episode (mild): Continue SGLT2i while treating the infection 1

   • Implement preventive measures (see below)
   • Monitor for resolution

2. For recurrent or severe infections: Consider temporary discontinuation of SGLT2i during treatment 3

   • Restart after complete resolution with enhanced preventive measures
   • If infections persist despite preventive measures, discuss alternative diabetes medications

3. For refractory cases: Permanent discontinuation of SGLT2i may be necessary 3

Prevention Strategies

Patients on SGLT2i should be counseled on preventive measures 1, 4:

• Maintain good genital hygiene
• Keep the genital area clean and dry
• Wear loose-fitting cotton underwear
• Avoid prolonged moisture in the genital area
• Consider daily washing with mild soap and thorough drying
• Patient education significantly reduces infection risk (p<0.001) 4

Important Clinical Considerations

1. Risk factors: Female sex and prior history of genital fungal infections are significant risk factors for developing infections with SGLT2i use (OR 4.22 and 2.41, respectively) 5

2. Infection rates: Genital mycotic infections occur in approximately 25.9% of patients on SGLT2i, with 12.2% experiencing a second episode 4

3. Causative organisms: While Candida albicans is most common, non-albicans species like Candida glabrata may cause infections that are more resistant to standard azole therapy 6

4. SGLT2i benefits: Despite the risk of genital infections, SGLT2i provide significant cardiovascular and renal benefits in patients with type 2 diabetes and CKD, so continuation is generally recommended when possible 1

5. Common pitfalls:

   • Inadequate treatment duration
   • Failure to address predisposing factors
   • Missing concurrent infections
   • Overuse of topical corticosteroids which can worsen fungal infections 2

By following this treatment approach and implementing preventive strategies, most patients can continue to benefit from SGLT2i therapy while effectively managing penile candidiasis.