Medical Care

Disseminated infection should always be ruled out in patients with cutaneous cryptococcosis. CNS involvement is treated with intravenous amphotericin B combined with flucytosine, followed by oral fluconazole. In immunosuppressed patients, the initial treatments are similar; however, long-term maintenance therapy with fluconazole may be required. In immunocompromised patients with pulmonary infection, lumbar puncture should be performed to rule out meningitis. Patients with fungemia or dissemination (involvement of at least two noncontiguous sites or evidence of high fungal burden based on cryptococcal antigen titer ≥1:512) are treated as CNS disease. In immunocompetent patients, nondisseminated, non-CNS Cryptococcus infection can be treated with oral fluconazole for 3-6 months or with itraconazole for 6-12 months.

There have been no studies performed to evaluate the effectiveness of different treatment modalities for immunocompetent patients with primary cutaneous cryptococcosis. As per published case reports, fluconazole at a dose of 200-800 mg/day for a duration ranging from 2 weeks to 6 months or itraconazole at a dose of 100-400 mg/day for 3-6 months has been tried with good success rates. Success was achieved in 20 of 21 patients, with the only treatment failure reported with fluconazole at 400 mg/dat for 3 months.^[17]

Patients with acute, disseminated disease should be treated in an inpatient setting.

Also, see the following related clinical guidelines:

Surgical Care

Surgical excision or cryotherapy may play a role in primary cutaneous infections.^[9]

Consultations

Consultation with an infectious disease specialist should be obtained for all patients to evaluate for disseminated disease. As warranted, consultations should be obtained from a pulmonologist or neurologist, among others, depending on the extent of disease involvement.

Prevention

Avoidance of areas that may be contaminated by pigeon droppings, especially for immunosuppressed persons, can reduce the likelihood of infection. Early detection of HIV and the initiation of antiretroviral therapy to prevent severe immunodeficiency remains the most effective intervention to decrease the burden of cryptococcal infection.

Medication

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Media Gallery

Umbilicated papule of cutaneous Cryptococcus infection on the face of a male.

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Author

Aziz Khan, MD, MBBS Assistant Professor of Medicine, Department of Internal Medicine, University of Connecticut School of Medicine

Aziz Khan, MD, MBBS is a member of the following medical societies: American College of Physicians, Pakistan Medical and Dental Council

Disclosure: Nothing to disclose.

Coauthor(s)

Jun Lu, MD, FAAD Associate Professor, Director of Clinical Trial Unit, Director of Connective Tissue Disease Multispecialty Clinic, Farmington Site Director of Dermatology Residency Program, Department of Dermatology, University of Connecticut Health Center

Jun Lu, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Telemedicine Association, Connecticut Society of Dermatology and Dermatologic Surgery, New England Dermatological Society, Rheumatologic Dermatology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Noah S Scheinfeld, JD, MD, FAAD † Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

David G Moskowitz, MD Associate Physician, Department of Dermatology, Kaiser Permanente in Oakland, California

David G Moskowitz, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology

Disclosure: Nothing to disclose.

Cutaneous Cryptococcus Treatment & Management

Medical Care

Surgical Care

Consultations

Prevention

References

Tables

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