MedicineToday 2014; 15(6): 35-47

PEER REVIEWED FEATURE

2 CPD POINTS

Therapies
for common
cutaneous
fungal
infections
KENG-EE THAI MB BS(Hons), BMedSci(Hons), FACD

Key points
Fungal infection should
always be in the differential
diagnosis of any scaly rash.
Topical antifungal agents are
typically adequate treatment
for simple tinea.
A practical approach to the diagnosis and treatment of common fungal
infections of the skin and hair is provided. Topical antifungal therapies
areeffective and usually used as first-line therapy, with oral antifungals
being saved for recalcitrant infections. Treatment should be for several
weeks at least.

Oral antifungal therapy may
be required for extensive
disease, fungal folliculitis and
tinea involving the face, hair-
bearing areas, palms and
soles.
Tinea should be suspected if
there is unilateral hand
dermatitis and rash on both
feet one hand and two feet
involvement.
Oral antifungal treatments
can often be pulsed intermit
tently, reducing the overall
dose required.
GETTY IMAGES/SPL CREATIVE
T
inea and yeast infections are among the
most common diagnoses found in general
practice and dermatology. Although
antifungal therapies are effective in these
infections, an accurate diagnosis is required to
avoid misuse of these or other topical agents.
Furthermore, subsequent active prevention is
just as important as the initial treatment of the
fungal infection.
This article provides a practical approach
to antifungal therapy for common fungal infec-
tions of the skin and hair. It is not intended to
be an in-depth treatise on dermatomycoses,
and onychomycosis and cutaneous candidiasis
are not covered in detail. The initial section
briefly reviews the practical pharmacology of
dermatophytoses (tinea) and yeast infections
and their differential diagnoses and treatments
are then discussed (Table).
ANTIFUNGAL THERAPIES
Topical antifungal preparations are the most
commonly prescribed agents for dermatomy-
coses, with systemic agents being used for
complex, widespread tinea or when topical agents
fail for tinea or yeast infections. The pharmacol-
ogy of the systemic agents is discussed first here.
Systemic antifungal agents
Terbinafine
Terbinafine is a highly effective antifungal agent,
by virtue of its fungicidal property. It is an ally-

commonly used antifungal agents, in order to lamine and works by inhibiting squalene epoxi-
guide their use. The defining features of various dase. It has greater affinity for fungal squalene

Dr Thai is a Consultant Dermatologist and Visiting Medical Officer at the Epicutaneous Patch Testing Clinic and Hair
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and1 Nail
17/01/12 1:43 PM
Clinic, Prince PageHospital,
of Wales 4 Randwick; a Visiting Medical Officer at the Macquarie University Hospital,
Macquarie Park; and in private practice in Gordon, Sydney, NSW.

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Treating common fungal infections CONTINUED

epoxidase than the human type. Inhibition interactions and there are no contraindi- may reduce absorption of griseofulvin; they
results in a deficiency of ergosterol (an impor- cations to its use with other drugs. How- should be taken two hours after the anti-
tant fungal cell wall constituent) and the ever, because it is an inhibitor of cytochrome fungal agent. Griseofulvin can increase the
accumulation of squalene, both of which P450 2D6, care should be taken when metabolism of warfarin and the contra-
disrupt fungal cell membranes. It is especially administering it to patients taking tricyclic ceptive pill. When co-administered with
effective against infections caused by der- antidepressants and other drugs metabo- alcohol, patients should be warned about
matophytes (Epidermophyton, Micro- lised by this isozyme. the disulfiram-like reaction that can occur.
sporum and Trichophyton).
About 80% of an oral dose of terbinafine Griseofulvin Itraconazole
is absorbed, regardless of food intake, but Griseofulvin was the first important oral Itraconazole, a triazole, is useful in the
first-pass metabolism limits bioavailability antifungal agent available for the treat- treatment of onychomycosis and dermato
to 40%. Terbinafine is lipophilic and thus ment of fungal skin infections. Histori- mycoses. It is also useful for infections
widely distributed, with significant and cally its main use was in the treatment of caused by Candida, Malassezia and some
rapid distribution in skin stratum cor- tinea capitis. Being only fungistatic, it nondermatophyte moulds. It acts by inhib-
neum, sebum, hair and nails. is not as effective as the other agents iting 14-demethylase, resulting in inhi-
High concentrations of the medication described here. bition of ergosterol production from
are reached in the stratum corneum within Treatment needs to be continuous until lanosterol.
hours of commencement of therapy. After mycological and clinical cure when gri- Being a highly lipophilic drug, itracona-
12 days of terbinafine 250mg per day, there seofulvin is used to treat dermatophyte zole is best taken with a meal. A low pH
is enough drug in the skin to maintain a infections. This often leads to protracted gastric environment is also useful to aid
minimum inhibitory concentration (MIC) courses (several weeks to months), espe- absorption. In patients who have relative
for two to three weeks after cessation of cially with onychomycosis, for which up achlorhydria (i.e. those taking H2-antago-
treatment. Terbinafine is found in the dis- to 18 months of treatment may be required. nists, proton pump inhibitors or antacids)
tal nail after one week of therapy, and after It is important to note that griseofulvin or who are taking the drug on an empty
six or more weeks of treatment it is detect- has no activity against the yeasts Candida stomach, absorption is aided by the
able for at least another 30 weeks (indicat- and Malassezia (formerly known as co-administration of a cola soft drink. The
ing the potential for continued action). It Pityrosporum). drug is often used in a pulsatile manner.
is also found in the hair after one week of Typical doses in children are 10 to Itraconazole rapidly presents into the
treatment, and may be detected for up to 15mg/kg daily, with recalcitrant cases stratum corneum and persists for three to
another 50 days after just two weeks of requiring up to 25mg/kg daily, and in four weeks after cessation of therapy. In
treatment. adults, 500mg to 1g daily. The medication the nail, a MIC is achieved after only one
As terbinafine is metabolised in the liver is best taken with a fatty meal to increase week of 200mg itraconazole twice a day.
and the metabolites are excreted in the absorption. For children, the tablets can be After several one-week-per-month pulses
urine, dose adjustment is required in crushed and administered with, for exam- of treatment, the drug can persist for
patients with renal failure where the serum ple, chocolate, full-cream ice cream or months in the nail plate. Appreciable
creatinine level exceeds 300mol/L. With peanut butter. The medication is presented amounts are present in hair after only one
the exception of those with renal insuffi- to the skin via sweat, concentrating in the week of therapy, with higher concentrations
ciency, dose adjustment is not required in stratum corneum. It is quickly cleared from found with longer pulses. Itraconazole can
the elderly. skin and hair after cessation of therapy. persist for up to nine months after cessation
Terbinafine is generally a very safe Although well tolerated, side effects are of therapy.
agent. The most common adverse effects common with the use of griseofulvin and
are headache, gastrointestinal symptoms include headaches, photosensitivity, drug Fluconazole
and drug eruptions; hepatic and haema- rashes, gastrointestinal disturbance, uri- Fluconazole is a commonly used
tological complications are quite uncom- nary and menstrual disturbances, liver broad-spectrum triazole that, like other
mon. Blood counts and liver function tests dysfunction and neurological effects azoles, inhibits 14-demethylase. However,
should be performed if terbinafine is to be (fatigue, mood changes, dizziness, blurred it is much less lipophilic and much less
used continuously for more than six weeks. vision). Changes to spermatogenesis occur, protein-bound than other azoles. It has
One peculiar side effect is a disturbance, and men taking griseofulvin should not very high bioavailability and its absorption
or even loss, of taste in some patients, father children for at least six months after is not affected by food.
which can be irreversible. ceasing
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PM Page 4 When used as a once-a-week 150mg
Terbinafine has no serious drug The use of antacids and H2-antagonists pulse, fluconazole is present in the skin

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TABLE. TREATMENT OPTIONS FOR COMMON CUTANEOUS FUNGAL INFECTIONS

Fungal infection First-line therapy Second-line therapy General notes

Tinea corporis, Topical terbinafine Oral terbinafine 250mg for 2to 4 Keep skin dry
Tinea capitis, Topical imidazoles weeks Identify and eliminate
Tinea cruris, Fluconazole 200mg weekly for 2 to source
Tinea faciei, 4 weeks (off-label use)
Tinea manuum Itraconazole 200mg twice daily for
1 week per month for several
months
Griseofulvin 500mg daily for several
weeks

Tinea incognito Oral agent as above, with topical agent as adjunct Cease topical
corticosteroid use
Identify and eliminate
source

Tinea pedis Topical terbinafine or econazole spray-on Add topical mometasone furoate Dry feet and
interdigital type lotion lotion to reduce inflammation interdigital spaces
Topical miconazole tincture thoroughly, e.g. with
hair dryer
Tinea pedis Topical terbinafine cream Typically needs oral agent
Add antifungal
moccasin type Topical imidazoles Oral terbinafine 200mg daily for 2 to
powders to shoes
4 weeks
Wear open shoes
Fluconazole (off-label use) or
whenever possible,
itraconazole as above
go barefoot at home
Remove shoes under
desk at work

Kerion Oral terbinafine 250mg daily until clinically Fluconazole 200mg weekly until Treat with oral agent
and mycologically cured cured until clinically cured
Antidandruff shampoo daily to reduce Itraconazole 200mg twice daily for and hairs start
shedding of fungal elements 1 week per month regrowing
Cephalexin 500mg three times daily to treat Griseofulvin 500mg daily until cured
secondary bacterial infection Prednisone 0.25 to 0.5mg/kg daily if
significant inflammation or scarring

Seborrhoeic Scalp and body disease: daily antifungal Fluconazole 200mg weekly for Daily scalp
dermatitis shampoo for scalp and body for 10 days; 4 weeks shampooing to
then twice weekly long-term. Treat top half of reduce accumulated
body, down to groin; leave shampoo lather scale
on for 10 minutes each time. Change type of Always use
shampoo with each new bottle conditioner to restore
Facial disease: topical imidazoles or topical moisture to hairs
combination therapy such as hydrocortisone
1% with either miconazole 2% or
clotrimazole 1% creams

Pityriasis Econazole 1% as a foaming solution over Fluconazole 200 mg weekly for Discolouration takes
versicolor 3 nights or antidandruff shampoo as for 4 weeks (off-label use) months to even out
seborrhoeic dermatitis, followed by twice Itraconazole 200mg once daily for
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weekly antifungal shampoo long-term 7to 10 days

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Treating common fungal infections CONTINUED

after the first dose, and with continuous absorbs into and binds the stratum cor- mess. Tinctures are also useful in the toe
therapy can persist several days after neum, sebum and hair follicles. High MICs webs, as they dry the area applied to by
cessation. It is present in the nail after one are achieved in the skin after a few days of virtue of the alcohol base (they are also
dose as well, but after several months of therapy, and its avidity for the keratin layer useful under the nail plate). Some commer-
once-weekly therapy, it is still present in helps prevent reinfection during cial tinctures, however, can stain the
the nail after six months. treatment. tissues.
As the drug is primarily cleared by renal Creams and spray formulations of ter- Antifungal powders can be dusted into
excretion, a dose adjustment is needed binafine are available. Creams are effective skin folds, helping dry the area. However,
when there is renal impairment (creatinine on the body and can be used with little a powder used with any cream can result
clearance, less than 50mL/min). There is irritation in the folds. Spray preparations in a gritty paste, which causes irritation.
no need for dose reduction in renally are useful in the interdigital areas, as the The author finds powders most useful
impaired patients receiving a single dose sprayed lotion dries on the skin, avoiding when placed in shoes; they do not treat
for vaginal candidiasis. maceration. Twice-daily applications are the tinea pedis per se, but can reduce the
Fluconazole is very well tolerated. Head- most practical. rate of re-infection by reducing the fungal
ache, gastrointestinal upset and mild liver Terbinafine is a well-tolerated topical load in the shoes and socks.
function test abnormalities are uncommon. agent and should be considered a first-line Antifungal shampoos are useful in the
At very high doses, anorexia and hair loss therapy for dermatophyte skin infections. treatment of seborrhoeic dermatitis. The
have been reported. It is important to note that it is not effective two key clinical pearls of wisdom are to
against Candida or Malassezia infections. leave the lathered preparation on for up to
Ketoconazole 10 minutes before rinsing to allow the anti-
Oral ketoconazole was deregistered and Imidazoles fungal agents to work, and to regularly
discontinued in Australia and New Zea- The topical imidazole antifungals are the rotate shampoos to reduce the risk of resist-
land in December 2103 because of its risk most commonly prescribed antifungal ance to one active agent. In extensive tinea
of hepatotoxicity. preparations. This group includes ketocona- capitis, antifungal shampoos are used with
Before its discontinuation, oral keto- zole, bifonazole, clotrimazole, econazole and a systemic agent in order to reduce the
conazole was the oldest of the systemic miconazole. They are effective against most spread of fungal spores from the scalp.
imidazoles available for the treatment of dermatophytes and against Candida and A foaming solution of econazole is use-
fungal infections but had been largely Malassezia. Of interest, miconazole and ful in the initial treatment of pityriasis
replaced in clinical practice by terbinafine, econazole also show modest antibacterial versicolor or seborrhoeic dermatitis.
griseofulvin, itraconazole and fluconazole. properties and may be serendipitously A two-part proprietary treatment kit
It was, however, considered still useful in efficacious in treating erythrasma, ecthyma is available for onychomycosis: a urea-
the treatment of widespread pityriasis ver- and mild impetigo. containing ointment that is applied to the
sicolor because of its significant excretion Practically, the various topical prep nail for one to three weeks to soften it,
in eccrine sweat, a 10-day course being arations are equivalent in efficacy. They allowing most of it to be scraped away,
generally regarded as being reasonably safe. should be used twice daily for dermato- and bifonazole cream that is then applied
phyte infections, to increase efficacy and daily for four weeks.
Topical antifungal agents to ensure that if forgotten occasionally, Imidazole preparations formulated with
Topical antifungals are the most common patients are still getting therapy every day. hydrocortisone acetate (as are available for
agents prescribed for dermatomycoses. In Clinicians should become familiar with a clotrimazole and miconazole) have the
general, dermatophyte infections are better few products in different bases, i.e. creams, added benefit of the corticosteroids mild
treated with terbinafine, and yeast infec- lotions, tinctures, powders and shampoos, anti-inflammatory effect. These are useful
tions with the imidazoles. Regardless of allowing different agents to be used in where an inflammatory rash or itch accom-
the treatment used, general measures that d ifferent situations. panies the infection, such as with sebor-
keep infected areas dry and in good con- Topical imidazoles are often used to rhoeic dermatitis on the face and when
dition are just as important. treat tinea pedis. The interdigital spaces there is irritancy and candidal co-infection
are often moist with prolonged use of shoes in tinea of the skin folds.
Terbinafine and socks. Thus, putting a cream prepara-
Being both fungistatic and fungicidal, ter- tion here can perpetuate the maceration Amorolfine
binafine is likely to be the most effective that occurs with tinea infections. Spray-on Amorolfine is a broad-spectrum topical
topical antifungal therapy.
CopyrightAs mentioned
_Layout lotions
1 17/01/12 1:43are
PMuseful
Pagein4 this site, as the product antifungal agent that also acts by disrupting
earlier, it is highly lipophilic and efficiently can dry on the skin and not leave a boggy fungal cell membranes through inhibition

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Treating common fungal infections CONTINUED

treatment of infections that have a signif-
icant inflammatory component. The key
to avoiding misuse of a topical corticoster-
oid in fungal infections is an accurate diag-
nosis in the first instance. Tinea should
always be considered in any eruption that
is scaly or has an annular or serpiginous
appearance, and skin scrapings should be
taken for fungal microscopy and culture.
Once antifungal therapy has com-
Figure 1. Tinea corporis on a leg. Note menced, it is reasonable to occasionally add
the active, advancing border, central in a topical corticosteroid, tailoring the
clearing and scale. Skin scrapings potency to the degree of inflammation, to
should be performed from the edges. reduce the inflammatory itch and discom-
fort. Corticosteroids can also help restore
the integrity of the skin and improve its
of ergosterol synthesis. It is available as an barrier function as the fungal infection is
over-the-counter lacquer paint formulation being treated. Practical examples include
for the treatment of onychomycosis caused adding a corticosteroid lotion to an imida-
by dermatophytes and yeasts. Although zole lotion/spray in the treatment of inflam-
early clinical trials showed some benefit, it matory interdigital tinea, and using topical
is relatively expensive, has variable effec- or systemic corticosteroids in addition to
tiveness and is unlikely to be useful for antifungal therapy in the treatment of
extensive, deep onychomycosis; systemic highly inflammatory tinea capitis in chil-
agents are best used for these infections. dren to reduce hair loss and scarring.
Patients are required to file down the
affected nail and apply the preparation on COMMON CLINICAL
a once- or twice-weekly basis until the DERMATOMYCOSES
onychomycosis is cured. Most patients give Dermatomycoses are caused by dermato-
up with this treatment; of those who do phytes and some yeasts. The three classic
use it for more than a year, less than half sources of dermatophyte infections or
will achieve clinical cure. The role of amo- tinea in humans are animals (zoophilic
rolfine may well be only for white superfi- dermatophytes), the soil (geophilic derma-
cial onychomycosis. tophytes) and other humans (anthropo-
philic dermatophytes). These infections of
Role of topical corticosteroids skin, hair and nails can present in a similar
Traditionally, the use of topical cortico fashion, although the zoophilic types tend
steroids for treating cutaneous infections to be somewhat more inflammatory. It may
has been discouraged. When potent topical be important to identify the source of the
corticosteroids are used on dermatomy- fungus in order to prevent further reinfec-
coses, the annular erythema of the rash tion or spread to others; for example, a new
can be reduced, making it look quite non- guinea pig, cat or other pocket pet may be
specific. Thus the ringworm loses its clas- the source of facial tinea in a young child
sic appearance tinea incognito and (through cuddling of the pet), and a child
misdiagnosis can result. Furthermore, with a kerion may well disseminate the tinea
topical corticosteroids can reduce the to classmates.
bodys inflammatory/immune response to Fungal infections of the skin and hair
the infection and thus facilitate its spread. tend to be treated similarly regardless
The availability of several combination of the specific fungus causing the
products, however, is testament
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fulness of corticosteroids in the adjuvant One common classification of tinea is
based upon the body site infected, and this
is the classification followed in the discus-
sion below of common dermatophyte
infections (tinea infections of the nail
tinea unguium, or onychomycosis are
common but beyond the scope of this arti-
cle). Two Malassezia infections are also
discussed. The treatments of these fungal
infections are summarised in the Table.
Body tinea corporis
Tinea corporis, classically known as ring-
worm, presents as erythematous patches
with scales on the trunk, arms or legs (Fig-
ure 1). There should be an active border
with accentuation of the clinical findings;
this is the spreading edge of the patch of
tinea. Patches may be quite large and exten-
sive with long-term infections, but the
classic features of scale and activity at the
border should be present. Multiple patches
may be found, and tinea in other body sites
should be sought.
Tinea incognito. Patches of tinea inadvert-
ently treated with topical corticosteroids
will look less impressive, with less erythema
and little scale. This disguises the true
nature of the dermatophyte reaction, hence
the term tinea incognito. Rashes that are
spreading or poorly responsive to topical
corticosteroids should prompt the consid-
eration of corticosteroid-modified tinea.
Fungal folliculitis. Fungal folliculitis can
occur in hair-bearing skin, manifesting as
follicular pustules in an area of tinea. It can
be accentuated by the use of topical
corticosteroids.
Differential diagnoses
The many differential diagnoses for the
annular or discoid rash of tinea corporis
include the following:
discoid eczema the dry and scaly
rash is rounded but not often annular
(i.e. no central clearing); it can be
intensely itchy, whereas tinea corporis
may not be
psoriasis is typically a thicker
plaquethan tinea corporis, with
thicker silvery scales, and not annular;
it should be sought on the extensor

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 Treatment
Unless the clinician is absolutely certain of
the diagnosis, skin scrapings from the edge
of an annular rash should always be taken
to diagnose tinea corporis. Microscopy
should show fungal elements, and culture
will identify the variant of fungus and sen-
sitivities to aid treatment. A skin biopsy
can be useful to rule out the more sinister
differential diagnoses.
Figure 2. Kerion of the scalp. As mentioned previously, identification
of the infection source is important to
reduce reinfection. Tinea corporis in an
surface of the elbows and knees individual may be due to autoinoculation
granuloma annulare is also ring-like, from another body site; tinea pedis, tinea
but occurs much more slowly and cruris and onychomycosis should be
insidiously; there is never scale, as it sought.
is a deeper dermal eruption General measures such as fastidious
fixed drug eruptions tend to have a drying of skin folds is important. Treatment
peculiar pigmented, red or purple with topical terbinafine is generally more
appearance, and scale is not often a effective than with an imidazole. Treatment
feature; new lesions occur with should occur twice daily for several weeks,
continued medication use, and older until the rash disappears completely. Any
ones reactivate in the same spot other sources in a patient should be treated,
subacute cutaneous lupus erythema- and strategies for preventing reinfection
tosus can present as an annular and may be needed (such as improving personal
polycyclic eruption that is scaly and hygiene, taking more care in public show-
may have the appearance of an active ering facilities or having the family pet
border, thus looking very much like treated for fungal skin infections).
tinea; however, it is found in a photo- Fungal folliculitis, extensive tinea cor-
distributed area, with worsening after poris, tinea incognito, kerion or any other
solar exposure. Arthritis, facial rash atypical fungal infection should be treated
and other manifestations of cutaneous additionally with an oral antifungal agent.
lupus should be sought Treatment should continue until clinical
annular lichen planus although cure is achieved. Oral terbinafine is highly
typically occurring on the genitals, effective (250mg daily for at least two to
this can inadvertently have an annular four weeks until the rash settles). It is not
appearance on the body. The rash is on the Pharmaceutical Benefits Scheme for
made up of small purple, raised this indication, but generics are available
papules with a characteristic lacy scale that make it a viable option. Fluconazole
(Wickhams striae) on the top of the 150 to 200mg weekly for up to four weeks
papules; itch is often a feature is therapeutic and economical (off-label
erythema annulare centrifugum is use). Itraconazole 200mg twice daily for
one of several rare annular rashes that one week per month is an alternative, but
represent a reaction pattern to a variety the cost in Australia is prohibitive. Oral
of stimuli; in most cases no cause is griseofulvin 500mg daily is a traditional
found. These lesions start as a small treatment, but less efficacious than other
patch or papule that evolves slowly to agents. With any prolonged oral therapy,
a larger annular patch, with a liver function tests may be appropriate
characteristic rim of scale_Layout
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PM Page
free edge on the inner side of the ring. hepatotoxicity.
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Figure 3. Extensive inflammatory
scarring and resultant hair loss around
a kerion of the scalp.
Scalp tinea capitis
The clinical presentation of tinea capitis
can vary greatly. Typically there is a patch
of hair loss with easily extractable hairs but
different species of dermatophyte will cause
differing degrees of scaling and inflamma-
tion. The variants are:
alopecia areata-type discreet patch
of hair loss with dull-grey hairs
coated with the fungal spores
(ectothrix infection)
black dot tinea linear patches with
the hair shafts broken at skin level
(endothrix infection); there is
minimal scale, although a low-grade
folliculitis is often seen
agminate folliculitis (diffuse pustular-
type) a sharply-defined dull red
plaque studded with follicular pustules
kerion a large, boggy, erosive,
pustular, inflammatory mass that
resembles an abscess (Figure 2)
favus a rare variant that has a
characteristic cup-shaped scale at
the base of the hair shaft.
Scarring from excessive inflammation
can lead to permanent hair loss (Figure 3).
Differential diagnosis
Although it is important to recognise other
scalp disorders that can have scale and hair
loss, differentiating tinea capitis is usually
straightforward. Alopecia areata has no
scale associated, nor does trichotilomania.
Seborrhoiec dermatitis should have no hair
loss. Psoriasis has thicker, adherent scale,
and alopecia is not common. Other scarring
x JUNE 2014, VOLUME 15, NUMBER 6 41
Treating common fungal infections CONTINUED

adult men, tinea cruris can occur in teen-

agers and women. Once again, there may
be tinea at other sites, and the feet and nails
should be checked. Scrapings for fungal
microscopy and culture confirm the
diagnosis.
Note that chronic tinea corporis often
involves skin folds and can be rather
recalcitrant to therapy.

Figure 4. Candidiasis in the inguinal Figure 5. Submammary psoriasis. This

Differential diagnosis
region. Note the satellite lesions away can be difficult to differentiate from
Infectious differential diagnoses for tinea
from the main infection. tinea and seborrhoeic dermatitis.
cruris are candidiasis and seborrhoeic
dermatitis:
candidiasis wet, macerated
alopecias such as folliculitis decalvans, recalcitrant cases (up to 1g). erythematous folds with whitish
lichen planopilaris and dissecting cellulitis Should either terbinafine or griseofulvin discharge may be due to candidiasis,
of the scalp are chronic conditions, each be contraindicated, the use of fluconazole which is characterised by the
with a different quality of inflammation. (off-label use) or itraconazole is reasonable. presence of satellite lesions, red
The doses would be as for tinea corporis papules or pustules further away
Treatment but treatment should be continued until from the main front of the
Skin scrapings and hair plucks should be clinical and mycological cure is achieved. erythematous rash (Figure 4). The
sent for fungal microscopy and culture to The daily use of an antidandruff sham- submammary fold is a common site
confirm the diagnosis and help guide poo is also useful to reduce the continued for candidiasis. It is important to
therapy. shedding of spores from the patients scalp. remember that terbinafine is not
As for other types of tinea, other body Furthermore, it may be important to keep effective in the treatment of
sites of fungal infection should be sought a child away from school for the first two candidiasis and that the imidazole
in an attempt to identify a source. Use of weeks of the infection, reducing the risk of antifungals work for both candidiasis
an oral antifungal agent is mandatory spread to his or her schoolmates. and dermatophyte infections
because of the involvement of hair follicles. Although kerion may resemble an seborrhoeic dermatitis can present
Terbinafine is often the first choice, given abscess, incisional drainage is not useful in the flexures (the axillae and pubic
at 250mg daily for several weeks until clin- as there is no cavity, only inflammatory areas are common sites), although it
ical and mycological cure is achieved. The granulation tissue. Often, however, there more often occurs in the scalp and
authors empirical habit is to review treat- is a coexistent bacterial infection. If this is eyebrows and on the face and chest.
ment after six weeks, including a liver the case, an oral antifungal agent and a The rash is pale pink with friable,
function test and looking for settling of the broad-spectrum antibiotic such as loose small scales.
inflammation and regrowth of hairs; fur- cephalexin should be used. Antifungal Noninfectious differential diagnoses
ther therapy may be required. In children, therapy is prolonged, typically at least six for tinea cruris are flexural psoriasis and
the daily dose of terbinafine is adjusted to weeks. Excessive inflammation may lead irritant contact dermatitis:
body weight: for children weighing up to to scarring alopecia; dermatologists may flexural psoriasis has no scale,
20kg, use 62.5mg (i.e. a quarter of a tablet); use oral corticosteroids in some cases to involves the depth of the fold and has
for those weighing 20 to 40kg, use 125mg limit this inflammatory scarring. a characteristic glazed appearance;
(half a tablet); and for those above 40kg, the submammary and the inguinal
use the full adult dose (250 mg; one Skin folds tinea cruris folds are typical sites of involvement
tablet). A typical site for flexural tinea is the ingui- (Figure 5)
Griseofulvin is a traditional agent and nal fold. Tinea cruris is easily diagnosed irritant contact dermatitis dermatitis
is now typically used as a second-line treat- and presents as a flexural erythematous secondary to urine in the folds can be
ment for tinea capitis, at a dose of 500mg/ rash with an active border; there may not seen in infants as napkin dermatitis
day for adults and 10mg/kg/day for children be a lot of scale, given the occluded nature and in the neglectful elderly as an
for six weeks or longer. Higher
Copyright doses1may
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PM Pagebut 4the rash is often itchy. ammoniacal dermatitis. This
be required in children (15mg/kg/day) or Although most commonly ascribed to eczematous rash typically spares

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MedicineToday x JUNE 2014, VOLUME 15, NUMBER 6 43

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Treating common fungal infections CONTINUED

Figure 7. Tinea incognito. Treatment of

tinea faciei with topical corticosteroid Figure 8. Kerion of the moustache
has obscured its classic features. area.

Figure 6. Tinea faciei. The source of

help with the diagnosis. suspected, a history of possible
the infection was a new kitten.
Fungal folliculitis of the beard (tinea exposure needs to be explored
barbae) may be quite inflammatory and rosacea typically affects the
the depths of the folds, although can present as a kerion; hairs are easily convexities of the mid face (cheeks,
not always. Co-infection with extracted (Figure 8). nose, chin). Flushing and blushing are
Candida or the incidental presence of common historical features, and the
a dermatophyte should always be Differential diagnosis rash is of telangiectasias, background
considered. There are multiple differential diagnoses erythema, papules and pustules. There
to be considered with a facial rash. A skin is no active border per se, and rosacea
Treatment scraping should make the diagnosis of tinea often spares the nasolabial folds.
Tinea cruris should be treated the same easier. Occasionally a biopsy can be per- Perioral dermatitis typically occurs
way as tinea corporis, with deliberate dry- formed, though the clinician needs to con- around the peri-alar lip, and extends to
ing of the folds being particularly impor- sider the legacy of a small scar. the skin around the rest of the
tant. A change in underwear style that Differential diagnoses include the cutaneous lip and chin, including the
avoids skin-on-skin contact in the depth following: nasolabial folds. Papules and pustules
of the folds can help aerate the fold and seborrhoeic dermatitis and facial accompany the rash. It is associated in
reduce sweating (i.e. a style where there is psoriasis as well as being difficult to many cases with the use of potent
a layer of fabric on the thigh as well as the distinguish from tinea faciei, these two topical corticosteroids on the face.
genital area; boxer shorts may be too loose conditions can be difficult to cutaneous lupus erythematosus if
and allow the fold to occlude so there is distinguish from each other. Both the rash is photosensitive, lupus
skin against skin). have an erythematous rash with greasy, should be suspected as it can be quite
loose scales but seborrhoeic dermatitis inflammatory, scaly, scarring and
Face tinea faciei, tinea barbae is typically found on the mid face, over annular. Rash should be sought in
Tinea faciei often presents in an annular the eyebrows and paranasal sinuses other parts of the skin, especially the
pattern similar to tinea corporis (Figure 6). (and as dandruff on the scalp) whereas photoexposed areas, and systemic
However, topical corticosteroids are often psoriasis is found on the rest of the illness also. A biopsy is mandatory
prescribed initially, leading to tinea incog- body and on the margins of the scalp if the patient does not respond to
nito (Figure 7). Solar exposure can worsen atopic dermatitis and contact antifungal therapy or if there is
the inflammation. As mentioned earlier, dermatitis atopic dermatitis is systemic illness.
pets may be the source of facial tinea, and common on the face, with the eyelids
the possibility that a new pet is the source affected most often in adults. The skin Treatment
of fungus should be explored. Although tends to be drier than with tinea faciei, Therapy is as for tinea corporis; a systemic
much less commonly recognised than with ill-defined edges to the rash. antifungal is likely to be required for
tinea elsewhere, theCopyright
clinical features
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1:43 PMdermatitis
Page 4 may look similar to extensive disease, folliculitis and beard
annular rash with an active border should atopic eczema; if contact dermatitis is kerion.

44 MedicineToday x JUNE 2014, VOLUME 15, NUMBER 6

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Figure 9. Tinea manuum. Note the
scaly, serpiginous superior border just
above the metacarpophalangeal
joints. Diagnosis is made difficult due
to prior topical corticosteroid use.
Hands tinea manuum
Tinea of the hands can be difficult to diag-
nose and is often confused with pompho-
lyx, hand dermatitis, psoriasis and
keratolysis exfoliativa. A scaly rash that has worm on the dorsum of the feet are easy
an active border should be easily diagnosed
as tinea (Figure 9). More often, the pres-
entation is a dry, slightly scaly and peeling interdigital tinea (athletes foot)
erythema of the palmar surface that can
be confused with dermatitis. It can also be
quite inflammatory, with blisters at the
edge, like p
ompholyx. The rash can affect
both the palmar and dorsal surface in
continuity with each other. A classic
description is that only one hand is
involved; the above-mentioned differential
diagnoses are often symmetrical.
Other areas of co-infection are possible,
and the feet should always be checked as
often there is one hand, two feet involved
with tinea. Onychomycosis can be seen on
the fingernails.
Treatment
Skin scrapings, fungal microscopy and
culture is key to a diagnosis. Topical anti-
fungal agents can be used for small areas.
However, given that tinea manuum can be
extensive and commonly coexist
Copyright with other
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areas of dermatophyte infection, an oral
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Figure 10. Interdigitial tinea pedis. Note
the white, boggy macerated skin in the
depth of the fold, and the associated
inflammatory tinea pedis on the
adjacent skin.
agent may be appropriate (see tinea corpo-
ris). Once again, treatment is until clinical
cure, which can take several weeks.
Feet tinea pedis
The feet are an exceedingly common site
for dermatophyte infections. Spots of ring-
to diagnose, but there are several variants
that clinicians should recognise:
tinea pedis. The chronic dermatophyte
often occurs in the setting of a wet,
macerated webspace, which often has
broken, boggy, white skin (Figure 10).
This should be seen as an infected
irritant intertrigo, where there is both
an inflammatory irritant dermatitis as
well as the dermatophyte infection.
The ringworm component of
interdigital tinea may spread to the
adjacent dorsum of the foot
moccasin tinea describes an
erythematous, scaly fungal infestation
of the plantar surface of the feet, as if
the patient was wearing a pair of
fungal moccasins (Figure 11).
Moccasin tinea is common, and often
missed as many older patients have
dry scaly feet. An active margin at the
sides of the feet, where the erythema
and scale appear to stop, should be
1:43 PMfor.Page
It may
4 coexist with
interdigital tinea. Skin scrapings
MedicineToday
Figure 11. Moccasin tinea pedis. Note
the dry scaly fissured infected skin
involving the entire sole.
should be at the edge of the erythema
for the greatest yield of hyphae
inflammatory tinea highly
inflammatory tinea pedis can have
vesicles, pustules, erosion and
maceration.
Differential diagnosis
Differential diagnoses may include bacte-
rial cellulitis, pustular psoriasis and sec-
ondarily infected pompholyx. Once again,
fungal scrapings for microscopy and cul-
ture are useful, but also bacterial swabs to
rule out a secondary or co-infection.
In patients with recurrent cellulitis of
the legs, it is important to look for and treat
infection creates broken skin, which is the
portal of entry for the bacteria responsible
for cellulitis.
Treatment
General measures are important to keep
the feet as dry as possible. These measures
include:
fastidious drying of the feet and the
toe webs after showering using a
hair dryer on a low heat setting can
help
wearing open shoes when possible, to
air the feet if appropriate, desk-bound
office workers should remove their
shoes when seated to reduce sweating
regular changes of socks, and laundering
at above 60C to decontaminate them
of fungus
use of antifungal powders in shoes to
help prevent reinfection in the future.
With interdigital tinea, therapeutic
x JUNE 2014, VOLUME 15, NUMBER 6 45
Treating common fungal infections CONTINUED

The treatment rationale is that these areas

are where the reservoir of yeast is greatest.
Patients should wait for about 10 minutes
before rinsing off the shampoo, to allow it
time to work. Initial treatment with the
shampoo is every day for seven to 10 days to
eliminate the yeast. Subsequently, a long-
term, twice-weekly, all-over body shampoo
regimen limits further fungal overgrowth.
Patients should buy a different shampoo
Figure 12. Seborrhoeic dermatitis. Figure 13. Pityriasis versicolor. (with a different active ingredient) each time,
thus preventing the development of antifun-
gal resistance. Any flare of disease should
lotions/sprays (e.g. terbinafine spray-on Differential diagnosis trigger a change in shampoo and another
lotion, econazole spray-on lotion or Psoriasis is the most common differential seven to 10-day course of therapy.
miconazole tincture) should be used as they diagnosis for seborrhoeic dermatitis. Pso- Recalcitrant cases can be treated with a
dry on the skin, whereas cream-based prod- riasis, however, has a more chronic course, short course of oral antifungal agent. Various
ucts may encourage more maceration and more intense erythema and a thicker layer regimens are available but a simple one
wetness. If there is excessive inflammation, of scales. Rash should be looked for on more involves fluconazole 200mg once a week for
a topical antifungal can be used in con- pathognomonic sites, such as elbows, knees four weeks. The above antidandruff regimen
junction with a topical corticosteroid lotion, and affected nails. Sometimes it is not pos- should then be used twice weekly as well.
such as mometasone furoate 0.1% drops. sible to differentiate seborrhoeic dermatitis
Moccasin tinea and tinea with inflam- and psoriasis, and the term sebopsoriasis Pityriasis versicolor
matory changes can be recalcitrant to is used. Pityriasis versicolor is another yeast infec-
topical therapy. Should regular use of tion caused by Malassezia. It manifests as
terbinafine or an imidazole cream fail, then Treatment a salmon-pink spotty, scaly rash on fair
a systemic antifungal agent should be As the putative cause of this rash is the over- skin, and as a paler or white spotty, scaly
considered. growth of a commensal organism, treatment rash on darker or tanned skin (Figure 13).
is aimed at reducing the skins yeast load as It is distributed mainly over the back, shoul-
Seborrhoeic dermatitis well as targeting the inflammation. ders, trunk and upper limbs. The infection
Seborrhoeic dermatitis is probably due to Facial dermatitis will usually respond to is most prevalent in the warmer months as
an inflammatory response to Malassezia. a mild topical corticosteroid/imidazole the hot, humid, sweaty conditions favour
This yeast is a commensal organism on combination such as hydrocortisone 1%/ fungal proliferation.
human skin but appears to overgrow in miconazole 2% cream or hydrocortisone
some individuals, leading to an inflamma- 1%/clotrimazole 1% cream used two to three Differential diagnosis
tory reaction. times daily. Alternatively, ketoconazole 2% Pityriasis versicolor may be confused with
Seborrhoeic dermatitis presents as a pale cream can be used alone. For more severe guttate psoriasis. However, the rash of
pink, ill-defined erythematous rash char- inflammation, a mid-potency corticosteroid pityriasis versicolor is macular and the
acterised by loose, flaky scale. Dandruff is can also be used, such as desonide 0.05% scales are powdery and fine, and that of
seborrhoeic dermatitis on the scalp. The lotion. guttate psoriasis consists of small plaques
mid face, along the eyebrows, nasolabial To treat scalp and skin disease as well as with thicker scales.
folds, and cheeks and beard areas are clas- reduce the overall yeast load, an antidandruff
FIGURE 13: GETTY IMAGES/ SPL CREATIVE

sically affected. The rash may also be pres- shampoo is used. Ciclopirox olamine solu- Treatment
ent on the central chest, upper back and in tion has the greatest in vitro fungicidal activ- Topical antifungals are effective for pityri-
the axillae (Figure 12). Seborrhoeic derma- ity, but in practice all antifungal shampoos asis versicolor, but need to be used over a
titis is more common in people who are are equally effective. Patients are advised to large area. Econazole is available as a 1%
psychologically stressed, fatigued or in poor wet the scalp and entire skin, and then turn foaming solution specifically for this pur-
general health. HIV infection and other the shower off. The shampoo is used to lather pose. This is distributed on wet skin after
immunodeficiencies are a common asso- up the scalp hair and as a bodywash to cover an evening shower and left on overnight;
ciation, as are Parkinsons
Copyrightdisease,
_Layoutstroke the 1:43
1 17/01/12 top half
PM of the body,
Page 4 including the face, the top half of the body is treated, including
and other neurological diseases. beard, chest, back, axillae and pubic region. the scalp. Thereafter, a twice-weekly

46 MedicineToday x JUNE 2014, VOLUME 15, NUMBER 6

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antidandruff shampoo regimen is instituted to reduce the rate of
relapse (as for seborrhoeic dermatitis, see above).
Alternatively, recalcitrant cases can be treated with fluconazole
(off-label use) or itraconazole.
The characteristic scaling of pityriasis versicolor is a good
indication of continued activity, as it disappears with effective
fungal clearance. The pink spots disappear over a few weeks, but
repigmentation may take months. Patients are advised that should
they subject themselves to a suntan within the next few months,
the previously affected spots can look very obviously pale. When
the next summer does come, patients can use the twice-weekly
antidandruff shampoo regimen to reduce the risk of the yeast
repopulating their skin.

CONCLUSION
The key to the effective use of antifungal agents is an initial
accurate diagnosis of the fungal infection. The classic finding
of the active border and fine scale is pathognomonic of tinea,
and dermatophyte infection should always be in the differential
diagnosis when dealing with red, scaly rashes.
Topical antifungal preparations are usually adequate treatment
for simple tinea but systemic antifungal treatment should be
considered with complex, widespread tinea or when topical agents
fail. A relatively dry skin is an important general treatment
measure. MT

FURTHER READING
Mycology Online. University of Adelaide. http://mycology.adelaide.edu.au/
Mycoses/Cutaneous/Dermatophytosis (accessed May 2014).

UpToDate. Dermatophyte infections. http://uptodate.com/contents/

dermatophyte-tinea-infections (accessed May 2014).

DermnetNZ. http://dermnetnz.org/fungal/tinea.html (accessed May 2014).

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