eMedicine Specialties > Emergency Medicine > Infectious Diseases
Tinea: Treatment & Medication
Updated: May 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
Certain forms of tinea can easily be identified and treated with antifungals in the ED. However, the diagnosis should probably be confirmed with a potassium hydroxide smear and/or cultures.
A common practice that is highly discouraged is the prescribing of combined steroid/antifungal creams.
Consultations
A dermatologist may be consulted. Outpatient phototherapy protocols have been developed for chronic situations in which oral medications are not tolerated.
Medication
Tinea corporis infections may be treated with topical agents (ie, creams, lotions, solutions, powders, sprays) as the drug of choice or with oral antifungals in extensive or recalcitrant disease.6,7
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).8
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.9
Medication classes
- Two classes of antifungal medications are most commonly used: azoles and the allylamines.
- 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.
Antifungals
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.
Ketoconazole 2% cream (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.
Adult
Rub gently into affected area qd or bid for 2-4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes
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.
Adult
Gently massage into affected and surrounding skin areas bid for 2-6 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes
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.
Adult
Apply sparingly over affected areas qd for 2-6 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes
Miconazole 2% cream (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.
Adult
Cream and lotion: Cover affected areas bid for 2-6 wk
Powder: Spray or sprinkle liberally over affected area bid
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes
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.
Adult
Terbinafine tab
Tinea cruris, tinea corporis: 250 mg/d PO for 2-4 wk
Tinea pedis: 250 mg/d PO for 2-6 wk
Tinea capitis: 250 mg/d PO for 4 wk
Fingernail infection: 250 mg/d PO for 6-8 wk
Toenail infection: 250 mg/d PO for 3-4 mo
Terbinafine 1% cream
Tinea corporis, tinea cruris: Apply to affected area qd for 1-4 wk
Tinea pedis: Apply to affected area bid for 1-4 wk
Pediatric
Terbinafine tab, treatment duration similar to that in adults
12-20 kg: 62.5 mg/d PO
20-40 kg: 125 mg/d PO
>40 kg: 250 mg/d PO
Terbinafine 1% cream
<12 years: Not established
>12 years: Administer as in adults
Coadministration of PO form may increase cyclosporine clearance; rifampin and phenobarbital may decrease terbinafine level; cimetidine may decrease terbinafine clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if chemical irritation or signs of hepatobiliary dysfunction develop; topical dosage form is for external use only; avoid contact with eyes
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.
Adult
Cream: Gently massage sufficient quantity into affected area and surrounding skin qd for 2-4 wk
Gel: Gently massage sufficient quantity into affected and surrounding skin areas bid for 2-4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes
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.
Adult
Tinea corporis, tinea cruris, and tinea capitis: 500 mg microsize (330-375 mg ultramicrosize) PO in single or divided daily doses for 2-6 wk
Tinea pedis, tinea unguium: 0.75-1 g microsize (660-750 mg ultramicrosize) PO in single or divided doses for 2-6 wk
Pediatric
11 mg microsize/kg/d (5 mg/lb/d) PO or 7.3 mg ultramicrosize/kg/d (3.3 mg/lb/d) PO
May decrease hypoprothrombinemic activity of warfarin; patients may require a dosage adjustment; oral contraceptives may lose effectiveness when administered concurrently, possibly leading to breakthrough bleeding, amenorrhea, or unintended pregnancy; may reduce effects of cyclosporine; may decrease serum salicylate concentrations; barbiturates may decrease serum levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For prolonged therapy, observe patients closely; monitor renal, hepatic, and hematopoietic function regularly; lupuslike syndromes or exacerbation of lupus erythematosus may occur; photosensitivity may occur; patients should take protective measures against exposure to UV light or sunlight
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.
Adult
Tinea corporis, tinea cruris: 100 mg/d PO 2 wk or 200 mg/d PO for 1 wk
Tinea pedis: 200 mg bid PO for 1 wk
Toenail infection: 200 mg bid PO 1 for wk, given 1 wk/mo for 3-4 mo
Fingernail infection: 200 mg PO bid for 1 wk, given 1 wk/mo for 1-2 mo
Tinea capitis: 5 mg/kg/d (max dose 100 mg/d) PO for 2-4 wk
Pediatric
Not established
Suggested dose in children 3-16 years: 100 mg/d PO for 1 wk
Antacids may reduce absorption; edema may occur with coadministration of calcium-channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (lovastatin or simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce itraconazole levels (phenytoin metabolism may be altered)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic insufficiencies; absorption impaired when gastric acidity is decreased; discontinue if neuropathy attributable to itraconazole occurs
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.
Adult
Tinea corporis, tinea cruris: 150 mg/wk PO for 2-4 wk
Tinea pedis: 150 mg/wk PO for as long as 6 wk
Toenail infection: 150 mg/wk PO for 6-12 mo
Fingernail infection: 150 mg/wk PO for 3-6 mo
Pediatric
Not established
Levels may increase with hydrochlorothiazides; levels may decrease with chronic coadministration of rifampin; coadministration may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with coadministration; increases in cyclosporine concentrations may occur when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor patient closely if rashes develop, and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS, malignancy, or multiple concomitant medications; not recommended for breastfeeding women
Sertaconazole nitrate cream (Ertaczo)
Topical imidazole antifungal active against T rubrum, T mentagrophytes, E floccosum. Indicated for tinea pedis.
Adult
Apply topically bid to clean, dry skin between the toes and the immediate surrounding healthy skin
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For topical use only; may cause dermatitis, dry skin, burning sensation, pruritus, hyperpigmentation, desquamation, or skin tenderness
More on Tinea |
| Overview: Tinea |
| Differential Diagnoses & Workup: Tinea |
 Treatment & Medication: Tinea |
| Follow-up: Tinea |
| Multimedia: Tinea |
| References |
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References
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Further Reading
Keywords
tinea, ringworm, ring worm, fungal infection, dermatophytes, dermatophytosis, Epidermophyton, Microsporum, Trichophyton, tinea capitis, tinea corporis, tinea manuum, tinea pedis, tinea cruris, tinea barbae, tinea faciale, tinea unguium, onychomycosis, Trichophyton rubrum, Trichophyton tonsurans, Trichophyton interdigitale, Trichophyton mentagrophytes, Microsporum canis, Epidermophyton floccosum
