What is the recommended treatment for sporotrichosis?

Treatment of Sporotrichosis

Itraconazole 100-200 mg daily for 3-6 months is the first-line treatment for cutaneous and lymphocutaneous sporotrichosis, with success rates of 90-100%. 1

Cutaneous and Lymphocutaneous Sporotrichosis

Preferred Treatment:

• Itraconazole 100-200 mg orally daily for 3-6 months is the drug of choice 1, 2
• Success rates reach 90-100% based on multiple treatment trials 1
• A large Brazilian study of 645 patients demonstrated 94.6% cure rate with itraconazole, with most patients responding to just 100 mg/day 3
• Serum itraconazole levels must be checked after 2 weeks of therapy to ensure adequate drug exposure 1, 2

Alternative Options:

• Saturated solution of potassium iodide (SSKI) starting at 5 drops three times daily, increasing as tolerated to 40-50 drops three times daily for 3-6 months 1
• SSKI is much less expensive than itraconazole but causes frequent side effects including metallic taste, salivary gland enlargement, and rash 1
• Fluconazole 400 mg daily for 6 months should only be used if itraconazole is not tolerated, as it is significantly less effective 1
• Terbinafine 250 mg daily has shown comparable efficacy to itraconazole in a comparative study of 304 patients (92.7% vs 92% cure rates) 4
• Local hyperthermia for 2-3 months can be considered 1

Critical Pitfall: Ketoconazole should never be used for sporotrichosis as it is less effective than fluconazole 1, 2

Osteoarticular Sporotrichosis

Preferred Treatment:

• Itraconazole 200 mg twice daily for at least 12 months 1
• Response rates are more modest (73%) compared to cutaneous disease, with relapse occurring in approximately 36% of patients 1

Alternative:

• Amphotericin B (total dose 1-2 g) for severe cases 1
• Fluconazole 800 mg daily for 12 months has poor response rates (only 23% success) and should be avoided 1

Pulmonary Sporotrichosis

For Severe or Life-Threatening Disease:

• Amphotericin B lipid formulation 3-5 mg/kg IV daily is the preferred initial therapy 1, 5
• Amphotericin B deoxycholate 0.7-1.0 mg/kg IV daily is acceptable but not preferred due to tolerability 1, 5, 6
• After favorable response, transition to itraconazole 200 mg twice daily to complete at least 12 months total therapy 1, 5
• Surgery combined with amphotericin B is recommended for localized pulmonary disease 1, 5

For Less Severe Disease:

• Itraconazole 200 mg twice daily for at least 12 months can be used as initial therapy 1, 5

Critical Monitoring: Pulmonary sporotrichosis has poor outcomes, often fatal due to delayed diagnosis and underlying conditions like COPD and alcoholism 1

Meningeal Sporotrichosis

Initial Treatment:

• Amphotericin B lipid formulation 5 mg/kg daily for 4-6 weeks 1
• Amphotericin B deoxycholate 0.7-1.0 mg/kg daily is an alternative but not preferred 1

Suppressive Therapy:

• Itraconazole 200 mg twice daily after amphotericin B 1
• Fluconazole >800 mg daily can be considered for suppression 1

Disseminated Sporotrichosis

Initial Treatment:

• Amphotericin B lipid formulation 3-5 mg/kg daily 1
• Amphotericin B deoxycholate 0.7-1.0 mg/kg daily is acceptable 1

Step-Down Therapy:

• Itraconazole 200 mg twice daily after response to amphotericin B, completing at least 12 months total therapy 1

Special Populations

AIDS and Immunocompromised Patients:

• Initial treatment with amphotericin B (total dose 1-2 g), followed by itraconazole 200 mg twice daily 1
• Lifelong suppressive therapy with itraconazole 200 mg daily is required if immunosuppression cannot be reversed 1, 5, 2

Pregnancy:

• Amphotericin B lipid formulation 3-5 mg/kg daily or deoxycholate 0.7-1.0 mg/kg daily for severe disease 1, 5
• All azoles must be avoided during pregnancy due to teratogenic potential 1, 5, 2
• Local hyperthermia can be used for cutaneous sporotrichosis 1

Children:

• Itraconazole 6-10 mg/kg daily (maximum 400 mg) for cutaneous/lymphocutaneous disease 1
• SSKI starting at 1 drop three times daily, increasing to maximum of 1 drop/kg or 40-50 drops three times daily, whichever is lower 1
• Amphotericin B 0.7 mg/kg daily for disseminated disease, followed by itraconazole as step-down therapy 1

Critical Drug Interactions and Monitoring

Itraconazole Absorption:

• Take itraconazole capsules with food to enhance absorption 2
• Avoid concomitant use of proton pump inhibitors, H2 blockers, phenytoin, or rifampicin as these significantly decrease itraconazole efficacy 2

Drugs to Avoid:

• Voriconazole should never be used for sporotrichosis due to inferior activity against Sporothrix schenckii 2
• Fluconazole and ketoconazole are inferior to itraconazole 2