The treatment of superficial fungal infections caused by dermatophytic fungi may be accomplished (1) with topical antifungal agents, eg, clotrimazole, efinaconazole, econazole, ketoconazole, luliconazole, miconazole, oxiconazole, sertaconazole, sulconazole, ciclopirox olamine, naftifine, terbinafine, butenafine, and tolnaftate; or (2) with orally administered agents, ie, griseofulvin, terbinafine, fluconazole, and itraconazole. Their mechanisms of action are described in Chapter 48. Superficial infections caused by Candida species may be treated with topical applications of clotrimazole, miconazole, econazole, ketoconazole, oxiconazole, ciclopirox olamine, nystatin, or amphotericin B.
The topical imidazoles, which include clotrimazole, econazole, ketoconazole, luliconazole, miconazole, oxiconazole, sertaconazole, and sulconazole, have a wide range of activity against dermatophytes (Epidermophyton, Microsporum, and Trichophyton) and yeasts, including Candida albicans and Pityrosporum orbiculare (see Chapter 48).
Miconazole (Monistat, Micatin) is available for topical application as a cream or lotion and as vaginal cream or suppositories for use in vulvovaginal candidiasis. Clotrimazole (Lotrimin, Mycelex) is available for topical application to the skin as a cream or lotion and as vaginal cream and tablets for use in vulvovaginal candidiasis.
Efinaconazole (Jublia) is available as a 10% solution for the treatment of onychomycosis of the toenails. Daily application to affected toenails should be continued for 48 weeks.
Complete cure rates in clinical trials are between 15% and 18%. Econazole (Spectazole) is available as a cream for topical application. Oxiconazole (Oxistat) is available as a cream and lotion for topical use. Ketoconazole (Nizoral) is available as a cream for topical treatment of dermatophytosis and candidiasis and as a shampoo or foam for the treatment of seborrheic dermatitis. Luliconazole (Luzu) is available as a cream. Sulconazole (Exelderm) is available as a cream or solution. Sertaconazole (Ertaczo) is available as a cream. Topical antifungal-corticosteroid fixed combinations have been introduced on the basis of providing more rapid symptomatic improvement than an antifungal agent alone. Clotrimazole-betamethasone dipropionate cream (Lotrisone) is one such combination.
Onceor twice-daily application to the affected area will generally result in clearing of superficial dermatophyte infections in 2–3 weeks, although the medication should be continued until eradication of the organism is confirmed. Paronychial and intertriginous candidiasis can be treated effectively by any of these agents when applied three or four times daily. Seborrheic dermatitis should be treated with twice-daily applications of ketoconazole until clinical clearing is obtained.
Adverse local reactions to the imidazoles may include stinging, pruritus, erythema, and local irritation. Allergic contact dermatitis is uncommon.
Ciclopirox olamine is a synthetic broad-spectrum antimycotic agent with inhibitory activity against dermatophytes, Candida species, and P orbiculare. This agent inhibits the uptake of precursors of macromolecular synthesis; the site of action is probably the fungal cell membrane.