Posaconazole for the management of mucosal candidiasis

Mucocutaneous candidiasis (MC) is one of the first signs of HIV infection. In the pre-highly active antiretroviral therapy (HAART) era, more than 90% of patients with HIV infection eventually developed some form of oral candidiasis during their illness, and an additional 10% developed esophageal candidiasis (EC). Although several antifungal agents are available, systemic azoles (e.g., fluconazole and itraconazole) have replaced older topical antifungals (e.g., gentian violet and nystatin) in the management of MC in these patients. Overall, the azoles are safe and effective agents in HIV-infected patients with MC. However, clinical relapses are extremely common in HIV patients not on HAART or who are noncompliant. The relapses are dependent on the degree of immunosuppression and are more common following treatment with clotrimazole or ketoconazole than with fluconazole or itraconazole. Posaconazole is a new extended-spectrum triazole recently approved for the management of oropharyngeal candidiasis (OPC). In vitro, posaconazole possesses potent activity against Candida species, including strains that are resistant to fluconazole. Recent clinical trials demonstrate that posaconazole is as efficacious as fluconazole in producing a successful clinical response in HIV-infected patients with OPC/EC. In addition, posaconazole has been demonstrated to be well tolerated and more effective in sustaining clinical success after treatment was discontinued. Posaconazole appears to be an effective alternative in the management of MC in these difficult-to-treat infections.