Topical antifungal treatments for skin infections -
Although not routinely performed in many locations, susceptibility testing may be of value for patients with confirmed dermatophyte infections that fail to respond to appropriate course of treatment [ 24 ].
Infections have been reported in Asia, Europe, North America, and the Middle East [ 27 ]. indotineae cannot be identified through routine laboratory techniques due to morphologic similarities among T.
indotineae , Trichophyton mentagrophytes , and Trichophyton interdigitale. Genomic sequencing is required for identification. Misuse and overuse of topical antifungal drugs and topical corticosteroids are proposed to contribute to the spread of resistant T.
indotineae infections [ 25,26 ]. Overview — Tinea pedis also known as athlete's foot is a dermatophyte infection of the skin on the foot:.
Common causes are Trichophyton rubrum , T. Infection is usually acquired by means of direct contact with the causative organism, as may occur by walking barefoot in locker rooms or swimming pool facilities.
Other predisposing factors may include diabetes mellitus and the wearing of occlusive footwear [ ]. The three major clinical types of tinea pedis are:.
Associated interdigital fissures may cause pain. There is a variable degree of underlying erythema. Underlying erythema may be evident. The medial foot is often affected.
Infrequently, tinea pedis may manifest with interdigital erosions and ulcers ulcerative tinea pedis picture 11A-B. This presentation is usually associated with secondary bacterial infection.
Tinea pedis can occur in association with onychomycosis, tinea cruris, or tinea manuum picture 12A. Differential diagnosis — The differential diagnosis of tinea pedis is broad and varies according to the clinical subtype:. A positive potassium hydroxide KOH preparation demonstrating segmented hyphae distinguishes tinea pedis from nonfungal diseases.
Interdigital Candida infection will demonstrate budding yeasts, pseudohyphae, and septate hyphae on a KOH preparation picture 8A-B. See 'Diagnosis' above. Treatment — Topical antifungal therapy is the treatment of choice for most patients.
Systemic antifungal agents are primarily reserved for patients who fail topical therapy algorithm 1 :. Topical nystatin is not effective for dermatophyte infections. Amorolfine is not available in the United States. See 'Treatment principles' above. Topical antifungal treatment is generally applied once or twice daily and continued for four weeks.
A meta-analysis of randomized trials published prior to February supports efficacy of topical therapy, finding strong evidence of superiority of topical antifungal agents azoles, allylamines, ciclopirox , tolnaftate , butenafine , and undecanoate over placebo [ 33 ].
Allylamines may be slightly more effective than azoles. A meta-analysis of data from 11 trials that compared topical allylamines with topical azoles found slightly higher cure rates with allylamines risk ratio of treatment failure 0. Potential causes of treatment failure should be reviewed see 'Treatment failure' above :.
Typical treatment regimens for adults include [ 34 ]:. Griseofulvin , an oral antifungal agent frequently used for tinea capitis in children, can treat tinea pedis but may be less effective than other oral antifungals and requires a longer duration of therapy [ 34 ]. In a systematic review, terbinafine was found more effective than griseofulvin, while the efficacy of terbinafine and itraconazole were similar [ 35 ].
Typical adult doses of griseofulvin for tinea pedis are mg per day of griseofulvin microsize for four to eight weeks or mg per day of griseofulvin ultramicrosize for four to eight weeks [ 34 ]. Typical pediatric doses include:. The wet dressings can be applied for 20 minutes two to three times per day.
Placing gauze or cotton between toes may also be helpful. TINEA CORPORIS. Overview — The term "tinea corporis" refers to epidermal dermatophyte infections in sites other than the feet, groin, face, or hand:.
rubrum is the most common cause of tinea corporis. Other notable causes include Trichophyton tonsurans , Microsporum canis , T. indotineae , Microsporum gypseum , Trichophyton violaceum , and Microsporum audouinii.
Acquisition of infection may occur by direct skin contact with an infected individual or animal, contact with fomites, or from secondary spread from other sites of dermatophyte infection eg, scalp, feet, etc. In particular, T. tonsurans tinea corporis in adults may result from contact with a child with tinea capitis, which is often caused by this organism.
canis tinea corporis is often acquired by contact with an infected cat or dog. Tinea corporis can also occur in outbreaks among athletes who have skin-to-skin contact, such as wrestlers tinea corporis gladiatorum.
tonsurans is a common cause of tinea corporis gladiatorum [ 36 ]. Central clearing follows, while an active, advancing, raised border remains. The result is an annular ring-shaped plaque from which the disease derives its common name ringworm picture 2A-D.
Multiple plaques may coalesce picture 24A-B. Pustules occasionally appear picture Extensive tinea corporis should prompt consideration of an underlying immune disorder, such as HIV, or for diabetes. Differential diagnosis — Examples of features that should prompt consideration of alternative diagnoses include extensive skin involvement and an absence of scale.
A positive potassium hydroxide KOH preparation distinguishes tinea corporis. Tinea corporis may be confused with other annular skin eruptions, particularly subacute cutaneous lupus erythematosus SCLE , granuloma annulare, and erythema annulare centrifugum:.
SCLE can be idiopathic or occur in association with systemic lupus erythematosus or drug exposure. See "Overview of cutaneous lupus erythematosus", section on 'Subacute cutaneous lupus erythematosus'. Unlike tinea corporis, scale is absent. See "Granuloma annulare: Epidemiology, clinical manifestations, and diagnosis".
A trailing rim of scale is often evident in the superficial variant of this disorder. See "Erythema annulare centrifugum". Other disorders, such as nummular eczema picture 29A-B , psoriasis, pityriasis rosea picture 30A-B , and disciform erythrasma picture 31 , may also exhibit scaling plaques that resemble tinea corporis.
See "Approach to the patient with annular skin lesions". Treatment — The extent of skin involvement with tinea corporis influences the approach to treatment algorithm 1 :. Topical antifungal treatment is generally administered once or twice per day for one to three weeks table 1.
The endpoint of treatment is clinical resolution. The topical antifungal agents listed above are all considered effective. Pooled data from randomized trials supports the efficacy of two allylamines, terbinafine and naftifine , for tinea corporis and tinea cruris [ 18 ].
There are also data that suggest similar efficacy of topical allylamines and topical azoles [ 18 ]. Potential causes of treatment failure should be reviewed. See 'Treatment failure' above.
Terbinafine and itraconazole are common treatments. Griseofulvin and fluconazole can also be effective but may require longer courses of therapy. Randomized trials support the efficacy of systemic therapy [ ]:. Reasonable pediatric doses are:. Overview — Tinea cruris also known as jock itch is a dermatophyte infection involving the crural fold:.
Other frequent causes include E. floccosum , T. Tinea cruris is far more common in males than females. Often, infection results from the spread of the dermatophyte infection from concomitant tinea pedis. Predisposing factors include copious sweating, obesity, diabetes, and immunodeficiency.
The infection spreads centrifugally, with partial central clearing and a slightly elevated, erythematous or hyperpigmented, sharply demarcated border picture 3A-E. Infection may spread to the perineum and perianal areas, into the gluteal cleft, or onto the buttocks.
In males, the scrotum is typically spared. Differential diagnosis — Other common skin disorders that may present with erythematous patches or plaques in the inguinal region include:. Candidal pseudohyphae, hyphae, and yeast cells are seen on potassium hydroxide KOH preparation picture 8A-B.
In contrast to tinea cruris, scrotal involvement is common in males with candidiasis of the crural folds. See "Intertrigo". Patients may also have findings of seborrheic dermatitis in other body areas. See "Seborrheic dermatitis in adolescents and adults". Patients may or may not have psoriasis in other body areas.
See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Inverse intertriginous psoriasis'. Intertriginous involvement may present as erythematous to brown patches or thin plaques picture 35A-B. The detection of coral red fluorescence during examination with a Wood's lamp can confirm the diagnosis picture See "Erythrasma".
A KOH preparation positive for hyphae rules out nonfungal disorders. Treatment — Treatment is similar to treatment of tinea corporis algorithm 1 :. Nystatin is not effective for dermatophyte infections.
See 'Tinea corporis' above. Potential causes for treatment failure should be reviewed. Concomitant tinea pedis should be treated to reduce risk for recurrence.
Treatment of onychomycosis may also reduce recurrences. Other interventions that may be helpful include daily use of desiccant powders or drying lotions in the inguinal area and avoidance of tight-fitting clothing and noncotton underwear. OTHER CLINICAL VARIANTS — Various other terms are used to describe additional clinical subtypes of dermatophyte infection.
Onychomycosis — Dermatophyte infection is a common cause of onychomycosis fungal infection of the nail. Clinical manifestations include nail discoloration, subungual hyperkeratosis, and other forms of nail dystrophy picture 5. Onychomycosis is reviewed separately. See "Onychomycosis: Epidemiology, clinical features, and diagnosis" and "Onychomycosis: Management".
Tinea faciei — Tinea faciei is a dermatophyte infection of facial skin devoid of terminal hairs. The eruption may begin as small, scaly papules that evolve to form an annular plaque picture 37 [ 28 ].
Tinea faciei is managed similarly to tinea corporis. Tinea manuum — Tinea manuum is a dermatophyte infection of the hand. Patients present with a hyperkeratotic eruption on the palm or annular plaques similar to tinea corporis on the dorsal hand. Tinea manuum commonly occurs in association with tinea pedis and is often unilateral picture 12A-B.
This clinical presentation is often referred to as "two feet-one hand syndrome. See 'Tinea pedis' above. Tinea capitis — Tinea capitis, a dermatophyte infection of scalp hair, usually occurs in small children picture 4A-B.
Oral antifungal therapy is the treatment of choice. Tinea capitis is reviewed in detail separately. See "Tinea capitis". Tinea barbae — Tinea barbae is a dermatophyte infection involving beard hair in adolescent and adult males picture 38A-B.
Oral antifungal therapy is necessary. Tinea barbae is reviewed separately. See "Infectious folliculitis", section on 'Dermatophytic folliculitis' and "Infectious folliculitis", section on 'Management'.
Majocchi's granuloma — Majocchi's granuloma is an uncommon subtype of dermatophyte infection in which the dermatophyte invades the deep follicle and dermis. The clinical findings are typically characterized by a localized area with erythematous or hyperpigmented, perifollicular papules or small nodules picture 6A-C.
Pustules may also be present. Treatment consists of oral antifungal therapy. Majocchi's granuloma is reviewed separately. Tinea imbricata — Tinea imbricata also known as Tokelau ringworm is a variant of tinea corporis caused by Trichophyton concentricum.
The disorder primarily occurs in the South Pacific Islands, South Asia, and South America. Tinea imbricata is characterized by concentric, annular, scaly, erythematous plaques picture 39A-B. A potassium hydroxide KOH preparation demonstrates hyphae, and fungal culture confirms T.
concentricum infection. The most effective treatments may be oral terbinafine and griseofulvin [ 46 ]. Systemic therapy is often combined with a topical keratolytic agent. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
See "Society guideline links: Dermatophyte infections". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.
These organisms metabolize keratin and cause a range of pathologic clinical presentations, including tinea pedis picture 1A-C , tinea corporis picture 2A-D , tinea cruris picture 3A-E , tinea capitis, and onychomycosis. See 'Microbiology' above and 'Tinea pedis' above and 'Tinea corporis' above and 'Tinea cruris' above and 'Other clinical variants' above.
A potassium hydroxide KOH preparation can be used to confirm the diagnosis picture 7A. For patients with tinea pedis, limited tinea corporis, or limited tinea cruris, we suggest initial treatment with a topical antifungal drug with antidermatophyte activity rather than oral antifungal therapy algorithm 1 Grade 2C.
Examples of effective topical antifungal agents are azoles, allylamines, ciclopirox , butenafine , and tolnaftate. For patients who fail topical therapy, reasons for treatment failure should be reviewed.
See 'Tinea pedis' above and 'Tinea corporis' above and 'Tinea cruris' above. For patients with tinea pedis, use of desiccating foot powders, placement of antifungal powder in shoes, and avoidance of occlusive footwear may help to reduce recurrences.
Patients with tinea cruris may benefit from treatment of concomitant tinea pedis or tinea unguium, use of desiccating powders in the groin, and avoidance of occlusive clothing and noncotton underwear. See 'Tinea pedis' above and 'Tinea cruris' above.
Management of dermatophytid reactions involves treatment of the associated dermatophyte infection. Topical corticosteroids and antipruritic agents may be beneficial for symptom relief. See 'Id reactions' above. Why UpToDate? Product Editorial Subscription Options Subscribe Log In. Learn how UpToDate can help you.
Select the option that best describes you. View Topic. Font Size Small Normal Large. Dermatophyte tinea infections. Formulary drug information for this topic.
No drug references linked in this topic. Find in topic Formulary Print Share. View in language Chinese English. Authors: Adam O Goldstein, MD, MPH Beth G Goldstein, MD Section Editors: Robert P Dellavalle, MD, PhD, MSPH Moise L Levy, MD Ted Rosen, MD Deputy Editor: Abena O Ofori, MD Contributor Disclosures.
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jun This topic last updated: Jun 30, Typical treatment regimens for adults include [ 34 ]: - Terbinafine — mg per day for two weeks - Itraconazole — mg twice daily for one week - Fluconazole — mg once weekly for two to six weeks Griseofulvin , an oral antifungal agent frequently used for tinea capitis in children, can treat tinea pedis but may be less effective than other oral antifungals and requires a longer duration of therapy [ 34 ].
Typical pediatric doses include: - Terbinafine tablets: 10 to 20 kg — Reasonable pediatric doses are: - Terbinafine tablets: 10 to 20 kg — Epidemiological trends in skin mycoses worldwide. Mycoses ; 51 Suppl Seebacher C, Bouchara JP, Mignon B.
Updates on the epidemiology of dermatophyte infections. Mycopathologia ; Ameen M. Epidemiology of superficial fungal infections. Clin Dermatol ; Levitt JO, Levitt BH, Akhavan A, Yanofsky H. The sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a pooled analysis.
Dermatol Res Pract ; Solomon M, Greenbaum H, Shemer A, et al. Toe Web Infection: Epidemiology and Risk Factors in a Large Cohort Study. Dermatology ; Meena S, Gupta LK, Khare AK, et al. Topical Corticosteroids Abuse: A Clinical Study of Cutaneous Adverse Effects.
Indian J Dermatol ; Verma SB. A Closer Look at the Term "Tinea Incognito:" A Factual as Well as Grammatical Inaccuracy. Holubar K, Male O. Tinea incognita vs. tinea incognito. Acta Dermatovenerol Croat ; Ilkit M, Durdu M, Karakaş M.
Majocchi's granuloma: a symptom complex caused by fungal pathogens. Med Mycol ; Smith KJ, Neafie RC, Skelton HG 3rd, et al. Majocchi's granuloma. J Cutan Pathol ; Tse KC, Yeung CK, Tang S, et al. Majocchi's granuloma and posttransplant lymphoproliferative disease in a renal transplant recipient.
Am J Kidney Dis ; E Kim ST, Baek JW, Kim TK, et al. Majocchi's granuloma in a woman with iatrogenic Cushing's syndrome. The preparation may be heated gently over a flame to highlight the fungal elements.
If dimethyl sulfoxide has been added to the KOH, heating is not required. During examination of the sample, the condenser of the microscope should be in the down position.
The presence of septate hyphae confirms the diagnosis of tinea. The examiner should make sure that hyphae are being seen rather than the edge of an epithelial cell. It is helpful to visualize the hyphae crossing the path of more than one cell. If clinical decisions are to be made based on microscopic examination, practitioners must comply with Clinical Laboratory Improvement Amendments CLIA regulations.
Performing KOH examinations requires a Provider—Performed Microscopy PPM certificate. Obtaining the latter requires completion of paperwork and does not require a site inspection. The American Academy of Dermatology publishes a handbook with directions for compliance with the PPM regulation.
Mycologic culture is rarely indicated in the diagnosis of tineas other than tinea unguium and tinea capitis. In some cases, even though clinical suspicion is high, diagnosis may be a challenge. Culture, while relatively simple to perform, requires one to four weeks to grow and clinical expertise to interpret the result.
The most common medium used for isolating dermatophytes is Sabouraud's peptone-glucose agar. The latter has the added advantage of a phenol indicator that turns red in the alkaline environment produced by dermatophytes. All media require collection of an adequate sample of infected material.
Scale may be collected in a manner similar to that used for the KOH preparation or with a cotton swab. The swab must first be moistened with sterile water and then rubbed vigorously over the active border of the lesion. This method is best used when the lesion is not scaly or when the use of a blade or slide is impractical.
Performing cultures requires a level of certification that necessitates a laboratory inspection. When the diagnosis of a dermatophyte infection remains in question after office testing or failure to respond to treatment, biopsy specimens may be submitted to a pathologist for evaluation.
Fungal staining with periodic acid—Schiff highlights fungal elements. Most tinea corporis, cruris, and pedis infections can be treated with topical agents.
Consideration should be given to systemic treatment when lesions covering a large body-surface area fail to clear with repeated treatment using different topical agents. Because fungi thrive in moist warm environments, patients should be encouraged to wear loose-fitting garments made of cotton or synthetic materials designed to wick moisture away from the surface.
Socks should have similar properties. Areas likely to become infected should be dried completely before being covered with clothes. Patients should also be advised to avoid walking barefoot and sharing garments. A variety of traditional agents without specific antimicrobial function are still in use, including Whitfield's ointment and Castellani's carbol fuchsin solution paint.
The efficacy of these preparations has not been well quantified. The antifungal agents can be grouped by structure and mechanism of action. The two principal pharmacologic groups are the azoles and the allylamines. Polyenes amphotericin B [Fungizone] and nystatin [Mycostatin] are not discussed in this article because this group of compounds is not effective in the treatment of dermatophyte infections.
Other agents that do not fit into the two main groupings are tolnaftate Tinactin , haloprogin Halotex , ciclopirox Loprox and butenafine Mentax. Because there are few direct comparisons of individual topical agents, it can be difficult to justify the choice of one preparation over another.
This choice is made less clear because several genera and species may produce the same clinical condition. When treating a dermatophyte infection, it is unlikely that the physician will know the infecting species.
In general, tinea corporis and tinea cruris require once- to twice-daily treatment for two weeks. Tinea pedis may require treatment for four weeks. The application area should include normal skin about 2 cm beyond the affected area.
Guidelines regarding the optimal vehicle of treatment e. In addition to specific anti-fungal properties, some preparations have antibacterial and anti-inflammatory properties that may influence their efficacy. Combination therapy antifungal plus steroid can be considered when inflammation is an issue.
Combination agents should not be used when the diagnosis is in question because that may lead to their overuse or to adverse effects. The mechanism of action may have an effect on efficacy. The newer agents have fungicidal activity, which may translate into higher cure rates and lower relapse rates.
Clinical judgment with regard to prior treatments and complicating conditions bacterial growth or intense inflammation , along with knowledge of the agent's properties, will help guide the choice of therapy.
When inflammation is a salient clinical feature, it must be considered in the selection of a treatment option. This narrow-spectrum antifungal has no antibacterial or anticandidal activity.
Introduced after tolnaftate, haloprogin combines equivalent efficacy with a broadened fungal spectrum including yeasts.
This broad-spectrum agent is effective against dermatophytes, yeasts, and some bacteria. It has been shown to be more effective than the nonprescription agent clotrimazole Lotrimin in the treatment of tinea pedis. Ciclopirox 8 percent lacquer Penlac , which was approved for treatment of onychomycosis in late , has limited efficacy.
In two trials of daily application to infected toenails for 48 weeks, complete cure was achieved in 5. Only the latter was statistically significant compared with placebo. Partial clearance was also low 12 percent in the more successful trial.
Penlac requires daily application for up to 48 weeks and monthly follow-up for nail debridement. This agent is similar in structure to that of the allylamines. Butenafine is fungicidal for dermatophytes in vitro. This class includes many over-the-counter and prescription preparations.
Members of this class include clotrimazole, econazole Spectazole , ketoconazole Nizoral , miconazole Micatin , oxiconazole Oxistat , and sulconazole Exelderm. These agents have broad-spectrum activity, including activity against some gram-positive bacteria.
Ketoconazole, 29 sulconazole and oxiconazole 30 require only once-daily application because of their long durability in the superficial layers of the skin.
Clotrimazole, miconazole, and econazole require twice-daily application. Naftifine Naftin and terbinafine Lamisil are applied once-daily and remain active in the skin for up to one week after application.
Terbinafine was more efficacious after one week than ketoconazole was after two weeks. This formulation combines an effective antifungal agent with a potent steroid. Patients who have symptomatic inflammatory dermatophytosis with erythema, pruritus, and burning are optimally treated twice daily with this combination.
The steroid component provides rapid symptomatic relief while the slower-acting antifungal agent eradicates the causative organism. Inflammation typically occurs in tineas caused by zoophilic dermatophytes.
The efficacy of this combination treatment has been demonstrated in two randomized controlled studies, 40 , 41 the first treating tinea cruris and the second treating tinea cruris and corporis.
In each study, the combination was better than either of the components alone in clearing the tinea infection. Because of these results, it is inferred that the steroid may enhance the antifungal activity of the clotrimazole. An analysis of the use of this product found that nondermatologists are more likely to use combination therapy.
Because of the potent steroid component, this medication provides rapid relief, but it must be used judiciously. Caution must be used when treating areas of thin skin and naturally occluded body areas, such as the groin, axillae, breast, and face.
Treatment of these areas should be avoided whenever possible. When the groin is affected by dermatophytosis, the cream should be used sparingly and only for two weeks. The recommended duration of treatment for tinea pedis is four weeks. This combination should not be used in children younger than 12 years.
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The length skim treatment depends on infectioons type of fungal infection you have, how severe it is and if you have any other health antjfungal - for example, problems with your immune system. Some courses Paleo diet shopping list treatment can treamtents Paleo diet shopping list short Injury prevention in youth athletes a few days for example, for treatnents thrush. Other courses can be as long as eight weeks for example, for ringworm infection of the scalp. There are several types of antifungal medicines. They come as creams, sprays, powders, solutions, anrifungal designed to go into the vagina pessariesshampoos, medicines to take by mouth, and injections. Most work by damaging the cell wall of the fungus, which causes the fungal cell to die. These are used to treat fungal infections of the skin, scalp and nails. Intertrigo is caused antiungal cutaneous inflammation of Toipcal skin surfaces. It is more common in hot and humid environments and during the Paleo diet shopping list. Topicap folds, including inframammary Figure 1intergluteal, axillary, and Enhances mental quickness Figure 2 skni, may tretaments involved. Intertrigo most often Paleo diet shopping list in patients with obesity body mass index more than 30 kg per m 2diabetes mellitus, or human immunodeficiency virus infection, and in those who are bedridden. It also occurs in patients with large skin folds and those who wear diapers or other items that trap moisture against the skin. There is a linear increase in the severity of obesity and the presence of intertrigo. As the stratum corneum becomes macerated because of hyperhydration, the friction intensifies and further weakens and damages the epidermal tissue.
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