Mucocutaneous
candidiasis is frequently one of the first signs of human immunodeficiency virus (
HIV) infection. Over 90% of patients with
AIDS will develop oropharyngeal
candidiasis (OPC) at some time during their illness. Although numerous
antifungal agents are available,
azoles, both topical (
clotrimazole) and systemic (
fluconazole,
itraconazole,
voriconazole,
posaconazole) have replaced older topical antifungals (
gentian violet and
nystatin) in the management of oropharyngeal
candidiasis in these patients. The systemic
azoles, are generally safe and effective agents in HIV-infected patients with oropharyngeal
candidiasis. A constant concern in these patients is relapse, which is dependent on the degree of immunosuppression commonly seen after topical
therapy, rather than with systemic
azole therapy. Candida
esophagitis (CE) is also an important concern since it occurs in more than 10% of patients with
AIDS and can lead to a decrease in oral intake and associated
weight loss.
Fluconazole has become the most widely used antifungal in the management of mucosal
candidiasis. However,
itraconazole and
posaconazole have similar clinical response rates as
fluconazole and are also effective alternative agents. In patients with
fluconazole-refractory mucosal
candidiasis, treatment options now include
itraconazole solution,
voriconazole,
posaconazole, and the newer
echinocandins (
caspofungin,
micafungin, and
anidulafungin).