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.