Management of common superficial fungal infections in patients with AIDS

Cutaneous fungal infections are a major source of morbidity in HIV-infected patients, and their management poses special challenges. Superficial mycoses, such as tinea pedis, tinea cruris, tinea corporis, and onychomycosis, are no more common in HIV-infected patients than in the HIV-negative population but are of greater severity. Although they respond to topical and systemic antifungal agents, HIV-positive patients are predisposed to frequent recurrences. Unusual types of fungal infections such as Majocchi's granuloma are more likely to develop in HIV-infected patients and respond best to systemic antifungal therapy with imidazoles or triazoles. Infections with Candida albicans develop in virtually all HIV-positive patients. Although mucosal involvement is the most common, patients may also develop superficial cutaneous infections. Topical agents are frequently all that is necessary, but in some, oral medications are required. Although fluconazole is effective, an appreciable number of isolates are resistant. Patients with pityriasis versicolor and seborrheic dermatitis, in which Pityrosporum species are thought to be involved, respond well to short courses of oral ketoconazole. Milder forms of seborrheic dermatitis can also be treated with low-potency topical steroids or topical ketoconazole. The oral triazole fluconazole is not particularly effective in the management of seborrheic dermatitis. Although the cause of eosinophilic pustular folliculitis, a common disorder in immunosuppressed HIV-positive patients, is unknown, some can be cured with high doses of itraconazole, suggesting that fungi are important in the pathogenesis of the disease in some patients.