What is the medical management of resistant Candida fungal skin infections?

Medical Management of Resistant Candida Fungal Skin Infections

For resistant Candida skin infections, echinocandins are the recommended first-line treatment, with voriconazole as an alternative for fluconazole-resistant strains. 1

Diagnostic Approach

• Confirm diagnosis through direct microscopy and culture to identify the specific Candida species and determine antifungal susceptibility 1
• Testing for azole susceptibility is strongly recommended for all clinically relevant Candida isolates, especially in resistant cases 1
• Echinocandin susceptibility testing should be considered in patients with prior echinocandin exposure or infections with C. glabrata or C. parapsilosis 1

First-Line Treatment for Resistant Candida Skin Infections

• For fluconazole-resistant strains, an echinocandin (caspofungin, micafungin, or anidulafungin) is the recommended first choice 1
  • Caspofungin: loading dose 70 mg, then 50 mg daily
  • Micafungin: 100 mg daily
  • Anidulafungin: loading dose 200 mg, then 100 mg daily 1
• Treatment duration typically ranges from 7-14 days, depending on clinical response 1

Alternative Treatment Options

• For fluconazole-resistant C. glabrata:
  • Amphotericin B deoxycholate (0.3-0.6 mg/kg daily for 1-7 days) with or without oral flucytosine (25 mg/kg 4 times daily) 1
  • Topical boric acid (600 mg daily for 14 days) for localized infections 1
• For C. krusei infections:
  • Amphotericin B deoxycholate (0.3-0.6 mg/kg daily for 1-7 days) 1
  • Voriconazole has shown efficacy against resistant Candida strains in skin lesions 2

Special Considerations for Different Types of Infections

• For intertrigo and other skin fold infections:
  • Keep the infected area dry (critical for successful treatment) 3
  • Topical azoles (clotrimazole, miconazole) may be effective for mild cases, but resistant infections require systemic therapy 3
• For paronychia (infection around nails):
  • Drainage is the primary intervention, followed by appropriate antifungal therapy 3
  • For resistant cases, oral itraconazole may be required 4
• For recurrent infections:
  • Address underlying predisposing factors (diabetes, immunosuppression) 1
  • Consider maintenance therapy with weekly fluconazole (150 mg) for 6 months in cases of recurrent infection 1

Management of Complicated Cases

• For extensive or systemic involvement:
  • Surgical debridement may be necessary for fungal abscesses or necrotic tissue 1
  • Combination therapy with two antifungal agents from different classes may be considered for highly resistant strains 5
• For immunocompromised patients:
  • More aggressive and prolonged therapy is often required 1
  • Consider combination therapy or higher doses of antifungals 5

Common Pitfalls and Caveats

• Failure to identify the correct Candida species can lead to inappropriate treatment selection 6
• Resistance to azoles is increasing, particularly with C. glabrata and C. krusei, due to widespread use of fluconazole 7
• Treatment failure is often due to:
  • Poor adherence to treatment regimen
  • Inadequate treatment duration
  • Reinfection rather than true antifungal resistance 6
• Keeping infected areas dry is crucial; moisture promotes fungal growth and can lead to treatment failure 3
• Using topical therapy alone for nail infections is ineffective; systemic therapy is required 3

By following this evidence-based approach to managing resistant Candida skin infections, clinicians can optimize treatment outcomes and reduce morbidity associated with these challenging infections.