What is the recommended treatment for a severe skin fungal infection?

Treatment of Severe Skin Fungal Infections

For severe skin fungal infections, an echinocandin (caspofungin: loading dose of 70 mg, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: loading dose of 200 mg, then 100 mg daily) is the recommended first-line treatment. 1

First-line Treatment Options

• For severe fungal skin infections, particularly those caused by Candida species, an echinocandin is the preferred initial therapy due to its fungicidal activity and excellent safety profile 1
• Specific echinocandin dosing:
  • Caspofungin: 70 mg loading dose, then 50 mg daily 1
  • Micafungin: 100 mg daily 1
  • Anidulafungin: 200 mg loading dose, then 100 mg daily 1
• For patients who are less critically ill and have had no recent azole exposure, fluconazole (loading dose of 800 mg [12 mg/kg], then 400 mg [6 mg/kg] daily) can be considered as an alternative 1

Treatment Based on Specific Fungal Species

For Candida albicans:

• Initial treatment with an echinocandin, then transition to fluconazole (400 mg daily) once the patient is clinically stable and the isolate is confirmed to be susceptible 1
• Treatment should continue until all lesions have resolved on repeat imaging, which may take several weeks to months 1

For Candida glabrata:

• An echinocandin is strongly preferred due to higher rates of azole resistance 1
• Transition to fluconazole or voriconazole therapy is not recommended without confirmation of isolate susceptibility 1

For Candida parapsilosis:

• Fluconazole is the preferred treatment (400 mg daily) due to potentially reduced susceptibility to echinocandins 1

Alternative Treatment Options

• Lipid formulation of amphotericin B (3-5 mg/kg daily) is an effective alternative if there is intolerance to or limited availability of echinocandins 1
• Voriconazole (loading dose of 400 mg [6 mg/kg] twice daily for 2 doses, then 200-300 mg [3-4 mg/kg] twice daily) can be considered, particularly when additional mold coverage is desired 1, 2

Duration of Therapy

• Treatment should continue for at least 2 weeks after documented clearance of the infection and resolution of symptoms 1
• For deep tissue or disseminated infections, therapy may need to be extended for several months until complete resolution of all lesions on imaging 1

Special Considerations

• Any infected central venous catheter should be removed if possible, particularly in non-neutropenic patients with candidemia 1
• For patients with neutropenia and severe fungal infections, consider adding G-CSF-mobilized granulocyte transfusions if candidemia persists and prolonged neutropenia is expected 1
• For denture-related oral candidiasis, disinfection of the denture in addition to antifungal therapy is essential for successful treatment 1, 3

Monitoring and Follow-up

• Regular clinical assessment for improvement of symptoms and signs of infection 3
• For disseminated infections, follow-up imaging is recommended to confirm resolution of lesions 1
• For candidemia, follow-up blood cultures should be performed to document clearance of the infection 1

Common Pitfalls to Avoid

• Failure to identify and address underlying risk factors (immunosuppression, diabetes, broad-spectrum antibiotics) can lead to treatment failure or recurrence 3
• Inadequate treatment duration is a common cause of relapse, particularly in immunocompromised patients 1, 3
• Failure to consider resistant species (particularly C. glabrata and C. krusei) in cases not responding to initial therapy 3
• Neglecting to remove infected devices or catheters when present 1