Chromoblastomycosis Treatment & Management

Updated: May 11, 2020
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Treatment

Approach Considerations

One of the most characteristic features of chromoblastomycosis is its refractoriness to treatment. Treatment options include oral itraconazole (as monotherapy or with oral 5-flucytosine [5-FC]), locally applied heat therapy, cryosurgery, photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) irradiation, and combination therapy. [67] Successful treatment of severe chromoblastomycosis with itraconazole and 5-FC association has been reported. [68] Therapeutic success is related to the causative agent, as well as the clinical form and severity of the chromoblastomycosis.

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Medical Care

Several authors indicate itraconazole as the best choice of therapy. [18, 69, 70] 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.

Overall results of the various treatments in one Mexican study were as follows: 31% of the conditions were cured, 57% improved, and 12% did not respond to treatment. Optimal results were obtained with cryosurgery for small lesions; itraconazole for large ones; and, in some cases, the combination of both. [71] Combination therapy with itraconazole and terbinafine during the early stages of treatment of chromoblastomycosis caused by F monophora has been suggested. [72]  Another report noted this combination can be effective. [73]

Although few studies have been published, the association of itraconazole and 5-FC is promising. [74] 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 [75] 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 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 [76] in 2005, posaconazole at 800 mg/d was associated with an overall success rate of 82% in persons with refractory chromoblastomycosis.

There is a case report of one application of topical imiquimod being beneficial. [77]

Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) irradiation may be adjunctive, in combination with antifungal medication. [78]  PDT can be combined with terbinafine. [79]  Positive clinical improvement was obtained when voriconazole at 200 mg was combined with terbinafine at 250 mg in treating one patient with refractory chromoblastomycosis. [80] Successful treatment using ALA-PDT has been described in a patient with leukopenia. [81]  

Heat therapy is another treatment. 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. [82]  It may take as long as 6 months or more. [83]

As there is no standard treatment and high rates of relapse, topical imiquimod has been used with substantial improvement documented both with and without concurrent oral antifungal therapy. [84]

Lymphedema and secondary infection or ulcerated lesions are common complications of chromoblastomycosis on the lower limbs. Physiotherapy and lymphatic drainage are useful in preventing lymphedema. Ulcers and secondary infection are dealt with by appropriate nursing care. Oral antibiotics may be used.

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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. Combination therapy with cryotherapy and terbinafine has been advocated. [85]  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. [86]

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. [87] Final treatment with surgical excision may be beneficial. [88]

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