II. Indications
III. Contraindications (due to lack of efficacy; these require systemic Antifungals)
IV. Precautions
- Start with narrower spectrum Topical Antifungals
- See protocol below
- Advance to more potent Antifungals as indicated for refractory course
- Consider adjunctive agents
- Highly absorbent powder (e.g. Zeasorb)
- Avoid using high-potency Topical Antifungal-Corticosteroid combination agents (e.g. Lotrisone)
- Potent Corticosteroids may reduce the efficacy of the Antifungal (higher resistance rates)
- Potent Topical Corticosteroids risk significant local adverse effects
V. Technique
- Apply Topical Antifungals to an area encompassing the affected skin area
- Application should extend beyond the affected margin by at least 1 inch
- Apply the Topical Antifungals consistently for 1-6 weeks
- Apply more potent Antifungals (Butenafine, Terbinafine) for at least 1 to 2 weeks
- Apply other Antifungals (e.g. Clotrimazole, Miconazole) for at least 2 to 4 weeks
- Continue topical agents for 1-2 weeks beyond the time the lesions appear to heal
- If Corticosteroid is indicated for concurrent inflammation
- Apply low dose Topical Corticosteroid (e.g. Hydrocortisone OTC) between doses of Topical Antifungal
- See precaution above above avoiding potent Topical Corticosteroids (especially in combination agents)
VI. Medications: Older, narrow spectrum fungistatic agents
-
Tolnaftate (Tinactin, OTC)
- Narrow spectrum with no effect on candida species
- Fungistatic for dermatophytes and Tinea Versicolor
- Haloprogin (Halotex)
- Similar to Tolnaftate with added candida coverage
- Increased risk of irritant dermatitis
VII. Medications: First-line topical fungicidal agents
- Polyene Topical Antifungal (for Cutaneous Candidiasis)
- Imidazole Topical Antifungal (broader spectrum for Tinea Infection and Cutaneous Candidiasis)
- Twice daily dosing
- Clotrimazole 1% (Lotrimin, Mycelex, OTC)
- Miconazole Nitrate 2% (Micatin, Monistat-Derm, OTC)
- Econazole Nitrate 1% (Spectazole)
- Once daily dosing (long durability agents)
- Ketoconazole 2% (Nizoral)
- Oxiconazole nitrate 1% (Oxistat)
- Sulconazole (Exelderm)
- Twice daily dosing
VIII. Medications: Second line topical fungicidal agents for refractory Tinea Infection
- Cost effective OTC agents ($16 for 30 grams in 2014)
- Terbinafine (Lamisil AT)
- Butenafine (Mentax, Lotrimin Ultra)
- Similar to allylamines
- Highly effective fungicidal agent
- Other agents
- Ciclopirox (Loprox, Penlac)
- Naftifine (Naftin)
- Luliconazole (Luzu)
- Not recommended as cost is nearly $400 for 60 grams (in 2014)
- Niche appears to be the convenience of once daily dosing
- References
- (2014) Presc Lett 21(5): 28
IX. Protocol
- See Vulvovaginal Candidiasis
-
Cutaneous Candidiasis Management
- Polyene (e.g. Nystatin)
- Imidazoles (e.g. Clotrimazole)
- Dermatophyte Infections (e.g. Tinea Corporis)
- Imidazoles (e.g. Clotrimazole)
- Refractory Dermatophyte Infections
X. Safety
- Topical azoles are considered safe in pregnancy
- Clotrimazole 1% for dermatophyte infections
- Miconazole 2% for candida infections