Practice guidelines for the management of patients with sporotrichosis

The recommendations for the treatment of sporotrichosis were derived primarily from multicenter, nonrandomized treatment trials, small retrospective series, and case reports; no randomized, comparative treatment trials have been reported. Most cases of sporotrichosis are non-life-threatening localized infections of the skin and subcutaneous tissues that can be treated with oral antifungal agents. The treatment of choice for fixed cutaneous or lymphocutaneous sporotrichosis is itraconazole for 3-6 months. The preferred treatment for osteoarticular sporotrichosis also is itraconazole, but therapy must be continued for at least 12 months. Pulmonary sporotrichosis responds poorly to treatment. Severe infection requires treatment with amphotericin B; mild to moderate infection can be treated with itraconazole. Meningeal and disseminated forms of sporotrichosis are rare and usually require treatment with amphotericin B. AIDS patients most often have disseminated infection and require life-long suppressive therapy with itraconazole after initial use of amphotericin B. Overview. Sporotrichosis is caused by the dimorphic fungus Sporothrix schenckii, which is found throughout the world in decaying vegetation, sphagnum moss, and soil [1]. The usual mode of infection is by cutaneous inoculation of the organism. Pulmonary and disseminated forms of infection, although uncommon, can occur when S. schenckii conidia are inhaled. Infections are most often sporadic and usually associated with trauma during the course of outdoor work. Infection can also be related to zoonotic spread from infected cats or scratches from digging animals, such as armadillos [2, 3]. Outbreaks have been well-described and often are traced back to activities that involved contaminated sphagnum moss, hay, or wood [4-7]. Most cases of sporotrichosis are localized to the skin and subcutaneous tissues. Dissemination to osteoarticular structures and viscera is uncommon and appears to occur more often in patients who have a history of alcohol abuse or immunosuppression, especially AIDS. Spontaneous resolution of sporotrichosis is rare, and treatment is required for most patients. Although sporotrichosis localized to skin and subcutaneous tissues is readily treated, management of osteoarticular, other localized visceral, and disseminated forms of sporotrichosis is difficult [8]. Objective. The objective of these guidelines is to provide recommendations for the treatment of various forms of sporotrichosis. Outcomes. The desired outcomes of treatment include eradication of S. schenckii from tissues, resolution of symptoms and signs of active infection, and return of function of involved organs. In persons with AIDS, eradication of the organism may not be possible, but clinical resolution should be attained and subsequently maintained with suppressive antifungal therapy. Evidence. The English-language literature on the treatment of sporotrichosis was reviewed. Although randomized, blinded, controlled treatment trials were sought, none were found to have been performed for the treatment of sporotrichosis. Therefore, most weight was placed on those reports that were derived from multicenter trials of specific treatment modalities for sporotrichosis. Small series from a single institution and individual case reports were accorded less importance. Values. The highest value was placed on clinical efficacy and the ability of the antifungal regimen to eradicate the organism, but safety, tolerability, and cost of therapy were also valued. Benefits and costs. The benefits of successfully treating sporotrichosis accrue primarily for the patient. Because this infection is not spread from person-to-person, public health aspects of treatment are of minor importance. Most forms of sporotrichosis are not life-threatening; thus, therapy is aimed at decreasing morbidity, improving quality of life, and allowing the patient to return to occupational and familial pursuits. Treatment options. Treatment options for sporotrichosis include local measures (hyperthermia), saturated solution of potassium iodide (SSKI), azoles (ketoconazole, itraconazole, and fluconazole), polyenes (amphotericin B), and allylamines (terbinafine). SSKI and amphotericin B clearly are effective, but these agents have not been subjected to specific treatment trials. The studies that have been reported included triazole agents. Two trials showed a 100% response rate, and another study showed a 90% response rate for lymphocutaneous infection treated with itraconazole [9-11] compared with a 71% response rate for treatment with fluconazole [12]. For osteoarticular disease, the response is modest with itraconazole and poor with fluconazole. Sharkey-Mathis et al. [9] reported a 73% rate of response to itraconazole, although 4 of 11 patients later relapsed and required further therapy. Winn et al. [13] described 6 patients with osteoarticular sporotrichosis, all of whom responded to itraconazole. The rate of response to fluconazole was poor; only 3 of 13 patients with osteoarticular infection responded favorably [12]. Too few patients with other forms of sporotrichosis have been studied to establish response rates, but it appears that itraconazole is superior to other azoles [8].