Chromomycosis: Treatment, Cost and Side Effects

A unique host-parasite relationship produces a wide spectrum of clinical diseases, sometimes difficult to treat and one such disease is Chromomycosis. Chromomycosis (also known as Chromoblastomycosis), is a chronic fungal infection of the skin and the subcutaneous tissues (a chronic subcutaneous mycosis) caused by traumatic inoculation of a specific group of fungi, usually Fonsecaea pedrosoi or Fonsecaea compacta. Usually found in sub-tropical regions. There are four major recognised categories- Superficial Chromomycosis, Chromoblastomycosis, Chromohyphomycosis and Chromomycetoma. This results in the formation of slow-growing, warty plaques, cauliflower-like lesions which may ulcerate. Chromohyphomycosis characterised by skin nodules occurs very rarely, Subcutaneous abscesses also called phaeomycotic cysts, are more frequent especially after corticoid and immunosuppressive therapy. Treating this infection is painful and prolonged along with many side effects. Initially presents as white or grey to tan to black nodules.

It is rare that this infection resolves itself, leaving behind a scar. This is treated using antifungal oral medications or surgical methods. It can be a combination of itraconazole, posaconazole or voriconazole (a triazole to treat fungal infection) and terbinafine (which is an oral medication or can be applied directly on the skin as a cream or ointment). Local heat, cryotherapy (using a cold substance to destroy superficial skin lesions, using liquid nitrogen, for example), flucytosine (an antifungal medication, available in form of capsules) and surgery to remove the infected skin. Though most of these treatment options are difficult and prolonged.

Chromomycosis has a very low cure rate and a high relapse rate. The antifungal oral treatment, that is itraconazole, terbinafine and flucytosine range from 200mg daily, 250mg daily and 50 to 150mg per kg per day respectively in 4 doses. In extreme cases, intravenous amphotericin B up to 1mg per kg every day is administered. The lesions can be removed surgically, although there is a high risk of the infection spreading. Application of local heat also helps to reduce the size of the lesion as well as cryotherapy once a month, when used with thiabendazole, has a promising result. Although, it is important to note that these therapies can only be done if the lesions are small. For severe to moderate forms of Chromomycosis, combination therapy is recommended. Cream, ointments, gels or sprays with terbinafine is applied on the affected area twice a day for about one to four weeks. Terbinafine emits a fungal enzyme and stops the cells from making ergosterol, the main component of the cell wall.

Depending upon the severity of the infection, different treatment plans are recommended. The treatment is started right when the infection is diagnosed, be it any stage. Different stages have different treatment methods. The complications are a significant factor affecting the treatment. The aetiological agent, size, location and the extent of the infection contribute to the selection of the treatment. In patients diagnosed with small and early lesions, the main aim of the treatment is a complete cure. In the case of an extensive lesion, there is no complete cure and the only aim is to reduce, control and prevent further complications. Cryosurgery for small lesions, itraconazole treatment for extensive lesion and a combination of both methods. Mild and moderate forms may be successfully cured in 6 to 12 months. Severe forms show significant improvement after several months of therapy, a long-term cure is rarely observed. Although, after the termination of the treatment, relapses have commonly occurred.

There are no inadmissible patients as such, everybody can get a treatment. Patients affected with extensive lesions cannot be cured completely, although they can be treated with extensive therapies as mentioned previously. Patients with small lesions are often cured. Relapses are very common in these treatments. All these treatments do have a few side effects.

All these treatments do have few effects like nausea and vomiting, headache, dizziness, constipation, enlargement of breasts in male, abnormal liver function tests, allergic skin rash, congestive heart failure (due to the itraconazole), stomach pain, indigestion, diarrhoea, water retention in arms and legs, blurred vision or increased eyes sensitivity to light, soreness at injection site (due to voriconazole), feeling of fullness, abdominal pain, painful muscles and joints, taste disturbance, loss of appetite, liver disease (although very rare), allergic skin rash (due to terbinafine). Most of these are very uncommon but when occurred is deadly. Also, heart patients have to be treated very carefully, as there are increased risks.

There are no post-treatment guidelines mentioned. Relapses in this disease are very common. A cure has not been found yet, the main aim now is to control the infection and prevent any pain. If the lesion appears again after the treatment period, it has to be started again.

Depending on the severity, the recovery time varies, it takes years to recover. The treatment period is itself about six months to a year or more.

The exact cost of the treatment is unknown, but it is very economical and relatively low. No financial aid was provided to the patients, in the cases reported.

Cases where the lesions were less severe, the disease is completely curable and the results are permanent. Other than that, there is a high chance of relapse in moderate and severe cases. They have not discovered a permanent cure as of such.

Oral drugs, surgery and physically applicable drugs are treatment methods. If left untreated, the disease may manifest several folds. Not treating the disease will further provide a lot of harm to the patient. So, other than the treatments already mentioned, there are no alternatives.