Journal of Dermatological Treatment

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The association of isoconazole–diflucortolone in

the treatment of pediatric tinea corporis

Stefano Veraldi, Rossana Schianchi, Paolo Pontini & Alberto Gorani

To cite this article: Stefano Veraldi, Rossana Schianchi, Paolo Pontini & Alberto Gorani (2018)
The association of isoconazole–diflucortolone in the treatment of pediatric tinea corporis, Journal of
Dermatological Treatment, 29:2, 200-201, DOI: 10.1080/09546634.2017.1360988

To link to this article: https://doi.org/10.1080/09546634.2017.1360988

Accepted author version posted online: 28

Jul 2017.
Published online: 19 Sep 2017.

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JOURNAL OF DERMATOLOGICAL TREATMENT, 2018
VOL. 29, NO. 2, 200–201
https://doi.org/10.1080/09546634.2017.1360988

ORIGINAL ARTICLE

The association of isoconazole–diflucortolone in the treatment of pediatric

tinea corporis
Stefano Veraldia, Rossana Schianchib, Paolo Pontinia and Alberto Gorania
a
Department of Pathophysiology and Transplantation, Universit
a degli Studi di Milano, I.R.C.C.S. Foundation, C
a Granda Ospedale Maggiore
Policlinico, Milan, Italy; bCentro Dermatologico Milanese (C.D.M.), Milan, Italy

ABSTRACT ARTICLE HISTORY

Background: Tinea corporis is a common mycotic infection in children. Staphylococcus aureus superinfec- Received 5 July 2017
tions may be observed in atopic children with tinea corporis suffering from severe pruritus and conse- Accepted 24 July 2017
quent scratching.
Objective: From 2006 to 2011, we observed 288 children with mycologically proven tinea corporis. In 39
KEYWORDS
of them (13.5%) tinea corporis was superinfected by S. aureus: all these children were affected by atopic Atopic dermatitis; children;
dermatitis. We interpreted these bacterial superinfections as the clinical result of scratching due to diflucortolone valerate;
pruritus. isoconazole nitrate;
Methods: In 2012, we decided to treat all children with a single lesion of tinea corporis with a combin- Staphylococcus aureus; tinea
ation of 1% isoconazole nitrate and 0.1% diflucortolone valerate cream (one application/day for 5–7 days), corporis
followed by a treatment with isoconazole or clotrimazole or ciclopirox cream (two applications/day for
two weeks).
Results: From 2012 to 2014, we observed 108 children with tinea corporis confirmed by mycological
examinations. Clinical and mycological recovery was observed in 93 of them (86.1%). Only four of these
children (3.7%) developed S. aureus superinfections.
Conclusions: Our study in atopic children with tinea corporis superinfected by S. aureus confirms that a
topical therapy with the association isoconazole–diflucortolone is useful and safe.

Introduction
Tinea corporis is a common mycotic infection in children.
Transmission is due to contacts with animals, humans, and soil.
Microsporum canis, Trichophyton rubrum, Trichophyton mentagro-
phytes, and Microsporum gypseum are the species more frequently
involved. Latency time ranges from one to three weeks. The face
and upper limbs are usually involved. Tinea corporis presents with
a single round or oval erythematous lesion, with scales in the cen-
ter and well defined, vescicular borders. Pruritus is usually mild to
moderate (1). Staphylococcus aureus superinfections may be
observed in atopic children suffering from severe pruritus and
consequent scratching. We present the results of a sponsor-free
study about the use of the topical association isoconazole–diflu-
cortolone in children with tinea corporis.
Patients and methods
From 2006 to 2011, we observed 288 children, aged between 4
and 12 years, with mycologically proven tinea corporis. In 39 of
them (13.5%) tinea corporis was superinfected by S. aureus: all
these children were affected by atopic dermatitis. We interpreted
these bacterial superinfections as the clinical result of scratching
due to pruritus. In 2012, we decided to treat all children with a
single lesion of tinea corporis with a combination of 1% isocona-
zole nitrate and 0.1% diflucortolone valerate cream (one applica-
tion/day for 5–7 days), followed by a treatment with isoconazole
or clotrimazole or ciclopirox cream (two applications/day for two
weeks).
Results
From 2012 to 2014, we observed 108 children, aged between 4
and 11 years, with tinea corporis confirmed by mycological exami-
nations. Clinical and mycological recovery was observed in 93
of them (86.1%). Only four of these children (3.7%) developed
S. aureus superinfections.
Discussion
As previously mentioned, we believe that staphylococcal superin-
fections of tinea corporis in atopic children are due to scratching.
A once daily application of isoconazole and diflucortolone cream
for 5–7 days, followed by the application of a specific antimycotic,
reduces the itching, the scratching, and bacterial superinfections.
Furthermore, it was demonstrated that isoconazole is effective
in vitro on S. aureus: the minimal inhibitory concentration was
6.3 lg ml 1 (2–6). However, isoconazole has no activity on Gram-
negative bacteria (4,5). The antibacterial action of isoconazole
involves an increase in reactive oxygen substances (ROS). The
increased ROS levels within bacteria results in oxidative stress that
causes apoptosis and cell death (5). In 2012, two of us (SV and RS)
published the results of a multicenter, sponsor-free study that
evaluated the clinical and mycological efficacy and tolerability of
the combination isoconazole–diflucortolone cream (twice daily for
one week, followed by isoconazole cream alone, twice daily for
two weeks) compared with a monotherapy with isoconazole
cream (twice daily for three weeks) in adult patients with tinea
inguinalis. The combination isoconazole–diflucortolone was

CONTACT Stefano Veraldi stefano.veraldi@unimi.it Dermatology Unit, University of Milan, Via Pace 9, 20122 Milan, Italy
ß 2017 Informa UK Limited, trading as Taylor & Francis Group

superior to isoconazole alone regarding erythema and pruritus:
both of them resolved in a larger percentage of patients and
more quickly. No side effects were reported or observed in both
groups. Mycological cure rates were similar in both groups: 83.9%
in the monotherapy group and 85.2% in the combination group
(7). The combination isoconazole–diflucortolone showed to be
effective in some anedoctical cases of tinea corporis (8), tinea cru-
ris (9–11), tinea pedis (12–14), tinea incognito (15), and intertrigo
(16–19) and balanitis (18) by Candida albicans. Our study in atopic
children with tinea corporis superinfected by S. aureus confirms
that a topical therapy with the association isoconazole–diflucorto-
lone can be useful for several reasons: (a) isoconazole eradicates
causative microorganisms, (b) diflucortolone induces a rapid
improvement of pruritus, (c) another benefit is the increased bio-
availability of isoconazole in the skin, when it is applied together
with diflucortolone: due to the local vasoconstrictive action of
diflucortolone, the dispersal of isoconazole via the circulation is
delayed (20,21). After 24 h of exposure to the combination isoco-
nazole–diflucortolone, epidermal, and dermal isoconazole concen-
trations reach 120 and 13 lg ml 1, respectively, compared to 40
and 4 lg ml 1, respectively, for isoconazole alone (21): the dur-
ation of antimycotic activity is therefore prolonged, (d) the incorp-
oration of a corticosteroid reduces the risks of irritant and allergic
contact dermatitis that can be caused by topical antimycotics, (e)
finally, the incorporation of a topical corticosteroid reduces
scratching and the incidence of bacterial superinfections. Similar
clinical results were observed in single pediatric cases of tinea cor-
poris (22–25). The possibility that topical corticosteroids induce
skin atrophy is purely theoretical, if we consider the single daily
application and the duration (5–7 days).
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
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