Medication Summary

The two classes of antifungal medications most commonly used to treat dermatophyte infections are the azoles and the allylamines.^[36]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.^[37]

To achieve the best results, particularly with follicular or extensive disease, the authors often recommend a combination of topical and systemic therapy.

Class Summary

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 (Lamisil)

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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 (Mentax)

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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 (Lotrimin, Mycelex)

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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 (Sporanox)

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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).

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Media Gallery

Pseudomonas folliculitis. Courtesy of Hon Pak, MD.

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Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Coauthor(s)

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

David P Fivenson, MD Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan

David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Michigan State Medical Society, Society for Investigative Dermatology, Photomedicine Society, Wound Healing Society, Michigan Dermatological Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Olegas Ceburkovas, MD, to the development and writing of this article.