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Topical Antifungal in Children and Adult

Topical Antifungal

Healthcare◦
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Topical antifungal - the tips DrT eohXi nY un Derma t ol ogist Depa rtment of D e rmatolog y Hospital Q ueenE l izabeth 11 thMay 20 25 Dr Teoh Xin Yun Dermatologist Department of Dermatology Hospital Queen Elizabeth 11th May 2025
Superficial fungal infections • Superficial fungal infection affects about 20% to 25% of the world's population • Primarily involve the outermost layers of the skin, nails and hair • Main group of fungi • Dermatophytes (tinea): • Trichophyton spp., Microsporum spp., Epidermophyton spp. • Yeasts • Candida spp (candida intertrigo), Malassezia spp (pityriasis versicolor), Piedra (black and white piedra) • Moulds – less common, immunocompromised patients. • Topical is the first line treatment in uncomplicated cases in primary care setting. Ameen M. Clin Dermatol. 2010 Mar 4;28(2):197-201.
Topical antifungals for superficial fungal infections – do you use them correctly?
What is your diagnosis? • Systemic antifungals (e.g., griseofulvin, terbinafine) are the mainstay of treatment • Topical antifungals serves as adjunctive therapy to reduce the carriage of viable spores and reduce transmission to others Which topical antifungal to use?
Preparation for scalp Antifungal shampoos primarily used to treat dandruff/seborrhoeic dermatitis, play an adjunctive role in the management of tinea capitis The most effective ingredients are ketoconazole and selenium sulfide It is recommended to use at least twice weekly to decrease shedding of fungal spores All household members, even if asymptomatic, advised to use the antifungal shampoo to reduce risk of asymptomatic carriage and infection.
Antifungal shampoo • Selenium sulfide 1% or 2.5%, ketoconazole 1% or 2% shampoo • Antifungal and anti-inflammatory properties, slow keratinocyte proliferation, helping to control scaling and flaking • Indications: seborrheic dermatitis, tinea versicolor, tinea capitis (adjunctive therapy) • Scalp: Massage into wet scalp, leave for 2 - 3 minutes, rinse • Body: Apply to affected areas, lather with a small amount of water, leave on skin for 10 - 15 minutes, rinse
Antifungal shampoo • Shampoo containing Zinc pyrithione 1% has antifungal properties • Indication: pityriasis versicolor, seborrhoiec dermatitis • Pityriasis Versicolor – Apply daily for 1 week to affected areas, then 2-3 times per week • Benefits of zinc pyrithione 1% shampoo include wide nonprescription availability of this product. • However, compared with ketoconazole and selenium sulfide shampoo, clinical trial data for zinc pyrithione are limited.
Household members screening in tinea capitis • More than 50% of family members (including adults) may be affected, often with occult disease. • Failure to treat the whole family will result in high recurrence rates. • All household members should be examined for signs of tinea capitis and treated. • Asymptomatic close contacts should be treated with antifungal shampoo for two to four weeks Fuller LC, et al. Br J Dermatol. 2014 Sep;171(3):454-63.
What is your diagnosis? Which topical antifungal to use? • Topical azole once or twice daily for 2–4 weeks • Topical terbinafine twice daily for 2 weeks
Rules of applications • “Rule of Two” • Apply at least 2cm beyond the margin of the lesion • Twice a day • Treatment should continue for at least two weeks beyond clinical resolution Madhu R, et al. Indian Journal of Practical Pediatrics. 2021; 23(1):22
What is your diagnosis? • Topical azoles twice daily for 2–4 weeks • Topical terbinafine twice daily for 2–4 weeks • Ketoconazole shampoo/Selenium sulphide 2.5% shampoo daily for 1 week then twice weekly for 2–4 weeks Which topical antifungal to use?
What is your diagnosis? • Soak with KMNO4 1:10,000 for 10—20 minutes • Topical azoles twice daily for 4 weeks • Topical terbinafine twice daily for 2 weeks • Keep web space dry with toe web spacer Which topical antifungal to use?
Potassium Permanganate 5% • Mechanism of action: Antiseptic, deodorising and astringent properties • Weeping lesions - Tinea pedis, groin candidiasis • Dilute 2 drops (0.1 ml) in 50 ml of normal saline/water to make 1:10,000 (Picture d) • Dilute 2 drops (0.1ml) in 100 ml of normal saline/water to make 1:20,000 (Picture c) • Use as wash/ dab/ wet wrap/ soak (10-20 minutes)/ sitz bath • Use immediately after dilution. Solution that are left standing can turn brown (oxidized) and is ineffective. • Stop using this solution once skin become dry to avoid fissuring of skin. • Side effects: staining on clothing/ skin/ nail, stinging sensation, dry skin and fissure (too concentrated) a/b: too diluted (ineffective) d-f: too concentrated (too drying) Ministry of Health, Topical preparation counselling guide for pharmacist, 2018
Castellani paint • Contains phenol, resorcinol, and boric acid - antifungal, antibacterial, and drying properties. • Apply on nails and web spaces (intertrigo) • Apply a small amount with an applicator, swab or a cotton bud on the affected area • Medication may stain skin and clothing • Web space can be kept dry by keeping the toes separated by using a toe separator
Which topical antifungal to use? • Whitfield ointment twice daily for 4 weeks • Topical azoles twice daily for 4 weeks/ topical terbinafine twice daily for 2 weeks • Moccasin type (usually caused by T. rubrum) – respond to oral terbinafine or oral itraconazole • Always check for nail involvement—which may serve as a reservoir. What is your diagnosis?
Whitfield ointment • Contains benzoic acid 6%, salicylic acid 3% • Mode of action: Fungistatic activity combines with keratolytic properties • Indication: Tinea pedis, tinea corporis, tinea versicolor • Apply twice daily on affected area for at least 4 weeks
What is your diagnosis? Which topical antifungal to use? • Due to poor nail penetration of topical monotherapy is often ineffective • Combination of oral and topical antifungal therapy • Amorolfine nail lacquer once weekly for 6-12 months • Topical azoles twice daily on nail and surrounding skin for 6-12 months
Onychomycosis – why and how to file • Thickened, infected nails impair penetration of topical antifungals • Filing helps reduce nail thickness, improving drug absorption and treatment outcomes • Use a disposable file to avoid contamination to other nails • Wiped with alcohol • File parallel to the surface of the diseased nails to reduce thickness of the nail • Use nail clipper to clip away the unattached infected part of the nail • Trim nails straight across and not rounding the corners to avoid ingrown toenails • Smooth the edges of your nail with a file
Onychomycosis – how to apply topicals • After filing the nail • Swab the nails with alcohol swab • Apply nail lacquer/cream/lotion evenly on affected nails, under the edge of the nails • Don’t forget the periungual skin - Apply cream/lotion on the skin around the nails and skin beneath the edge of the nails • Treat concomitant paronychia – avoid contact irritants (water, soap, detergents), apply topical corticosteroid on nailfold
Amorolfine nail lacquer 5% • Broad-spectrum activity against against dermatophytes, yeasts, dimorphic fungi, and a variety of filamentous and dematiaceous fungi • Apply once weekly after the surface of the nail is filed with a disposable file • Fingernails are treated for 6 months; toenails 9 to 12 months.
Clotrimazole 1% lotion • Broad spectrum activitiy against dermatophytes and yeasts. • Apply on affected nails twice daily • Fingernails are generally treated for six months; toenails are treated for 9 to 12 months
Onychomycosis • Topical treatments alone are generally unable to cure onychomycosis because of insufficient nail plate penetration • Topical and systemic antifungal drugs are the mainstay of therapy How to know if the treatment is working? • The new nail will grow slowly from its base • Fingernails take 4-6 months to grow and toenails 12-18 months to grow • Thus it may take 6-18 months for nail to appear normal again
Cleaning of fomites Fomites - inanimate objects that may be contaminated and spread infections eg bedding, towels, and clothing. Sharing of bedding/towels and washing of clothing together with contaminate clothing can potentially spread infections to the whole family. Viable spores have been isolated from hairbrushes and combs of patients with tinea capitis. Avoid sharing hair care tools, pillowcase and towels.
• Sock pieces were inoculated with seven terbinafine-resistant isolates of Trichophyton spp. • Multiple disinfection methods: - Quaternary ammonium compound (QAC) detergents (0.5–24 hrs) - Freezing at -20°C (0.5 -24 hours) - Domestic and steam washing (40°C with detergent) • Sock pieces were cultured for 4 weeks following disinfection. The primary end point was no growth at the end of week 4.
Cleaning of fomites • QAC detergent soak for 24 hrs: Disinfectant of 100% • Shorter QAC soak (0.5–2 hrs): Partial effectiveness (46.2%–84.6%) • Domestic 40°C washing with detergent: Minimal efficacy (7.7%) • Freezing & steam washing at 40°C with detergent: Ineffective Skaastrup KN, et al. Mycoses. 2022 Jul;65(7):741-746.
Cleaning of fomites • Laundering at temperature ≥60°C has been shown previously to be effective in the eradication of fungal pathogens. • In conclusion, this study proposed to launder clothes at a minimum of 60°C or soak their clothes in a QAC‐based detergent for at least 24 h prior to laundering to effectively reduce the risk of reinfection. Amichai B, et al. Int J Dermatol. 2013 Nov;52(11):1392-4. Skaastrup KN, et al. Mycoses. 2022 Jul;65(7):741-746.
What is your diagnosis? Which topical antifungal to use?
Preparation for oral candidiasis • Syrup Nystatin swish and swallow 5ml of 100,000 units/mL suspension for 2 weeks • Swish and retain in the mouth, and keep in contact with the affected areas for 5 min before swallowing • If esophageal candidiasis, require systemic antifungal therapy (oral fluconazole)
Preparation for oral candidiasis • Clotrimazole lozenges (10 mg) • Suck on one troche five times a day for two weeks
Preparation for angular cheilitis • Cheilitis is usually treated with topical steroids • In the cases of cheilitis refractory to topical steroids, candida infection should be considered • Topical azoles (miconazole 2%/ clotrimazole 1%) apply to the corner of the mouth twice daily for 2 weeks or until resolution
Preparation for vaginal candidiasis • Clotrimazole vaginal pessary 500mg single dose or 200mg daily for 3 days - to be inserted before bed time, using the applicator • Miconazole vaginal pessary 1.2g single dose or 200mg for 3 days • Nystatin vaginal pessary 100,000 units for 14 nights • Miconazole 2% vaginal cream: Insert 1 applicatorful once daily at bedtime for 7 days • Clotrimazole 1% vaginal cream: 1 applicatorful once daily at bedtime for 7 days
Antifungal Six main classes of antifungals: (1) Azoles (imidazole eg miconazole, triazole eg itraconazole) (2) Allylamines (e.g., terbinafine) (3) Polyenes (e.g., nystatin,amphotericin B) (4) Echinocandins (e.g., caspofungin) (5) Flucytosine (6) Griseofulvin Azoles and allylamines represent the two primary classes of topical antifungal agents
Mechanism of action Imidazoles and Allylamine interferes synthesis of ergosterol, essential component of the fungal cell membrane
Failure of topical therapy No clinical improvement after 1 month of adequate therapy Most failures of topical therapy are caused by inaccurate diagnosis or non-compliance or inappropriate use of topical therapy Tinea versicolor - persistent hypopigmentation or hyperpigmentation does not indicate treatment failure - Skin discoloration can persist for weeks to few months after successful treatment. Presence of the characteristic fine scale of tinea versicolor is a clinical sign that suggests active infection. Active infection should be confirmed with a positive KOH preparation.
Antifungal resistance • Emerging resistance of superficial fungal infections to antifungal therapy account for some treatment failures • Terbinafine resistance secondary to single point mutations in the squalene oxidase gene has been reported most frequently • The development of antifungal resistance is complex and depends on host and microbial factors • Patients with severe immunodeficiency are more likely to fail antifungal therapy • Over prescription of antifungal medications contributes to antifungal resistance Gupta K, et al. J Dermatolog Treat. 2022 Jun;33(4):1888-1895.
Topical steroid combination with topical antifungal • Not recommended • Use of strong topical steroid can mask the fungal infection and result in more extensive infection (tinea incognito) • Use of medium- or high-potency corticosteroids-antifungal combination (eg, clotrimazole- betamethasone dipropionate) can lead to local and systemic side effects of corticosteroid • Treatment failures - overuse of topical corticosteroids may contribute to resistant dermatophyte infections Rana P, et al. Indian J Pharmacol. 2021 Jan-Feb;53(1):82-84.
Topical antibiotics combination with antifungal • Not recommended • Prolonged treatment and extensive use may encourage the emergence of resistant bacteria
Special groups – pregnancy and children Topical clotrimazole, miconazole and terbinafine are safe during pregnancy. Topical miconazole is FDA approved for children ≥2 years of age Selenium sulfide shampoo is licensed to be used for children ≥2 years of age Ketoconazole shampoo is licensed to be used for adolescent ≥12 years of age
Referral to Dermatologist Referral to a dermatologist may be required for: Uncertain diagnosis. Unsuccessful treatment. Severe or extensive infection. Recurrent infection. Immunocompromised patients.
Summary • Superficial fungal infection is one of the major burden of skin disease worldwide. • Topical antifungal drugs is first line therapy against major skin dermatophytes and candida • Advantages of topical antifungal include site specific drug delivery, reduce systemic toxicity, ease of use, comparatively low cost of therapy • Inappropriate and irrational use of antifungal may result in the development of multidrug resistance fungal pathogens, unwanted toxicity, and low therapeutic efficacy. • Education of patients on the appropriate usage of topical antifungal is important to ensure the efficacy of topical therapy in treating superficial fungal infections
Thank you