Tinea in Emergency Medicine in Emergency Medicine Medication

  • Author: Rashid M Rashid, MD, PhD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 9, 2011
 

Medication Summary

Tinea corporis infections may be treated with topical agents (ie, creams, lotions, solutions, powders, sprays) as the drug of choiceor with oral antifungals in extensive or recalcitrant disease.[10, 11]

For tinea capitis and nail infections, topical therapy is ineffective. Findings with onychomycosis treatment were discouraging because of the need for prolonged therapy and the low success rate. However, in recent years, new oral antimycotic drugs have been developed as the drug of choice; these have greatly improved the outlook (especially for patients with fungal toenail infection).[12]

Use of oral medications requires baseline LFT checks as well as repeat labs half way through the typical 3 month course. Cultures are also recommended when managing children, as oral medications are more difficult for this age group.[13]

Medication classes

  • Two classes of antifungal medications are most commonly used: azoles and the allylamines.
  • Both classes have the common endpointoif inhibiting ergosterol production.
  • Azoles inhibit lanosterol 14-alpha-demethylase, an enzyme that converts lanosterol to ergosterol (important for the fungal cell wall). This leads to permeability 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.
Next

Antifungals

Class Summary

The optimal duration of topical therapy for dermatophytic infections of the skin has never been established. In most cases of tinea corporis and tinea cruris, 2 weeks of treatment may suffice. Tinea pedis may require treatment for as long as 8 weeks.

View full drug information

Ketoconazole topical (Nizoral)

 

Imidazole, broad-spectrum antifungal agent indicated for the topical treatment of tinea corporis, tinea cruris, and tinea pedis. Inhibits synthesis of ergosterol (main sterol of fungal cell membranes), causing cellular components to leak; results is cell death.

View full drug information

Clotrimazole 1% cream or lotion (Lotrimin, Mycelex)

 

Indicated for topical treatment of tinea corporis, tinea cruris, and tinea pedis. Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing fungal cell death.

View full drug information

Econazole 1% cream or lotion (Spectazole)

 

Effective in cutaneous infections. Interferes with RNA and protein synthesis and metabolism. Disrupts fungal cell-wall membrane permeability, causing fungal cell death.

View full drug information

Miconazole topical (Monistat, Daktarin)

 

Damages fungal cell-wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak and resulting in fungal-cell death. The lotion is preferred in intertriginous areas. If the cream is used, apply sparingly to avoid maceration effects.

View full drug information

Terbinafine (Lamisil)

 

Synthetic allylamine derivative that inhibits squalene epoxidase, a key enzyme in sterol biosynthesis of fungi, resulting in a deficiency in ergosterol that causes fungal cell death. Use until symptoms significantly improve.

View full drug information

Naftifine 1% cream (Naftin)

 

Indicated for the treatment of tinea corporis, tinea cruris, and tinea pedis. Broad-spectrum antifungal agent that appears to interfere with sterol biosynthesis by inhibiting the enzyme squalene 2,3-epoxidase. This inhibition results in decreased amounts of sterols, causing cell death. If no clinical improvement occurs after 4 weeks of treatment, reevaluate the patient.

View full drug information

Griseofulvin (Gris-PEG, Grifulvin V, Fulvicin, Griseofulvin)

 

Extensively used in the past to treat dermatophytic infections of the skin. However, with new antifungals now available, use is now limited. An antibiotic derived from a species of Penicillium that is deposited in the keratin precursor cells, which are gradually replaced by noninfected tissue; the new keratin then becomes highly resistant to fungal invasions. Most used therapy for treating tinea capitis, especially if caused by M canis.

View full drug information

Itraconazole (Sporanox)

 

Synthetic triazole antifungal agent that inhibits fungal cell growth by inhibiting the cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.

A 30-d course of 100 mg of itraconazole daily has been shown to effectively treat tinea capitis. This treatment could prove to be a beneficial alternative to griseofulvin therapy.

View full drug information

Fluconazole (Diflucan)

 

Broad-spectrum triazole antifungal agent. A potent and selective inhibitor of fungal enzymes necessary for ergosterol synthesis. Most commonly used in the treatment of candidiasis.

View full drug information

Sertaconazole nitrate cream (Ertaczo)

 

Topical imidazole antifungal active against T rubrum, T mentagrophytes, E floccosum. Indicated for tinea pedis.

Previous
Proceed to Follow-up
 
 
Contributor Information and Disclosures
Author

Rashid M Rashid, MD, PhD  Resident Physician, Department of Dermatology, University of Texas, Houston, MD Anderson Cancer Center, and Morzak Research Initiative

Rashid M Rashid, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Council for Nail Disorders, Houston Dermatological Society, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew C Miller, MD  Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC); Attending Physician, Department of Emergency Medicine, UPMC St Margaret's Hospital

Andrew C Miller, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP  Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Theodore J Gaeta, DO, MPH, FACEP  Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Satter EK. Tinea imbricata. Cutis. Apr 2009;83(4):188-91. [Medline].

  2. Zhu M, Li L, Wang J, Zhang C, Kang K, Zhang Q. Tinea Capitis in Southeastern China: A 16-Year Survey. Mycopathologia. Nov 21 2009;[Medline].

  3. Gupta AK, Sibbald RG, Lynde CW, et al. Onychomycosis in children: prevalence and treatment strategies. J Am Acad Dermatol. Mar 1997;36(3 Pt 1):395-402. [Medline].

  4. Mahe A, Prual A, Konate M, et al. Skin diseases of children in Mali: a public health problem. Trans R Soc Trop Med Hyg. Sep-Oct 1995;89(5):467-70. [Medline].

  5. Enweani IB, Ozan CC, Agbonlahor DE, et al. Dermatophytosis in schoolchildren in Ekpoma, Nigeria. Mycoses. Jul-Aug 1996;39(7-8):303-5. [Medline].

  6. Geddes ER, Rashid RM. Delusional tinea: a novel subtype of delusional parasitosis. Dermatol Online J. 2008;14(12):16. [Medline].

  7. Arenas R, Toussaint S, Isa-Isa R. Kerion and dermatophytic granuloma. Mycological and histopathological findings in 19 children with inflammatory tinea capitis of the scalp. Int J Dermatol. Mar 2006;45(3):215-9. [Medline].

  8. Del Boz J, Crespo V, Rivas-Ruiz F, de Troya M. Tinea incognito in children: 54 cases. Mycoses. Nov 26 2009;[Medline].

  9. Gorani A, Oriani A, Cambiaghi S. Seborrheic dermatitis-like tinea faciei. Pediatr Dermatol. May-Jun 2005;22(3):243-4. [Medline].

  10. Gupta AK, Sauder DN, Shear NH. Antifungal agents: an overview. Part I. J Am Acad Dermatol. May 1994;30(5 Pt 1):677-98; quiz 698-700. [Medline].

  11. Gupta AK, Sauder DN, Shear NH. Antifungal agents: an overview. Part II. J Am Acad Dermatol. Jun 1994;30(6):911-33; quiz 934-6. [Medline].

  12. Singal A, Pandhi D, Agrawal S, et al. Comparative efficacy of topical 1% butenafine and 1% clotrimazole in tinea cruris and tinea corporis: a randomized, double-blind trial. J Dermatolog Treat. 2005;16(5-6):331-5. [Medline].

  13. Ali S, Graham TA, Forgie SE. The assessment and management of tinea capitis in children. Pediatr Emerg Care. Sep 2007;23(9):662-5; quiz 666-8. [Medline].

  14. Avner S, Nir N, Henri T. Combination of oral terbinafine and topical ciclopirox compared to oral terbinafine for the treatment of onychomycosis. J Dermatolog Treat. 2005;16(5-6):327-30. [Medline].

  15. Bahamdan K, Mahfouz AA, Tallab T, et al. Skin diseases among adolescent boys in Abha, Saudi Arabia. Int J Dermatol. Jun 1996;35(6):405-7. [Medline].

  16. Brodell RT, Elewski BE. Clinical pearl: systemic antifungal drugs and drug interactions. J Am Acad Dermatol. Aug 1995;33(2 Pt 1):259-60. [Medline].

  17. Degreef HJ, DeDoncker PR. Current therapy of dermatophytosis. J Am Acad Dermatol. Sep 1994;31(3 Pt 2):S25-30. [Medline].

  18. Derya A, Ilgen E, Metin E. Characteristics of sports-related dermatoses for different types of sports: a cross-sectional study. J Dermatol. Aug 2005;32(8):620-5. [Medline].

  19. Devliotou-Panagiotidou D, Koussidou-Eremondi T, Badillet G. Dermatophytosis in northern Greece during the decade 1981-1990. Mycoses. Mar-Apr 1995;38(3-4):151-7. [Medline].

  20. [Guideline] Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: tinea capitis and tinea barbae. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. Feb 1996;34(2 Pt 1):290-4. [Medline].

  21. [Guideline] Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: tinea corporis, tinea cruris, tinea faciei, tinea manuum, and tinea pedis. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. Feb 1996;34(2 Pt 1):282-6. [Medline].

  22. Elewski BE. Clinical diagnosis of common scalp disorders. J Investig Dermatol Symp Proc. Dec 2005;10(3):190-3. [Medline].

  23. Elewski BE. The dermatophytoses. Semin Cutan Med Surg. 1996;2:1043-55.

  24. Elewski BE. Tinea capitis: itraconazole in Trichophyton tonsurans infection. J Am Acad Dermatol. Jul 1994;31(1):65-7. [Medline].

  25. Gold DT, McClung B. Approaches to patient education: emphasizing the long-term value of compliance and persistence. Am J Med. Apr 2006;119(4 Suppl 1):S32-7. [Medline].

  26. Gupta AK, Adam P, Dlova N, et al. Therapeutic options for the treatment of tinea capitis caused by Trichophyton species: griseofulvin versus the new oral antifungal agents, terbinafine, itraconazole, and fluconazole. Pediatr Dermatol. Sep-Oct 2001;18(5):433-8. [Medline].

  27. Kemna ME, Elewski BE. A U.S. epidemiologic survey of superficial fungal diseases. J Am Acad Dermatol. Oct 1996;35(4):539-42. [Medline].

  28. Koumantaki-Mathioudaki E, Devliotou-Panagiotidou D, Rallis E, et al. Is itraconazole the treatment of choice in Microsporum canis tinea capitis?. Drugs Exp Clin Res. 2005;31 Suppl:11-5. [Medline].

  29. Möhrenschlager M, Seidl HP, Ring J, et al. Pediatric tinea capitis: recognition and management. Am J Clin Dermatol. 2005;6(4):203-13. [Medline].

  30. Roberts DT. Prevalence of dermatophyte onychomycosis in the United Kingdom: results of an omnibus survey. Br J Dermatol. Feb 1992;126 Suppl 39:23-7. [Medline].

  31. Weitzman I, Summerbell RC. The dermatophytes. Clin Microbiol Rev. Apr 1995;8(2):240-59. [Medline].

  32. Welsh O, Welsh E, Ocampo-Candiani J, et al. Dermatophytoses in monterrey, méxico. Mycoses. Mar 2006;49(2):119-23. [Medline].

 
Previous
Next
 
Wax model of kerionlike tinea barbae. Courtesy of the Museum of the Department of Dermatology, University of Medicine, Wroclaw, Poland.
Gray-patch ringworm (microsporosis) is an ectothrix infection or prepubertal tinea capitis seen here in an African American male child. Gray patch refers to the scaling with lack of inflammation, as noted in this patient. Hairs in the involved areas assume a characteristic dull, grayish, discolored appearance. Infected hairs are broken and shorter. Papular lesions around hair shafts spread and form typical patches of ring forms, as shown. Culture from the lesional hair grew Microsporum canis.
Typical lesions of kerion celsi on the vertex scalp of a young Chinese boy. Note numerous bright yellow purulent areas on skin surface, surrounded by adjacent edematous, erythematous, alopecic areas. Culture from the lesion grew Trichophyton mentagrophytes. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.
Annular plaque (tinea corporis).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.