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

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