Chromoblastomycosis Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 16, 2012
 

Medical Care

One of the most characteristic features of chromoblastomycosis is its refractoriness to treatment. Treatment options include oral itraconazole (as monotherapy or with oral flucytosine [5-FC]), locally applied heat therapy, cryosurgery, and combination therapy.[51] Successful treatment of severe chromoblastomycosis with itraconazole and 5-flucytosine association has been reported.[52] Therapeutic success is related to the causative agent, as well as the clinical form and severity of the chromoblastomycosis.

Several authors indicate itraconazole as the best choice of therapy.[18, 53, 54] Daily doses range from 200-400 mg, and results vary greatly. Adverse effects are not common, but efficacy is not as high as one would desire. Severe cases should be treated for several years. The authors' experience in treating more than 25 patients with varying degrees of severity for as long as 5 years shows that itraconazole produces dramatic improvement after a few months of therapy; however, a complete cure is rarely reached, especially in severe cases. These results might be because of the predominantly fungistatic mechanism of action of the drug. In numerous cases, drug withdrawal led to relapse.

Although few studies have been published, the association of itraconazole and 5-FC is promising.[55] As with 5-FC and amphotericin B, itraconazole and 5-FC produce a synergistic effect. Multidrug therapy for chromoblastomycosis seems to be an interesting approach and may also be used with cryosurgery.

In 1996, Esterre et al[56] presented interesting results when using terbinafine to treat more than 100 patients in Madagascar. Similar to that of itraconazole, the drug presented below optimal results, it is exceedingly expensive, and treatment lasts several months. To date, no reports on the association of terbinafine and itraconazole or terbinafine and 5-FC have appeared in the literature.

Posaconazole (Noxafil), a new triazole derivative, has been experimentally used to treat chromoblastomycosis. Posaconazole has recently received approval from the US Food and Drug Administration for prophylaxis against invasive Aspergillus and Candida infections in patients at high risk because of severe immunosuppression. The results of isolated cases suggest that outcomes may be slightly superior to those obtained by itraconazole or terbinafine (Unpublished data on file, Dr. Shikanai-Yasuda, Department of Infectious Diseases, Univ. São Paulo). According to Keating[57] in 2005, posaconazole at 800 mg/d was associated with an overall success rate of 82% in persons with refractory chromoblastomycosis.

Heat therapy is another treatment. Especially in Japan, the use of pocket warmers has proven successful in the treatment of a limited number of cases. Apparently, an increase in skin temperature somehow impairs fungal development.[58]

Next

Surgical Care

Cryosurgery with liquid nitrogen can be used to treat chromoblastomycosis, especially localized lesions. Several reports have appeared in the literature showing that the method has been used on almost every continent with good results.

Freezing time in one study varied from 30 seconds to 4 minutes, and the number of cycles varied from 1 to more than 40. All localized lesions responded extremely well to treatment, with no relapse for as long as 15 years, a follow-up period unparalleled in the literature. Three patients with generalized lesions attained clinical and mycologic remission for as long as 26 months, and 3 had significant improvement without cure.[59]

Multiple treatment modalities are often combined, such as long courses of antifungals, surgical excision, and destructive physical therapies, because chromoblastomycosis is one of the most difficult deep mycotic infections to eradicate.[60] Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) irradiation may be adjunctive in combination with antifungal medication.[61, 62]

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Eugeniusz Baran, MD, PhD  Professor, Department of Dermatology, Venereology and Allergology, Head, Clinic of Dermatology and Venereology, Wroclaw Medical University, Poland

Eugeniusz Baran, MD, PhD is a member of the following medical societies: European Confederation of Medical Mycology and International Society for Human and Animal Mycology

Disclosure: Nothing to disclose.

Specialty Editor Board

Alexa F Boer Kimball, MD, MPH  Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital

Alexa F Boer Kimball, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Celgene Honoraria Safety Monitoring Committee

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Luiz Guilherme M Castro, MD, to the development and writing of this article.

References

  1. Rubin HA, Bruce S, Rosen T, McBride ME. Evidence for percutaneous inoculation as the mode of transmission for chromoblastomycosis. J Am Acad Dermatol. Nov 1991;25(5 Pt 2):951-4. [Medline].

  2. Castro LG, Pimentel ER, Lacaz CS. Treatment of chromomycosis by cryosurgery with liquid nitrogen: 15 years' experience. Int J Dermatol. May 2003;42(5):408-12. [Medline].

  3. McGinnis MR. Chromoblastomycosis and phaeohyphomycosis: new concepts, diagnosis, and mycology. J Am Acad Dermatol. Jan 1983;8(1):1-16. [Medline].

  4. Medlar EM. A cutaneous infection caused by a new fungus Phialophora verrucosa with a study of the fungus. J Med Res. 1915;32:507-22.

  5. Odds FC, Arai T, Disalvo AF, et al. Nomenclature of fungal diseases: a report and recommendations from a Sub-Committee of the International Society for Human and Animal Mycology (ISHAM). J Med Vet Mycol. 1992;30(1):1-10. [Medline].

  6. Terra F, Torres M, Fonseca Filho O. Novo tipo de dermatite verrucosa; micose por Acrotheca com associado de leishmaniose. Brasil Medico. 1922;36:363-8.

  7. Lane CG. A cutaneous disease caused by a new fungus Phialophora verrucosa. J Cutan Dis. 1915;33:840-6.

  8. Castro RM, Castro LG. On the priority of description of chromomycosis. Mykosen. Sep 1987;30(9):397-403. [Medline].

  9. Hoffman WH. Die Chromoblastomykose in Kuba. Arch Schiffs u Tropen Hyg. 1928;32:485-7.

  10. Pedroso A, Gomes JM. 4 casos de dermatite verrucosa produzida pela Phialophora verrucosa. Ann Paulistas de Medicina e Cirurgia. 1920;11:53-61.

  11. Brumpt E. Prés de Parasitologie. 3rd ed. Paris, France: Masson; 1922:1105.

  12. Negroni R. Estudio del primer caso argentino de cromomicosis, Fonsecaea (Negroni) pedrosoi (Brumpt) 1921. Rev Inst Bacteriol. 1936;7:419-26.

  13. Rippon JW. Chromoblastomycosis and related dermal infections caused by dematiaceous fungi. In: Medical Mycology. The Pathogenic Fungi and the Pathogenic Actinomycetes. 2nd ed. Philadelphia, Pa: WB Saunders; 1982:249-76.

  14. Lacaz CS, Porto E, Martins JEC. Fungos, actinomicetos e algas de interesse medico. In: Micologia Medica. 8th ed. Sao Paulo, Brazil: Sarvier; 1991:373-86.

  15. South DA, Brass C, Stevens DA. Chromohyphomycosis. Treatment wit ketoconazole. Arch Dermatol. May 1981;117(5):311-2. [Medline].

  16. Naka W, Harada T, Nishikawa T, Fukushiro R. A case of chromoblastomycosis: with special reference to the mycology of the isolated Exophiala jeanselmei. Mykosen. Oct 1986;29(10):445-52. [Medline].

  17. Barba-Gomez JF, Mayorga J, McGinnis MR, Gonzalez-Mendoza A. Chromoblastomycosis caused by Exophiala spinifera. J Am Acad Dermatol. Feb 1992;26(2 Pt 2):367-70. [Medline].

  18. Queiroz-Telles F, Purim KS, Fillus JN, et al. Itraconazole in the treatment of chromoblastomycosis due to Fonsecaea pedrosoi. Int J Dermatol. Nov 1992;31(11):805-12. [Medline].

  19. Padhye AA, Hampton AA, Hampton MT, Hutton NW, Prevost-Smith E, Davis MS. Chromoblastomycosis caused by Exophiala spinifera. Clin Infect Dis. Feb 1996;22(2):331-5. [Medline].

  20. Piepenbring M, Caceres Mendez OA, Espino Espinoza AA, Kirschner R, Schofer H. Chromoblastomycosis caused by Chaetomium funicola: a case report from Western Panama. Br J Dermatol. Nov 2007;157(5):1025-9. [Medline].

  21. Conant NF. The occurrence of a human pathogenic fungus as a saprophyte in nature. Mycologia. 1937;29:597-8.

  22. Zeppenfeldt G, Richard-Yegres N, Yegres F. Cladosporium carrionii: hongo dimorfico en cactaceas de la zona endemica para la cromomicosis en Venezuela. Rev Iberoam Micol. 1994;11:61-3.

  23. Najafzadeh MJ, Sun J, Vicente V, Xi L, van den Ende AH, de Hoog GS. Fonsecaea nubica sp. nov, a new agent of human chromoblastomycosis revealed using molecular data. Med Mycol. Mar 22 2010;[Medline].

  24. Badali H, Bonifaz A, Barrón-Tapia T, Vázquez-González D, Estrada-Aguilar L, Cavalcante Oliveira NM, et al. Rhinocladiella aquaspersa, proven agent of verrucous skin infection and a novel type of chromoblastomycosis. Med Mycol. Jan 29 2010;[Medline].

  25. Brygoo ER, Destombes P. Epidemiologie de la chromoblastomycose humaine. Bull Inst Pasteur. 1975;74:219-43.

  26. Nishimoto K. Chromomycosis in Japan. Ann Soc Belg Med Trop. Sep 1981;61(3):405-12. [Medline].

  27. Berger L, Langeron M. Sur un type noveau de chromomycose observé au Canada (Torula bergeri n. sp). Ann Parasit Hum Comp. 1949;24:574-99.

  28. Putkonen T. [Chromomycosis in Finland. The possible role of the Finnish sauna in its spreading]. Hautarzt. Nov 1966;17(11):507-9. [Medline].

  29. Sonck CE. Chromomycosis in Finland. Dermatology. 1975;19:189-93.

  30. Pradhan SV, Talwar OP, Ghosh A, Swami RM, Shiva Raj KC, Gupta S. Chromoblastomycosis in Nepal: a study of 13 cases. Indian J Dermatol Venereol Leprol. May-Jun 2007;73(3):176-8. [Medline].

  31. Xi L, Sun J, Lu C, et al. Molecular diversity of Fonsecaea (Chaetothyriales) causing chromoblastomycosis in southern China. Med Mycol. Feb 2009;47(1):27-33. [Medline].

  32. Salgado CG, da Silva MB, Yamano SS, Salgado UI, Diniz JA, da Silva JP. Cutaneous localized annular chromoblastomycosis. J Cutan Pathol. Feb 2009;36(2):257-61. [Medline].

  33. El Euch D, Mokni M, Haouet S, Trojjet S, Zitouna M, Ben Osman A. [Erythemato-squamous papular and atrophic plaque on abdomen: chromoblastomycosis due to Fonsecaea pedrosoi]. Med Trop (Mars). Feb 2010;70(1):81-3. [Medline].

  34. Sharma NL, Sharma VC, Mahajan V, Shanker V, Sarin S. Chromoblastomycosis with underlying osteolytic lesion. Mycoses. Nov 2007;50(6):517-9. [Medline].

  35. França K, Villa RT, de Azevedo Bastos VR, Almeida AC, Massucatti K, Fukumaru D, et al. Auricular Chromoblastomycosis: A Case Report and Review of Published Literature. Mycopathologia. Feb 17 2011;[Medline].

  36. Sharma A, Hazarika NK, Gupta D. Chromoblastomycosis in Sub-Tropical Regions of India. Mycopathologia. Jan 22 2010;[Medline].

  37. Naveen KN, Naik AS, Shetty PC, Pai VV, Hanumanthayya K, Udupishastry D. Chromoblastomycosis presenting as a phagedenic ulcer on the face. Int J Dermatol. Sep 19 2011;[Medline].

  38. Silva CM, da Rocha RM, Moreno JS, et al. [The coconut babaçu (Orbignya phalerata martins) as a probable risk of human infection by the agent of chromoblastomycosis in the State of Maranhão, Brazil]. Rev Soc Bras Med Trop. Jan-Mar 1995;28(1):49-52. [Medline].

  39. Salgado CG, da Silva JP, Diniz JA, et al. Isolation of Fonsecaea pedrosoi from thorns of Mimosa pudica, a probable natural source of chromoblastomycosis. Rev Inst Med Trop Sao Paulo. Jan-Feb 2004;46(1):33-6. [Medline].

  40. Martinez EC, Rey Valeiron C, Yegres F, Reyes R. [The goat: approach to an animal model in human chromomycosis]. Invest Clin. Jun 2005;46(2):131-8. [Medline].

  41. Tsuneto LT, Arce-Gomez B, Petzl-Erler ML, Queiroz-Telles F. HLA-A29 and genetic susceptibility to chromoblastomycosis. J Med Vet Mycol. 1989;27(3):181-5. [Medline].

  42. Campolina SS, Caligiorne RB, Rezende-Silva S, Hahn RC, De Hoog GS. A skin infection mimicking chromoblastomycosis by a Capnodialean fungus. Med Mycol. Feb 2009;47(1):81-5. [Medline].

  43. Miranda MF, Silva AJ. Vinyl adhesive tape also effective for direct microscopy diagnosis of chromomycosis, lobomycosis, and paracoccidioidomycosis. Diagn Microbiol Infect Dis. May 2005;52(1):39-43. [Medline].

  44. Vidal MS. Estudo imunoquimco de um antigeno de Fonsecaea pedrosoi e padronizao de teiicas sorologicas para cromoblastomicose causada por este fungo [dissertation/master's thesis]. Sao Paulo, Brazil: University of Sao Paulo; 2002.

  45. Oberto-Perdigon L, Romero H, Perez-Blanco M, Apitz-Castro R. [An ELISA test for the study of the therapeutic evolution of chromoblastomycosis by Cladophialophora carrionii in the endemic area of Falcon State, Venezuela]. Rev Iberoam Micol. Mar 2005;22(1):39-43. [Medline].

  46. de Andrade TS, Cury AE, de Castro LG, Hirata MH, Hirata RD. Rapid identification of Fonsecaea by duplex polymerase chain reaction in isolates from patients with chromoblastomycosis. Diagn Microbiol Infect Dis. Mar 2007;57(3):267-72. [Medline].

  47. Najafzadeh MJ, Sun J, Vicente VA, de Hoog GS. Rapid identification of fungal pathogens by rolling circle amplification using Fonsecaea as a model. Mycoses. Sep 2011;54(5):e577-82. [Medline].

  48. Ogawa MM. Cromoblastomicose: Teraplicas e alternativos linfocintilograpicas. Sao Paulo, Brazil: Tese de Mestrado, Escola Paulista de Medicina; 2001.

  49. Salfelder K, de Liscano TR, Sauerteig E. Atlas of Fungal Pathology. Kluwer/Dordrecht; 1990:145-50.

  50. Jawitz RS, Calder KB, Turner LM, Schlauder S, Morgan MB. Cryptic "chromo-fibroma". Am J Dermatopathol. Dec 2007;29(6):573-5. [Medline].

  51. Queiroz-Telles F, Esterre P, Perez-Blanco M, Vitale RG, Salgado CG, Bonifaz A. Chromoblastomycosis: an overview of clinical manifestations, diagnosis and treatment. Med Mycol. Feb 2009;47(1):3-15. [Medline].

  52. Antonello VS, Silva MC, Cambruzzi E, Kliemann DA, Santos BR, Queiroz-Telles F. Treatment of severe chromoblastomycosis with itraconazole and 5-flucytosine association. Rev Inst Med Trop Sao Paulo. Dec 2010;52(6):329-31. [Medline].

  53. Restrepo A, Gonzalez A, Gomez I, Arango M, de Bedout C. Treatment of chromoblastomycosis with itraconazole. Ann N Y Acad Sci. 1988;544:504-16. [Medline].

  54. Graybill JR. Future directions of antifungal chemotherapy. Clin Infect Dis. Mar 1992;14 Suppl 1:S170-81. [Medline].

  55. Pradinaud R, Bolzinger T. Treatment of chromoblastomycosis. J Am Acad Dermatol. Nov 1991;25(5 Pt 1):869-70. [Medline].

  56. Esterre P, Inzan CK, Ramarcel ER, et al. Treatment of chromomycosis with terbinafine: preliminary results of an open pilot study. Br J Dermatol. Jun 1996;134 Suppl 46:33-6; discussion 40. [Medline].

  57. Keating GM. Posaconazole. Drugs. 2005;65(11):1553-67; discussion 1568-9. [Medline].

  58. Kinbara T, Fukushiro R, Eryu Y. Chromomycosis--report of two cases successfully treated with local heat therapy. Mykosen. Dec 1982;25(12):689-94. [Medline].

  59. Pimentel ER, Castro LG, Cuce LC, Sampaio SA. Treatment of chromomycosis by cryosurgery with liquid nitrogen: a report on eleven cases. J Dermatol Surg Oncol. Jan 1989;15(1):72-7. [Medline].

  60. Ameen M. Managing chromoblastomycosis. Trop Doct. Apr 2010;40(2):65-7. [Medline].

  61. Lyon JP, Pedroso e Silva Azevedo Cde M, Moreira LM, de Lima CJ, de Resende MA. Photodynamic antifungal therapy against chromoblastomycosis. Mycopathologia. Oct 2011;172(4):293-7. [Medline].

  62. Yang Y, Hu Y, Zhang J, Li X, Lu C, Liang Y, et al. A refractory case of chromoblastomycosis due to Fonsecaea monophora with improvement by photodynamic therapy. Med Mycol. Feb 7 2012;[Medline].

  63. Bonifaz A, Carrasco-Gerard E, Saul A. Chromoblastomycosis: clinical and mycologic experience of 51 cases. Mycoses. 2001;44(1-2):1-7. [Medline].

  64. Zhang J, Xi L, Lu C, et al. Successful treatment for chromoblastomycosis caused by Fonsecaea monophora: a report of three cases in Guangdong, China. Mycoses. Mar 2009;52(2):176-81. [Medline].

  65. Tagami H, Ginoza M, Imaizumi S, Urano-Suehisa S. Successful treatment of chromoblastomycosis with topical heat therapy. J Am Acad Dermatol. Apr 1984;10(4):615-9. [Medline].

  66. Slesak G, Inthalad S, Strobel M, Marschal M, Hall M Jr, Newton PN. Chromoblastomycosis after a leech bite complicated by myiasis: a case report. BMC Infect Dis. Jan 12 2011;11:14. [Medline]. [Full Text].

  67. Mouchalouat Mde F, Gutierrez Galhardo MC, Zancopé-Oliveira RM, Monteiro Fialho PC, de Oliveira Coelho JM, Silva Tavares PM, et al. Chromoblastomycosis: a clinical and molecular study of 18 cases in Rio de Janeiro, Brazil. Int J Dermatol. Aug 2011;50(8):981-6. [Medline].

 
Previous
Next
 
Sclerotic cells on a potassium hydroxide preparation.
Micromorphology of Cladosporium carrionii (left) and Fonsecaea pedrosoi (right), the 2 most commonly isolated agents in chromoblastomycosis.
Chromoblastomycosis, tumoral form. Chronic disease led to elephantiasis and involvement of the entire lower limb.
Plaque lesion on the foot. The verrucous aspect of the lesion differentiates it from other infectious dermatoses that may present as a verrucous lesion, namely, cutaneous leishmaniasis, sporotrichosis, cutaneous tuberculosis, and cutaneous mycobacteriosis.
Culture of Fonsecaea pedrosoi on Sabouraud agar. The black velvety colony has the same macroscopic appearance as the colonies of other chromoblastomycosis-causing agents (eg, Cladosporium carrionii, Fonsecaea compacta, Phialophora verrucosa, Rhinocladiella aquaspersa, Exophiala species).
Hematoxylin and eosin–stained section shows typical sclerotic cells inside an abscess. Sclerotic cells present as round, thick-walled, cigar-colored structures.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.