Management and prevention

Cutaneous cryptococcosis without evidence of central nervous system invasion can be treated with fluconazole 200-400 mg/day. If extracutaneous disease is found then the recommended treatment is amphotericin B 0.7 mg/kg/day and flucytosine 100 mg/kg/day, for at least 2 weeks, and then followed by fluconazole 400 mg daily for at least 8 weeks. Liposomal forms of amphotericin B have proven to have a better safety profile for amphotericin B-induced kidney injury, and similar or even superior efficacy compared with amphotericin B deoxycholate. However, the cost can be a limiting factor for its use.[88]

Patients newly diagnosed with HIV infection with CD4 counts  below 50 cells/μL, should be tested for cryptococcosis prior to starting ART. If positive, it is recommended to withhold ART for at least 2 weeks after starting antifungal therapy for cryptococcosis.[89],[90] Primary prophylaxis is not recommended, particularly in the absence of a positive serum cryptococcal antigen. However secondary prophylaxis is the standard of care with either fluconazole 200- 400 mg/day or itraconazole 400 mg daily. It can be discontinued with immune reconstitution of CD4 cell counts over 200 cells/μL for 6 months (see section Key opportunistic infections).[91]