Superficial Fungal Infections

Recognize the pharmacologic category, dosage form (topical or oral), and Rx vs OTC status of antifungals used for superficial fungal infections

OTC Antifungal Agents - Topical

• Tolnaftate

  • Aerosol powder 1%, aerosol solution 1%, cream 1%, gel 1%, powder 1%, solution 1%

• Indecylenic acid

• Clontrimazole

  • Cream 1%, lotion 1%, ointment 1%, solution 1%

• Ketoconazole (also available in prescription by oral)

• Micronazole 

  • Aerosol powder 2%, aerosol solution 2%, cream 2%, ointment 2%, powder 2%, solution 2%

• Terbinafine (also available in prescription by oral)

  • Cream 1%

• Butenafine

  • Cream 1%

• Forms

  • Creams, lotions

  • Ointments

  • Solution

  • Foam, shampoo

  • Powder, aerosol spray or powder

  • Gel

  • Suspension 

Rx antifungal agents

• Oral

  • Fluconazole

  • Itraconazole

  • Terbinafine

  • Griseofulvin 

    • Narrow spectrum, ADE/toxicity/DDI

• Topical 

  • Ciclopirox

  • Nystatin

Athlete’s Foot (Tinea Pedis)

Nonpharm (athletes foot) 

• Avoid tight fitting or enclosed shoes for long periods of time 

• Wear protective/shower shoes in public showers

• Cleanse the skin daily with soap and water, and thoroughly pat dry including between toes

• Wear socks that don’t hold moisture/are moisture-wicking 

• Do not share towels, clothing, or other personal articles with family members, especially when an infection is present 

• Launder contaminated towels and clothing in hot water to prevent spreading the infection 

Use of Antifungal agents in athlete’s foot

• Some locations are harder to penetrate/reach/cure and may require oral therapy and/or longer treatment times

• Topical agents are considered first line therapy for infections of the skin 

• Topical products are available in different formulations for different reasons 

  • Powders do not work well for treatment but may be used for prevention (like in shoes)

  • creams/gels work best are are used mostly

  • Ointments are best for scaly or weeping areas

  • Solutions are easier for hairy areas

• Topical treatment duration = 4 weeks

  • Can cure by 2 weeks; some require 4-6w

• Oral therapy preferred when infection is extensive (covers as large skin area) or severe or when treating onychomycosis (nails)

OTC warning

• Always check the Drug Facts label for the active ingredient in the product 

• The same brand name of OTC product does not always contain the same active ingredient 

  • Eg. Lotrimin AF might have clotrimazole, miconazole, or tolnaftate

Differentiate between the antifungal OTC formulations and generations when selecting a product for a patient

Comparing OTCs for Tinea Pedis

• Earlier gen antifungals

  • Clontrimazole (fungistatic)

  • Miconazole (fungistatic)

  • Tolnaftate (fungistatic)

  • > 2 years of age; twice daily for 4 weeks, less expensive 

• Second gen antifungals

  • Butenafine (mixed info on fungistatic vs fungicidal)

  • Terbinafine cream, spray (fungicidal)

  • > 12 years of age: twice daily for 1 weeks or once daily for 4 weeks

  • Terbinafien preferred if also on bottom/sides of feet

• Third gen antifungal 

  • Terbinafine GEL formulation (fungicidal)

  • > 12 years of age: once daily for 1 week

Recommend an OTC product and counsel a patient on proper treatment of tinea; recognize exclusions for self treatment

Self-care fungal infections

• Tinea corporis (body)

• Tinea cruris (jock itch)

• Tinea pedis (athlete’s foot)

Exclusions to Self-Care

• Patient has a weakened immune or blood circulation system 

• Patient with diabetes if not currently under the supervision of provider

• Suspicion of systemic infection (eg. fever, malaise)

• Suspicion of bacterial infection also present (eg. oozing, purulent)

• If prior self-treatment failed to clear the rash and was used appropriately along with nondrug prevention measures 

  • Stronger agent may be needed 

• Certain tinea locations:

  • Since topical agents do not penetrate the hair shaft, infections associated with hair and hair follicles (e.g. scalp and beard tinea) 

    • Require oral prescription therapy

  • Fungal nail infections often respond better to oral therapy than topical therapy; if patient returns or has had before, likely best to refer to doctor 

    • May require prescription for oral therapy or stronger topical polish

  • Mucus membranes are also involved (e.g. mouth, genitalia unless recurrent vulvovaginal candidiasis – not covered in this unit)