Pharmacologic Therapy of Tinea Infections

© Since dermatophyte hyphae seldom penetrate into the living layers of the skin, instead remaining in the stratum corneum, most infections can be treated with topical antifungals. Infections covering large areas of the body or infections involving nails or hair may require systemic therapy. Treatment is typically initiated based on symptoms, rather than on microscopic evaluation. For infections accompanied by inflammation, combination therapy with a topical steroid can be considered (Tables 83-6 and 83-7). Patients with chronic infections or infections that do not respond to topical therapy are also candidates for systemic therapy.

For the treatment of tinea pedia, corporis, and cruris, topical agents can be utilized unless the infection is refractory. Typically, tinea pedis requires treatment one to two times daily for 4 weeks, while tinea corporis and tinea cruris require treatment one to two times daily for 2 weeks. When applying treatment, the medication should be applied at least 1 inch beyond the affected area. Treatment of any infection should continue at least 1 week after resolution of symptoms. Many practitioners opt to initiate therapy with nonprescription clotrimazole or terbinafine, reserving prescription topical agents, such as naftifine, ciclopirox, and butenafine, for second-line therapy or refractory cases. For refractory cases or widespread lesions, systemic therapy can be prescribed.

When recommending topical therapy, the selection of vehicle is based on the type of lesion and location of the infection. Solutions are recommended for hairy areas and oozing lesions, while creams are better for moderately scaling and nonoozing lesions. For hyperkeratotic lesions, ointments can be considered. The selected formulation should be applied to the affected area that is cleaned and dried. The medication should be rubbed into the infected area for improved penetration. Since most patients do not rub in sprays and powders, penetration of the epidermis is minimal, making them less effective than other formulations. Sprays and powders should be considered as adjuvant therapy with a cream or lotion or as prophylactic therapy to prevent recurrence.

Due to the severity of infection and inflammation, tinea capitis does not adequately respond to topical agents. Oral agents for 6 to 8 weeks are recommended for eradication of tinea capitis. Griseofulvin has long been considered the treatment of choice due to its ability to achieve high levels within the stratum corneum. Itraconazole has also demonstrated effectiveness. Due to its lipophilicity, itraconazole achieves high levels in the skin. These levels are maintained for 4 weeks after medication is discontinued. Some practitioners recommend adjunct therapy with the oral agent to decrease dissemination, including ketoconazole or selenium sulfide shampoos.

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