Clinical Notes : Infection and Sepsis

67. Management of Tinea infections

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Tinea infections

"Tinea" refers to a skin infection with a dermatophyte (ringworm) fungus.

Depending on which part of the body is affected, it is given a specific name :

Sometimes, the name gives a different meaning :

  • Tinea versicolor is more accurately called pityriasis versicolor. This is a common yeast infection on the trunk.

  • Tinea incognita (often spelled incognito) refers to a tinea infection in which the clinical appearance has changed because of inappropriate treatment.

  • Tinea nigra is a mould infection (not a dermatophyte). It affects the palms or soles, which appear brown (on white skin) or black (on dark skin).

Clinical variants include :

  • Tinea imbricata

  • Majocchi granuloma

  • Kerion

 
 

Traditional agents

 

A variety of traditional agents without specific antimicrobial function are still in use, including :

Whitfield's ointment

Castellani's (Carbol fuchsin solution) paint.

 

The efficacy of these preparations has not been well quantified (1)

 

Topical antifungal therapy 

 

There is no statistically significant differences among the antifungals concerning the outcome of mycologic cure at the end of treatment.(2)

For sustained cure, butenafine and terbinafine are superior to other topical preparations (3)

Addition of topical steroid increases the bioavailability of topical antifungals mostly imidazole groups in addition to better symptomatic relief in early inflammatory stage (4)

Steroids may helpful in initial improvement in symptoms but chronic use lead to a complication like atrophy, telangiectasia which is more prominent when lesions are present in flexures.

Nystatin is not effective for the treatment of dermatophyte infections (5)

Topical antifungals

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Oral antifungal therapy 

 

Systemic antifungals are indicated in case of extensive involvement and patients who fail topical therapy (6)

Terbinafine ans itraconazole are commonly prescribed. Griseofulvin and fluconazole are also effective but require long-term treatment (7)

Topical therapy is less effective than oral antifungals for the treatment of tinea pedis, and oral treatment is generally given for 4–8 weeks (8)

Secondary bacterial infection should be treated with oral antibiotics.

 

Other adjunctive therapies include use of antifungal powder may help to prevent maceration and avoidance of occlusive footwear.

Oral antifungals

Rx oral.png
 

Therapy in immunosuppressed and pregnancy

 

Characteristic morphology may be missing due to reduced inflammatory component of lesion attributed to suppressed immunity (9)

In a patient with associated comorbidities such as renal, hepatic impairment, and caution should be exercised while prescribing systemic antifungals.

Terbinafine clearance significantly reduced in patient in renal impairment, so dose should be adjusted accordingly, or drug from different group should be preferred.

Similarly, itraconazole should be avoided in patient with hepatic impairment.

Terbinafine is a category B drug in pregnancy. However, there is no clear cut guideline available for managing dermatophytic infection and treatment should be individualized and based upon risk-benefit ratio (10)

 

Chronic dermatophytosis

 

Chronicity can be considered in terms of duration and recurrences of infection although there is no standard definition for chronicity.

The emergence of such cases could be attributed to (11)

  • pathogenic agent (e.g. resistant strain)

  • host factors (e.g. host immune non-recognition of strain)

  • pharmacologic factors (e.g. non compliance)

Treatment of chronic dermatophytosis may extend over several months, with due care taken to monitor kidney and liver function.

 
British Association Dermatologists.jpg
journals.png

1. Weinstein A, Berman B.

Topical treatment of common superficial tinea infections.

Am Fam Physician. 2002;65:2095–102.

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2. Rotta I, Ziegelmann PK, Otuki MF, Riveros BS, Bernardo NL, Correr CJ.

Efficacy of topical antifungals in the treatment of dermatophytosis: A mixed-treatment comparison meta-analysis involving 14 treatments.

JAMA Dermatol. 2013;149:341–9.

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3. El-Gohary M, van Zuuren EJ, Fedorowicz Z, Burgess H, Doney L, Stuart B, et al.

Topical antifungal treatments for tinea cruris and tinea corporis.

Cochrane Database Syst Rev. 2014;8:CD009992.

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4. Havlickova B, Friedrich M.

The advantages of topical combination therapy in the treatment of inflammatory dermatomycoses.

Mycoses. 2008;51(Suppl 4):16–26

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5. Haedersdal M, Svejgaard EL. Systematic treatment of tinea pedis – Evidence for treatment?.

A result of a Cochrane review. Ugeskr Laeger.

2003;165:1436–8

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6. Lesher JL., Jr

Oral therapy of common superficial fungal infections of the skin.

J Am Acad Dermatol. 1999;40(6 Pt 2):S31–4

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7. Panagiotidou D, Kousidou T, Chaidemenos G, Karakatsanis G, Kalogeropoulou A, Teknetzis A, et al.

A comparison of itraconazole and griseofulvin in the treatment of tinea corporis and tinea cruris: A double-blind study. J Int Med Res. 1992;20:392–400.

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8. Bell-Syer SE, Khan SM, Torgerson DJ.

Oral treatments for fungal infections of the skin of the foot.

Cochrane Database Syst Rev. 2012;10:CD003584

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9. Millikan LE.

Role of oral antifungal agents for the treatment of superficial fungal infections in immunocompromised patients.

Cutis. 2001;68(1 Suppl):6–14.

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10. Elston CA, Elston DM.

Treatment of common skin infections and infestations during pregnancy.

Dermatol Ther. 2013;26:312–20

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11. Ghannoum MA, Wraith LA, Cai B, Nyirady J, Isham N.

Susceptibility of dermatophyte isolates obtained from a large worldwide terbinafine tinea capitis clinical trial. Br J Dermatol. 2008;159:711–3.

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Ireland notes.png

The following topical meds are available in Ireland:

Clotrimazole (Canesten)

Miconazole (Daktarin)

Terbinafine (Fungasil, Lamisil, Lenafine)

Amolorfine (Curanail, Loceryl)

The following oral meds are available in Ireland :

Terbinafine (Fungasil, Lamisil, Nailderm, Terbasil, Ternaf)

Fluconazole (Diflazole, Diflucan, Flucol, Fluconazole Actavis)

The following topical meds are not available in IrelandI :

Econazole

Amphoteracin B gel

Oxiconazole

Sentaconazole

Luliconazole

Eberconazole

Naftifens

Butenafine

The following oral meds are not available in Ireland :

Itaconazole

Griseofulvin 

 

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