What is the role of antifungal therapy in the treatment of allergic fungal sinusitis (AFS)?

Updated: Mar 16, 2018
  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Systemic antifungal therapy for allergic fungal sinusitis (AFS) initially was proposed to control the theoretical potential for progression to invasive forms of fungal sinusitis. As the unacceptably high rate of recidivism following surgery alone was recognized, antifungal therapy often was used in an attempt to provide some degree of control over recurrence of allergic fungal sinusitis (AFS). Early use of amphotericin B yielded to the use of less toxic agents, such as ketoconazole, itraconazole, and fluconazole, but the poor in vivo activity of these agents against dematiaceous fungi soon was discovered.

Objective data on the effects of this form of therapy for allergic fungal sinusitis (AFS) have been limited. Denning et al studied the effect of systemic itraconazole in patients with ABPA and demonstrated a decrease in total IgE (used as a marker of disease severity) and in systemic corticosteroid requirements. [25] Anecdotal reports of systemic itraconazole to prevent allergic fungal sinusitis (AFS) recurrence offer mixed results. Ferguson points out that the expense, limited available data, and potential drug-related morbidity of systemic antifungal therapy may limit the usefulness of this form of treatment for noninvasive fungal disease.

Topical application of antifungal agents may hold some benefit in the control of postoperative recurrence, and studies of this form of treatment currently are underway. Bent and Kuhn studied the in vitro susceptibility of fungi commonly encountered in patients with allergic fungal sinusitis (AFS) and determined that minimal inhibitory concentrations can be exceeded with certain antifungal agents when applied topically. Similarly, Ponikau et al support the use of topical antifungal agents. Supportive data are pending.


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