Systemic candidiasis

January 2005     View PDF     En español

Treatment

Many drugs are used to treat candidiasis, and they come in two types: topical (active only where it’s applied) and systemic (active throughout the body). Choice of therapy depends on where the infection is and how severe the symptoms are. Topical treatment is the first choice for oral, vaginal or skin infections, and it generally works for mild-to-moderate cases. If topical drugs do not work, or if outbreaks occur often, systemic drugs may be needed. Systemic treatment is always used for esophageal or disseminated disease.

Topical therapy

Topical therapy includes mouth rinses or lozenges, vaginal tablets, suppositories and creams. Topical drugs include amphotericin B suspension (Fungizone), clotrimazole (Lotrimin), econazole (Spectazole), ketoconazole (Nizoral), miconazole (Monistat) or nystatin (Mycostatin).

Mouth rinses
Mouth rinses are less effective as they only have contact with the mouth for a short time. However, they may be the best choice for someone with a very sore or dry mouth. Rinses are held in the mouth for as long as possible and should be swilled around and then swallowed. They are used at least four times a day and continued for a few days after the symptoms have gone. The most widely used rinse is nystatin (Mycostatin Oral Suspension).

Lozenges
For oral symptoms, one or two lozenges or troches are taken 3–5 times a day. They should be sucked slowly and not chewed or swallowed whole. Common brands are clotrimazole (Mycelex) and nystatin (Mycostatin).

Creams and ointments
Creams and ointments are used for skin and nail infections. They can be used at the corners of the mouth or rubbed into affected areas of skin, including the labia. They should be applied 2–4 times a day by gentle and thorough massage. The length of therapy varies, but it often takes 10–20 days and should continue for a few days after the symptoms clear up.

Products include amphotericin B (Fungizone), clotrimazole (Lotrimin), clotrimazole plus a steroid (Lotrisone), miconazole (Monistat-Derm), clotrimazole (Mycelex), nystatin plus a steroid (Mycolog-II), nystatin (Mycostatin), ketoconazole (Nizoral) and econazole (Spectazole). Creams containing a steroid should not be used for children under 12. Some creams can be bought over the counter and as a prescription. Over-the-counter products are usually labeled for treating athlete’s foot or jock itch.

Vaginal suppositories
Vaginal suppositories or tablets are put into the vagina once only clotrimazole or once a day for three days miconazole. Common brands are GyneLotrimin and Mycelex-G (clotrimazole) and Monistat 3 (miconazole). A single oral dose of fluconazole (Diflucan) is increasingly used for treating vaginal candidiasis.

Systemic therapy

Systemic treatments are used for esophageal and disseminated candidiasis. They can also be used for other infections that recur often or do not clear up with topical treatment.

Ketoconazole
Ketoconazole (Nizoral) is taken at 200 or 400mg once a day. It needs acid to be absorbed, so it should be taken with food. Antacids should be avoided. It should also not be taken at the same time as other therapies that may contain a buffer or antacid, like didanosine (ddI, Videx). It may not be well absorbed in people with gut problems or who cannot eat very much. Taking it with an acidic drink like a cola may help.

Fluconazole
Fluconazole (Diflucan) is taken at 200mg the first day, then 100mg once a day thereafter. Treatment typically lasts two weeks for oral or skin candidiasis and three weeks for esophageal infection (or two weeks after symptoms clear up, whichever is longer). The dose may be increased to 400mg per day if the lower dose does not work.

Studies suggest that fluconazole is more effective than ketoconazole. Some doctors still prefer to treat aggressive fungal infections with other drugs, like ketaconazole, in order to save the potent fluconazole for later use, if necessary. Resistance to fluconazole is well documented. Once it develops, then treatment options are very limited.

Fungizone
Fungizone (amphotericin B) is given directly into a vein. It’s used to treat disseminated candidiasis when other systemic therapies fail or the infection is very aggressive. It is sometimes used with another drug, flucytosine, to treat specific fungal infections like cryptococcal infections.

This used to be the standard treatment for systemic or serious fungal infections. It lasted 8–12 weeks and often gave severe side effects, like kidney damage and anemia. People are now usually given amphotericin B until they start to improve (usually two weeks). They are then switched to fluconazole at 200–400mg per day.

Other forms of amphotericin B are used when systemic infections become resistant or less responsive to standard therapy. These include amphotericin B colloidal dispersion (ABCD, Amphotec) and amphotericin B lipid complex (ABLC, Abelcet). These might have fewer side effects than standard amphotericin B, but all of them can be quite toxic.

Itraconazole
Itraconazole (Sporanox) appears to be at least as potent as ketoconazole and may be as good as fluconazole. It needs stomach acid to be absorbed, so it should be taken with food. The dose is 200mg per day. If not enough drug is being absorbed, blood levels may need to be checked so the dose can be increased.

Itraconazole oral solution is more effective and puts higher levels of the drug in the blood than the capsule. There is a great potential for interactions between itraconazole and many anti-HIV drugs. For more information, read Drug Interactions.

Diagnosis

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