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TINEA CORPORIS, CRURIS & PEDIS
Dermatophytoses are superficial fungal infections that have different presentations and are named based on location.
Tinea corporis (ringworm) usually presents with lesions of varying sizes, degree of inflammation and depth of involvement found on the trunk, extremities or face excluding the beard area in men.
Tinea cruris (jock itch) are lesions found on the groin. It may affect the proximal medial thighs and extend to the buttocks and abdomen. The scrotum and penis tend to be unaffected.
The red scaling lesions with raised borders have pustules and vesicles at the active edge of infected area.
Tinea pedis (athlete's foot) are lesions found in the interdigital spaces (most common), sole of foot, and sides of feet.

Principles of Therapy

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
  • For tinea pedis, treatment is targeted towards control of symptoms & spread to other parts of the body
    • Topical therapy is the preferred route of treatment

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 with antifungal should not be administered in children <12 years
  • Topical antifungals combined with corticosteroids are available. Please see prescribing information for specific formulations in the latest MIMS

Pharmacotherapy

Topical Antifungals

Allylamines

  • Eg Naftifine, Terbinafine
  • Actions: Fungicidal in vitro
  • Effects: Allylamines may produce a faster response & slightly more effective than azoles
  • Naftifine has anti-inflammatory properties

Azoles

  • Eg Clotrimazole, Eberconazole, Econazole, Efinaconazole, Fluconazole, Itraconazole, Ketoconazole, Luliconazole, Miconazole, Oxiconazole, Sertaconazole, Sulconazole 
  • Many imidazoles & triazoles 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
  • Sertaconazole & Luliconazole possess potent anti-inflammatory effects comparable to antifungal-corticosteroid combinations
  • Efinaconazole is a treatment option for patients w/ co-existing tinea unguium infection

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

Others

  • Amorolfine
    • Alternative treatment option for patients w/ tinea pedis
    • Effects: Active against dermatophytes, dimorphic fungi, yeasts, other filamentous & dematiaceous fungi
  • Amphotericin B
    • Treatment option for various mucocutaneous fungal infections including dermatophytosis, w/ minimal adverse events seen
    • Effects: Has broad-spectrum antifungal activity against most pathogenic fungi
  • 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 Vehicles 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

  • Eg Fluconazole, Griseofulvin, Itraconazole, Terbinafine 
  • May be considered in patients w/ extensive disease, unresponsive to treatments, immunocompromised, or severe moccasin-type tinea of the plantar surface 
    • 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
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