Fungal Skin Infections: Management, Treatment, and Prevention

To help counsel patients, pharmacists can focus on fungal skin infections that are amenable to self-treatment with OTC antifungals.

Pharmacists are likely to encounter patients seeking advice about the various nonprescription topical antifungals currently on the market.

These products are formulated to relieve the itching, burning, cracking, and scaling of skin that are often associated with fungal skin infections such as tinea pedis, tinea corporis, and tinea cruris (Online Table 1).¹

Active Ingredient

Indications

Examples of Products

Clotrimazole and miconazole nitrate

Indicated for treating tinea pedis, tinea cruris, and tinea corporis; typically applied twice a day for up to 4 wk; improvement may be observed after 2 wk of use; rare cases of mild burning and skin irritation have been reported

• Lotrimin AF (clotrimazole)
• Micatin (miconazole nitrate)
• Desenex antifungal (miconazole nitrate)

Terbinafine hydrochloride

Indicated for treating interdigital tinea pedis, tinea cruris, and tinea corporis caused by Epidermophyton floccosum, Trychophyton mentagrophytes, and Trychophyton rubrum; typically applied to affected area twice daily; common adverse effects include skin irritation, burning, and dryness

• Lamisil AT Antifungal Gel
• Lamisil AT cream or spray

Tolnaftate

The only nonprescription agent approved for both preventing and treating tinea infections; applied to affected area twice daily after the affected area is cleaned thoroughly; effective therapy usually takes 2-4 wk, although 4-6 wk may be required in some individuals

• Tinactin cream
• Tinactin Powder Spray
• Lamisil Defense Athlete’s Foot Spray Powder

Butenafine hydrochloride

Indicated for treating tinea pedis between toes, tinea cruris, and tinea corporis caused by E floccosum, T mentagrophytes, and T rubrum; Applied twice daily for 4 wk or as directed by primary health care provider for interdigital tinea pedis; for tinea cruris or tinea corporis, apply once a day for 2 wk or as directed by primary health care provider

• Lotrimin Ultra Cream

Dermatomycoses, also referred to as fungal skin infections, are frequently occurring cutaneous disorders.^1,2 Typically, these fungal infections are superficial and can involve the hair, nails, and skin.^1,2 The most prevalent fungal skin infection in humans is tinea pedis, which is commonly known as athlete’s foot.¹ Onychomycosis, or tinea unguium, affects the nails and may also occur in conjunction with tinea pedis.^1-5 The other commonly occurring fungal skin infections include tinea corporis (ringworm of the body) and tinea capitis (ringworm of the scalp), which are most prevalent among the prepubescent patient population, and tinea cruris (jock itch), which is most common among adult males.^1-5

While the signs and symptoms of these infections may vary in severity among individuals, most cases can be easily managed with proper treatment. Self-treatment of onychomycosis with topical nonprescription antifungals is not approved by the FDA; recommended treatment for this type of infection involves the use of prescription systemic agents or surgical removal of the affected area.^1,2 Like onychomycosis, tinea capitis cannot be successfully managed with the use of topical nonprescription antifungals.¹ This article focuses on fungal skin infections that are amendable to self-treatment with the use of currently available topical nonprescription antifungals.

The goals of treating antifungal skin infections are to provide the patient with symptomatic relief, successfully eliminate infection, and prevent recurrence of infections.¹

Nonprescription Topical Antifungals

Most cases of tinea pedis, tinea corporis, and tinea cruris can be successfully self-treated with nonprescription topical antifungals in conjunction with various nonpharmacologic measures. Available nonprescription topical antifungal agents include butenafine hydrochloride, clotrimazole, miconazole nitrate, terbinafine hydrochloride, and tolnaftate, which are considered safe and effective for treating mild to moderate fungal skin infections.¹ These products are available in dosage forms such as ointments, solutions, lotions, creams, powders, and aerosols. Various topical nonprescription products are also available to improve the appearance of nails during prescription therapy for onychomycosis. These products may decrease nail discoloration and smooth out thick or rough nails.¹

Patients should discuss the use of fungal nail treatments with their primary health care provider prior to use. According to the Handbook of Nonprescription Drugs, cream and solution dosage formulations are considered to be the most effective and efficient dosage forms for delivery of agent to the epidermis, while sprays and powders are considered to be less effective because they are often not rubbed into the skin.¹ Sprays and powders are considered to be useful in conjunction with creams and solutions or as preventive agents for new or recurring infections.¹

Prior to recommending any topical antifungal medication, pharmacists should ascertain whether self-treatment is appropriate and refer patients to their primary health care provider when warranted. Patients with diabetes or circulatory problems or who are immunocompromised should be referred to their primary health care provider prior to using any of these products.¹ The patient’s medical/allergy history and medication profile should be screened for potential contraindications.

During counseling, patients should be advised about the proper use of these products and reminded to adhere to the recommended duration of therapy, which is typically 2 to 4 weeks unless otherwise directed. To achieve optimal therapeutic effect and eradication of tinea infections, patient adherence is critical. In addition, pharmacists can provide patients with information about various nonpharmacologic measures to prevent or decrease the incidence of recurring infections and to prevent transmission of these infections to others (Table 2). Because recurring infections may be a sign of undiagnosed diabetes, immune system disorder, or other medical problem, affected patients should be referred to their primary health care provider.^1,2

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Newton G, Popovich N. Fungal skin infections. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Overview of dermatophytoses. In: Merck Manual for Healthcare Professionals (online edition). www.merckmanuals.com/professional/dermatologic_disorders/fungal_skin_infections/epidermophytonmicrosporumtrichophyton_overview_of_dermatophytoses.html. Accessed December 1, 2013.
• Tinea corporis. In: Merck Manual for Healthcare Professionals (online edition). www.merckmanuals.com/professional/dermatologic_disorders/fungal_skin_infections/tinea_corporis.html. Accessed December 1, 2013.
• Tinea cruris. In: Merck Manual for Healthcare Professionals (online edition). www.merckmanuals.com/professional/dermatologic_disorders/fungal_skin_infections/tinea_cruris.html. Accessed December 1, 2013.
• Tinea pedis. In: Merck Manual for Healthcare Professionals (online edition). www.merckmanuals.com/professional/dermatologic_disorders/fungal_skin_infections/tinea_pedis.html. Accessed December 1, 2013.
• Lotrimin product information. MSD Consumer Care website. www.lotrimin.com/products/index.html. Accessed December 1, 2013.
• Tinactin product information. MSD Consumer Care website. www.tinactin.com/get-the-facts.html. Accessed December 1, 2013.
• Lamisil AT. Novartis Consumer Health website. www.lamisilat.com/products/lamisil-cream-for-jock-itch/drug-facts.shtml. Accessed December 1, 2013.
• Micatin product information. WellSpring Pharmaceutical Corporation website. www.micatin.com/en. Accessed December 1, 2013.