What is the recommended oral fluconazole pulse (intermittent) dosing regimen for recurrent or chronic candidal intertrigo in healthy adults, immunocompromised patients (e.g., diabetes, HIV with CD4+ count <150 cells/µL, chronic steroid use), children older than 3 months, patients with impaired renal function, and pregnant women?

Oral Fluconazole Pulse Therapy for Candidal Intertrigo

For recurrent or chronic candidal intertrigo in healthy adults, fluconazole 100 mg three times weekly is the recommended pulse dosing regimen based on extrapolation from chronic suppressive therapy guidelines for mucocutaneous candidiasis. 1

Healthy Adults

• Pulse dosing: Fluconazole 100 mg orally three times weekly (e.g., Monday-Wednesday-Friday) is the standard intermittent regimen for chronic suppression of recurrent mucocutaneous candidal infections. 1
• This regimen is supported by strong recommendation with high-quality evidence from the IDSA 2016 guidelines for chronic suppressive therapy in patients with recurrent mucocutaneous candidiasis. 1
• Acute treatment first: Before initiating pulse therapy, treat the active infection with fluconazole 100–200 mg daily for 7–14 days to achieve clinical remission. 1
• Adjunctive measures are essential: Keeping affected skin folds dry and using topical barrier creams or powders must accompany systemic therapy; fluconazole alone without moisture control will fail. 1

Immunocompromised Patients

Diabetes Mellitus

• Use the same pulse regimen: fluconazole 100 mg three times weekly after initial treatment with 100–200 mg daily for 7–14 days. 1, 2
• Glycemic control is paramount: Optimizing diabetes management is the most effective preventive measure and should be addressed concurrently with antifungal therapy. 2
• Diabetic patients may require higher acute treatment doses (200 mg daily) or longer duration (up to 14 days) due to impaired immune response. 2

HIV-Infected Patients (CD4+ <150 cells/µL)

• Same pulse regimen: Fluconazole 100 mg three times weekly is recommended for chronic suppression. 1
• Antiretroviral therapy is critical: Optimizing ART is strongly recommended to reduce recurrence incidence and is more effective than antifungal prophylaxis alone. 1
• In severely immunocompromised patients (CD4+ <50 cells/µL), consider continuous daily therapy (100 mg daily) rather than pulse dosing if recurrences are frequent despite intermittent therapy. 1, 3
• Resistance monitoring: HIV patients on chronic fluconazole are at higher risk for developing azole-resistant Candida species (especially C. glabrata); however, clinical response usually remains adequate even with elevated MICs. 1, 3

Chronic Steroid Use

• Apply the standard pulse regimen: fluconazole 100 mg three times weekly. 1
• These patients may require longer acute treatment courses (14 days rather than 7 days) before transitioning to pulse therapy. 1

Pediatric Patients (>3 Months)

• Weight-based dosing: For chronic suppressive pulse therapy, use fluconazole 3 mg/kg three times weekly (maximum 100 mg per dose). 1
• Acute treatment first: Treat active infection with fluconazole 3–6 mg/kg daily for 7–14 days before initiating pulse therapy. 1
• Safety data for long-term pulse therapy in children are limited; reserve this approach for truly recurrent cases that significantly impair quality of life. 1

Renal Impairment

• Creatinine clearance >50 mL/min: No dose adjustment needed; use standard pulse regimen of 100 mg three times weekly. 4
• Creatinine clearance 20–50 mL/min: Reduce pulse dose to 50 mg three times weekly, as fluconazole elimination half-life is prolonged. 4
• Creatinine clearance <20 mL/min: Use 50 mg twice weekly (e.g., Monday-Thursday), as the elimination half-life is approximately three times normal. 4
• Hemodialysis patients: Administer 100 mg after each dialysis session (typically three times weekly), since approximately 38% of fluconazole is removed during a 3-hour dialysis session. 4

Pregnancy

• Fluconazole is contraindicated for chronic or pulse therapy during pregnancy. High-dose or prolonged fluconazole exposure (>150 mg or >7 days) has been associated with congenital abnormalities. 1
• Alternative approach: Use topical azoles (clotrimazole, miconazole) combined with aggressive moisture control and barrier protection for recurrent candidal intertrigo during pregnancy. 1
• If systemic therapy is absolutely necessary for severe disease, limit to short courses (≤7 days) of fluconazole 100 mg daily only after careful risk-benefit discussion. 1

Important Clinical Considerations

• Duration of pulse therapy: Continue three-times-weekly dosing for a minimum of 3–6 months; some patients may require indefinite suppression if recurrences are frequent and disabling. 1, 5
• Monitoring for resistance: The rate of developing fluconazole resistance is similar between continuous daily therapy and intermittent pulse therapy (approximately 46–56%), but clinical response usually remains adequate. 1, 3
• When to discontinue: Attempt to stop pulse therapy after 6–12 months if the patient has had no recurrences and underlying risk factors (obesity, diabetes, immunosuppression) have been optimized. 5
• Hepatotoxicity risk: For therapy extending beyond 21 days, obtain baseline and periodic liver function tests, as azoles can cause hepatotoxicity with prolonged use. 6