Topical Antifungal

Aka: Topical Antifungal, Antifungal Agents for Superficial Skin Infections

1. Indications
   1. Cutaneous Fungal Infections (i.e. Tinea Corporis, Tinea Cruris, Tinea Pedis)
   2. Cutaneous Candidiasis (e.g. Intertrigo)
   3. Vulvovaginal Candidiasis
2. Contraindications (due to lack of efficacy; these require systemic Antifungals)
   1. Tinea Unguium
   2. Tinea Capitis
3. Precautions
   1. Start with narrower spectrum Topical Antifungals
      1. See protocol below
      2. Advance to more potent Antifungals as indicated for refractory course
   2. Avoid using high-potency Topical Antifungal-Corticosteroid combination agents (e.g. Lotrisone)
      1. Potent Corticosteroids may reduce the efficacy of the Antifungal
      2. Potent Topical Corticosteroids risk significant local adverse effects
4. Technique
   1. Apply Topical Antifungals to an area encompassing the affected skin area
      1. Application should extend beyond the affected margin by at least 1 inch
   2. Apply the Topical Antifungals consistently for 1-6 weeks
      1. Continue topical agents for 1 week beyond the time the lesions appear to heal
   3. If Corticosteroid is indicated for concurrent inflammation
      1. Apply low dose Topical Corticosteroid (e.g. Hydrocortisone OTC) between doses of Topical Antifungal
      2. See precaution above above avoiding potent Topical Corticosteroids (especially in combination agents)
5. Preparations: Older, narrow spectrum fungistatic agents
   1. Tolnaftate (Tinactin, OTC)
      1. Narrow spectrum with no effect on candida species
      2. Fungistatic for dermatophytes and Tinea Versicolor
   2. Haloprogin (Halotex)
      1. Similar to Tolnaftate with added candida coverage
      2. Increased risk of irritant dermatitis
6. Preparations: First-line topical fungicidal agents
   1. Polyene Topical Antifungal (for Cutaneous Candidiasis)
      1. Nystatin
   2. Imidazole Topical Antifungal (broader spectrum for Tinea Infection and Cutaneous Candidiasis)
      1. Clotrimazole (Lotrimin, OTC)
      2. Miconazole (Micatin, OTC)
      3. Econazole (Spectazole)
      4. Ketoconazole (Nizoral)
      5. Oxiconazole (Oxistat)
      6. Sulconazole (Exelderm)
7. Preparations: Second line topical fungicidal agents for refractory Tinea Infection
   1. Cost effective OTC agents ($16 for 30 grams in 2014)
      1. Terbinafine (Lamisil AT)
      2. Butenafine (Mentax, Lotrimin Ultra)
         1. Similar to allylamines
         2. Highly effective fungicidal agent
   2. Other agents
      1. Ciclopirox (Loprox, Penlac)
      2. Naftifine (Naftin)
      3. Luliconazole (Luzu)
         1. Not recommended as cost is nearly $400 for 60 grams (in 2014)
         2. Niche appears to be the convenience of once daily dosing
   3. References
      1. (2014) Presc Lett 21(5): 28
8. Protocol
   1. See Vulvovaginal Candidiasis
   2. Cutaneous Candidiasis Management
      1. Polyene (e.g. Nystatin)
      2. Imidazoles (e.g. Clotrimazole)
   3. Dermatophyte Infections (e.g. Tinea Corporis)
      1. Imidazoles (e.g. Clotrimazole)
   4. Refractory Dermatophyte Infections
      1. Allylamines (e.g. Naftin, Lamisil)
9. References
   1. Gupta (1998) Drugs 55:645-74 [PubMed]
   2. Weinstein (2002) Am Fam Physician 65(10):2095-102 [PubMed]