Topical Antifungals

• Most tinea corporis, cruris & pedis infections can be treated topically
• Choice of agent will depend on cost, physician & patient preference
  
  • There are few direct comparison studies between agents of different groups; it is difficult to justify choice of one agent over another

Topical Corticosteroids

• Should only be used in combination w/ antifungal & limited only to confirmed fungal infections in patients suffering from symptomatic inflammation, itching, erythema & burning sensation
  
  • Should be used only in the first few days of treatment

• Effects: There is usually rapid symptomatic relief
• Use w/ caution when treating areas of thin skin & naturally occluded body areas (eg groin, axillae, breast & face)
• Combination topical corticosteroids w/ antifungal should not be administered in childn <12 yr
• Topical antifungals combined w/ corticosteroids are available. Please see prescribing information for specific formulations in the latest MIMS

Topical Antifungals

Allylamines

• Naftifine & Terbinafine are examples of allylamines
• Actions: Fungicidal in vitro
• Effects: Allylamines may produce a faster response than imidazoles but cure rates are similar
  
  • Naftifine has anti-inflammatory properties

Benzylamines

• Butenafine is similar in structure to the allylamines
• Actions: Fungicidal in vitro
• Effects: Has high cure rates & long disease-free intervals in treating interdigital tinea pedis

Imidazoles

• Many imidazoles are available & these agents have broad-spectrum activity
• Actions: Bind to phospholipids in the fungal cell wall membrane resulting in loss of essential intracellular elements, fungistatic in vitro
• Effects: Typically result in cure when treating tinea infections

Others

• Ciclopirox
  
  • Effects: Has broad-spectrum coverage against dermatophytes, yeasts & some bacteria

• Haloprogin
  
  • Effects: Has equivalent efficacy w/ Tolnaftate but has a broader fungal spectrum including yeasts

• Tolnaftate
  
  • Effects: Effective in most dermatophytoses & tinea versicolor but has narrow-spectrum antifungal activity; no antibacterial or anti-candidal activity

Optimal Vehicle of Topical Treatment

Creams

• Recommended for non-oozing & moderately scaling lesions

Lotions

• Easily spread on hairy areas
• Recommended for intertriginous areas or oozing lesions

Ointments

• Useful for hyperkeratotic lesions

Powders & Sprays

• May be used to prevent reinfection; should be applied to the feet rather than to the shoes
  
  • Typically not very effective in treating active infection

Oral Antifungals

• Moccasin-type tinea of the plantar surface responds poorly to conventional treatment thus oral antifungal is necessary
  
  • Recommended dose of oral Terbinafine has been shown to produce sustained cure rates of 71-94%
  • Griseofulvin use resulted in a 27-35% cure rate 

• Oral antifungals have been used to control acute vesicular tinea pedis
  
  • Pulse doses of Fluconazole, Itraconazole & Terbinafine have been shown effective
  • Use of Fluconazole in immunocompromised patients should be done sparingly