Majocchi Granuloma Medication
- Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD more...
The two classes of antifungal medications most commonly used to treat dermatophyte infections are the azoles and the allylamines. Azoles inhibit lanosterol 14-alpha-demethylase, an enzyme that converts lanosterol to ergosterol, an important component of the fungal cell wall. Membrane damage leads to permeability problems and renders the fungus unable to reproduce. Allylamines inhibit squalene epoxidase, an enzyme that converts squalene to ergosterol, leading to the accumulation of toxic levels of squalene in the cell and cell death. Examples of both classes of antifungal antibiotics are available for topical and systemic administration. Another possible therapy for refractory Majocchi granuloma is voriconazole.
To achieve the best results, particularly with follicular or extensive disease, the authors often recommend a combination of topical and systemic therapy.
The mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.
Terbinafine is an allylamine derivative that inhibits squalene epoxidase, a key enzyme in sterol biosynthesis in fungi. This inhibition results in a deficiency in ergosterol within the fungal cell wall that causes fungal cell death. Terbinafine is available by prescription only. Some clinicians reserve the use of this drug for more widespread and/or resistant infections because of its broad coverage and cost. This medication is effective and well tolerated in children.
Butenafine is a potent antifungal related to the allylamines. It damages fungal cell membranes, arresting fungal cell growth. Butenafine is available in cream form only. Use 1% cream.
Clotrimazole is a broad-spectrum agent that inhibits fungal growth by altering cell membrane permeability, causing fungal cell death. Reevaluate the diagnosis if no clinical improvement is seen after 4 weeks. Often, clotrimazole is a first-line topical drug. It is available by prescription only. Cream, solution/spray, and lotion forms are available. Use 1%.
Itraconazole has fungistatic activity. It is a synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Absorption is improved with food and in the presence of normal gastric acidity. Patients should be cautioned against ingesting grapefruit juice while on itraconazole therapy (decreased oral bioavailability of itraconazole). Discontinue if sensitivity or chemical irritation occurs; it is for external use only, and avoid contact with eyes.
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