SYSTEMIC & TOPICAL

ANTIFUNGALS
Talla, Viea
Tan De Guzman, Anne Tiffany
Tan, Alfred
SYSTEMIC
ANTIFUNGALS
 SYSTEMIC ANTIFUNGALS

TERBINAFINE
01

ITRACONAZOLE
02

FLUCONAZOLE
03

GRISEOFULVIN
04 (Not available in the Philippines)
 INDICATIONS:

1. Nail and hair infections

2. Reserved for widespread and more inflammatory
eruptions
a. Body Surface Area involvement >10%
b. Chronic or recurrent infections
c. Comorbidities
d. Elderly

Ellis, D., & Watson, A. (1996). Systemic antifungal agents for cutaneous fungal infections.
 REVIEW

● Dermatophytes: pathogenic fungus

that grows on the skin/hair/nails
● Transmission:
○ Direct contact
○ Animals
○ Soil
○ Fomites
● Principal etiologic agents:
○ Genera TRICHOPHYTON,
MICROSPORUM, and
EPIDERMOPHYTON
○ MALASSEZIA FURFUR
○ CANDIDA ALBICANS and
related species

Hainer, B. L. (2003). Dermatophyte infections. American family physician, 67(1), 101-108.

 TERBINAFINE
● MOA: An allylamine compound that inhibits squalene
epoxidase (fungicidal)
● Cream, powder, solution, spray, gel 1%, 250mg tablet
● PK: Lipophilic, distributing well into hair follicles, skin,
nails with minimal plasma concentrations and a long half
life
● SE:
○ Headache
○ GI symptoms (diarrhea, dyspepsia, abdominal pain,
nausea, flatulence)
○ Dermatologic (rash, pruritis, urticaria)
○ Severe: hepatotoxicity, hematologic disorders,
SJS-TEN
● CONRAINDICATED:
○ Patients with chronic/active liver disease
○ Hypersensitivity
● PREGNANCY CATEGORY: B
● COST: PHP 280/250mg tablet
Wolverton Comprehensive Dermatologic Drug Therapy
 TERBINAFINE
INDICATIONS AND DOSAGE:
Dermatophyte Onychomycosis Adult: 250 mg OD, 6 or 12 weeks
Children:
Tablets OD for 2-6 (T. tonsurans) or
8-12 weeks (M. canis)
○ 10-20 kg - 62.5 mg/day
FDA-
Tinea Capitis ○ 21-40 kg - 125 mg/day
Approved
○ >40 kg - 250 mg/day
Granules OD for 6 weeks
○ <25 kg: 125 mg
○ 25-35 kg: 187.5 mg
○ >35 kg: 250 mg

Tinea Corporis/Cruris 250 mg OD, 2-4 weeks

TInea Pedis 250 mg OD, 2-6 weeks
Off-Label
Seborrheic Dermatitis 250 mg OD, 4 weeks
Deep fungal infections 500-1000 mg, OD

Wolverton Comprehensive Dermatologic Drug Therapy

 ITRACONAZOLE
● MOA: a triazole that inhibits lanosterol demethylase (fungistatic)
● Capsule, Oral suspension, IV, Tablet
● PK:
○ Capsules: highest levels with full meal
○ Reaches skin via passive diffusion from plasma to the
keratinocytes
○ Reaches hair via sebum and incorporation into the hair follicle
● INDICATIONS:
○ FDA-A
■ Onychomycosis: dermatophyte
■ Oropharyngeal candidiasis
■ Esophageal candidiasis
■ Systemic mycoses (Blastomycosis, Histoplasmosis,
Aspergillosis)
○ Off-label uses
■ Tinea corporis/cruris
■ Tinea pedis
■ Pityriasis versicolor
■ Seborrheic dermatitis
○ Prophylaxis of tinea versicolor

Wolverton Comprehensive Dermatologic Drug Therapy

 ITRACONAZOLE (AZOLE)
INDICATIONS AND DOSAGE:

Indication Dose Duration

Toenail +/- fingernail: 200 mg OD

Toenail +/- fingernail: 12 weeks
Dermatophyte
Fingernail: Pulse dosing, with each
onychomycosis
pulse being 200 mg BID for 1 week Fingernail: 2 pulses
per month

7-14 days for initial therapy, up to

Oropharyngeal candidiasis Oral solution 200 mg OD
28 days for refractory disease

Esophageal candidiasis Oral solution 200 mg OD 14-28 days

Wolverton, S., & Wu, J. (2020). Comprehensive dermatologic drug therapy (4th ed., pp. 99-113). Philadelphia: Elsevier.
 ITRACONAZOLE
INDICATIONS AND DOSAGE:

Indication Dose Duration

Continuous: 200 mg OD
Candida onychomycosis Pulse: 1 week a month
Pulse: 400 mg OD

Continuous: 4-8 weeks

Capsule or tablet: 5 mg/kg OD
Tinea capitis Pulse: 1 week a month, for 2-4
Oral solution: 3 mg/kg OD
months

Tinea corporis/cruris 200 mg OD 1 week

Tinea pedis 100 mg OD 4 weeks

Prophylaxis for tinea

400 mg single dose Once a month for 6 months
versicolor

Wolverton, S., & Wu, J. (2020). Comprehensive dermatologic drug therapy (4th ed., pp. 99-113). Philadelphia: Elsevier.
 ITRACONAZOLE
● SE:
○ Headache, GI symptoms,
○ Cutaneous disorders (e.g., erythema multiforme,
angioedema)
○ Cardiovascular events (prolongation of QT
interval, ventricular tachycardia, etc.)
● CONTRAINDICATIONS:
○ Ventricular dysfunction/proarrhythmia
○ Hypersensitivity
○ Drug interactions
○ Active liver disease
● PREGNANCY CATEGORY: C
● COST:
○ 100mg: PHP 80/capsule (Canditral)

Wolverton Comprehensive Dermatologic Drug Therapy

 FLUCONAZOLE
● MOA: an triazole that inhibits lanosterol demethylase
(fungistatic)
● Tablet, Oral suspension, IV
● PK:
○ Highest percent bioavailability
○ Hydrophilic; Reaches skin through sweat and direct
diffusion
○ Half-life = ~24 hours
● SE: Headache, nausea, vomiting, abdominal pain, diarrhea
● CONTRAINDICATIONS:
○ Ventricular dysfunction/proarrhythmia
○ Drug interactions involving QT prolongation
○ Hypersensitivity
● PREGNANCY CATEGORY: C,D
● COST:
○ 50mg: PHP 150/capsule (mycozole)
○ 150mg: PHP 300/capsule (difluvid)
○ 200mg: PHP 760/capsule (funzela)
Wolverton Comprehensive Dermatologic Drug Therapy
 FLUCONAZOLE
● INDICATIONS:
○ FDA-A
■ Candidiasis (vaginal, oropharyngeal, esophageal)
○ Cryptococcal meningitis: 400-600 mg daily
○ Prophylaxis against candidiasis in immunocompromised
○ Off-label uses
■ Onychomycosis
■ Dermatophytosis
■ Cutaneous candidiasis
■ Chronic mucocutaneous candidiasis
■ Pityriasis Versicolor

Wolverton Comprehensive Dermatologic Drug Therapy

 Fluconazole
INDICATIONS AND DOSAGE:

Indication Dose Duration

Candida onychomycosis 50 mg OD
Fingernails: 6 weeks
or
Toenails: 3 months
300 mg pulse therapy once weekly

Dermatophyte onychomycosis Fingernails: 3-6 months

150-300 mg once weekly
Toenails: 9-12 months

Tinea corporis/cruris/pedis 150-300 mg once weekly (corporis/cruris) 2-4 weeks (corporis/cruris)

150 mg once weekly (pedis) 2-6 weeks (pedis)

Pityriasis versicolor 300 mg once weekly 1-4 weeks

Coccidioidal meningitis 400-600 mg OD 12 months

Prophylaxis 200-400 mg OD

Wolverton, S., & Wu, J. (2020). Comprehensive dermatologic drug therapy (4th ed., pp. 99-113). Philadelphia: Elsevier.
 GRUSEOFULVIN
● MOA: currently unclear
○ Binds to keratin in newly forming skin and
protects it from new infections
● Indications:
1. Systemic treatment of dermatophytosis
2. FDA approved for tinea capitis in children over 2
years old
● Adverse effects:
○ Allergic syndrome (serum sickness, skin
reaction)
○ Lupus-like syndrome
○ Hepatotoxicity
● NOT AVAILABLE IN THE PH
 TOPICAL
ANTIFUNGALS
 TOPICAL ANTIFUNGALS

POLYENES
01 Nystatin

AZOLES
02 Miconazole, Clotrimazole, Ketoconazole, Sertaconazole, Econazole

ALLYLAMINES, BENZYLAMINES
03 Terbinafine

OTHERS
04 Selenium sulfide, Amorolfine
 POLYENE

MOA ORGANISMS ADVERSE

Binds to ergosterol and ADDRESSED EFFECTS
alters permeability of Yeast infections Burning
the cell (Candida) Pruritus
Rash
Eczema
Pain on application
Hypersensitivity
reaction
 NYSTATIN
● TOPICAL ONLY
● Indications:
Oropharyngeal thrush 100,000 units 4x daily 7-14 days
suspennsion

Vaginal Candidiasis 100,000 units vaginal Once daily (Bedtime) 14 days

supposiitory/cream

Cutaneous Topical cream Apply 2-4 times a day 2-8 weeks

Candidiasis

● Contraindications
○ Hypersensitivity
● Adverse effects
○ Burning, pruritus, rash, eczema, pain on application, hypersensitivity reaction
● Pregnancy category: C
 NYSTATIN
● Available Locally as:
○ Triamcinolone acetonide 0.1%, Neomycin sulfate 0.25%, Gramicidin 0.025%, Nystatin
100,000 units/g (Nyscomb/Oticom)
○ Clobetasol propionate 0.5 mg, Neomycin sulfate 5 mg and Nystatin 100 000 units
(Dermovate NN)
○ Nystatin suspension (Orastin/Mycosyl)
○ Nystatin+Metronidazole (Flagystatin)
● Cost

Suspension

Watsons P349.25/12mL

South Star Drug P325/12mL

Rose Pharmacy P556/30mL

 AZOLES

MOA ORGANISMS ADVERSE

Inhibits ergosterol ADDRESSED EFFECTS
synthesis blocking Dermatophytes, Irritation
14ɑ-demethylation of Malassezia furfur, Candida Burning
lanosterol Maceration
Allergic dermatitis
 MICONAZOLE
● Indications:

Tinea pedis, tinea corporis, 2x daily 2-6 weeks

tinea cruris, cutaneous
candidiasis Cream

Pityriasis versicolor Once a day 2-6 weeks

Vaginal Candidiasis 1 dose, Repeat after 3 days if

Vaginal suppository
bedtime necessary

● Contraindications: Hypersensitivity.
● Adverse effects:
○ Irritation, burning, maceration, allergic dermatitis
● Pregnancy Category: C
 MICONAZOLE
● Available Locally as:
○ Miconazole nitrate (Micotran) vaginal suppository
○ Miconazole nitrate (Daktarin) cream/2% oral gel
○ Metronidazole+Miconazole nitrate (Metindaz, Metromic, Trimic)
● Cost

Miconazole nitrate
cream (Daktarin)

Watsons P399.75

South Star Drug P398.75

Rose Pharmacy P401.75

 CLOTRIMAZOLE
● Indications:

Tinea corporis, Tinea 1% cream BID/TID 2-6 weeks

cruris

Pityriasis versicolor 1% cream BID/TID 2-6 weeks

Cutaneous Otitis externa: 1% soln Otic: BID/TID 2 weeks

candidiasis Vaginal pessary (100mg) Vaginal: depends Depends

● Contraindications: Hypersensitivity
● Adverse effects:
○ Erythema, burning, irritation, stinging, peeling, blistering edema, pruritus, urticaria
● Pregnancy Category: B
 CLOTRIMAZOLE
● Available Locally as:
○ Clotrimazole 1% solution
○ Clotrimazole 1-2% cream
○ Vaginal suppository, 10% vaginal cream
○ Betamethasone 0.064% + Clotrimazole 1% cream (Clotrasone)
○ Hydrocortisone + Clotrimazole cream (Candacort)
● Cost

1% Clotrimazole
cream

Watsons P429/15mL

South Star Drug P119/3g

Rose Pharmacy P156.50/5g

 KETOCONAZOLE
● Indications:
Tinea corporis, Tinea 2% cream OD-BID 4-6 weeks
cruris, Tinea pedis,
Pityriasis versicolor,
Cutaneous
candidiasis

Seborrheic dermatitis 2% shampoo 3-4 times a week Until resolution

● Contraindications: Hypersensitivity
● Adverse effects:
○ Irritation, pruritus, stinging, pain on site of application
● Pregnancy Category: C
 KETOCONAZOLE
● Available Locally as:
○ 2% ketoconazole + zinc shampoo (Dermazole, Scalpex)
○ 2% ketoconazole cream (Nizoral)
● Cost:

2% Ketoconazole 2% Ketoconazole
cream Shampoo (Nizoral)

Watsons P360/10g P62.00/6mL

South Star Drug P215.50/5g P59.75/6mL

Rose Pharmacy P361.50/10g P67.00/6mL

 ECONAZOLE
● Derived from Miconazole
● Fungistatic but may be fungicidal
● Some activity against gram-positive and gram-negative organisms

Indications Dose

Tinea pedis Adults and children (12y/o below): 10mg/1mg

per gram; OD for 4 weeks

Pityriasis versicolor 10mg/1mg per gram; OD for 2 weeks

Tinea corporis
Tinea cruris

Cutaneous candidiasis 10mg/1mg per gram; BID for 2 weeks

Contraindications:
- Hypersensitivity
 ECONAZOLE

Adverse Effects:
- Burning/stinging sensation, pruritus, erythema, rash

Pregnancy Category: C

Local product: Nizolex 1% cream (with triamconolone)

Nizolex 1% 10mg Cream

South Star Drug P182/10mg cream

 SERTACONAZOLE
● Can be either fungistatic or fungicidal
● Relatively lipophilic
● Modest activity against Gram-Positive bacteria

Indications:
- Tinea pedis: BID for 4 weeks

Contraindications:
- Hypersensitivity

Adverse Effects:
- Allergic contact dermatitis
 SERTACONAZOLE
Pregnancy Category: C

Local product: Onabet 2% cream

Sertaconazole 20mg/g Cream

Watsons P671.75/20g cream

South Star Drug P670.80/20g cream

ALLYLAMINE/
BENZYLAMINES
ALLYLAMINE/BENZYLAMINES
● Broad-spectrum antifungal agents
● Fungistatic & fungicidal activity
● MOA: Inhibits ergosterol synthesis

ALLYLAMINE BENZYLAMINE
Naftifine Butenafine
Terbinafine
 TERBINAFINE
● Fungistatic and fungicidal activity
● Highly lipophilic
○ High concentration and binding to the stratum corneum, sebum
& hair follicles
● MOA: squalene epoxidase inhibition

Indications:
- Dermatophyte infections, P. Versicolor: OD or BID for 1-2 weeks

Contraindications:
- Hypersensitivity, chronic or active liver disease, lactation
 TERBINAFINE
Adverse Effects:
- Pruritus, acute contact dermatitis, irritation, burning/tingling
sensation, dryness at application site

Pregnancy Category: B

Local product: Lamisil AF 1% cream, RiteMED Terbinafine HCl 15g cream

Terbinafine 10mg/g 1% 10g cream

South Star Drug P465.25/10g cream

Rose Pharmacy P473/10g cream

OTHERS
 SELENIUM SULFIDE
● Liquid antiseborrheic, antifungal (2.5% lotion)
● Cytostatic on the epidermal and follicular epithelial cells

Indications:
- Dandruff, seborrheic dermatitis of the scalp: OD/BID for 2 weeks
- Pityriasis versicolor: OD for 7 days

Contraindications:
- Hypersensitivity, broken or severely inflamed skin

Adverse Effects:
- Skin irritation, oily or dry skin/hair, temporary hair loss

Pregnancy Category: C

Local product: Selsun Blue 1% shampoo

 SELENIUM SULFIDE
Indications:
- Dandruff, seborrheic dermatitis of the scalp: OD/BID for 2 weeks
- Pityriasis versicolor: OD for 7 days

Local product: Selsun Blue 1% shampoo

Selsun Blue Shampoo 120mL

Watsons P345/120mL
 AMOROLFINE
● Morpholine derivative
● Affects fungal cell membranes via sterol biosynthesis inference

Indications:
- Skin fungal infections: OD for 2-3 weeks, continue for 3-5 days
- Nail fungal infections: 1-2x weekly for 6-12 months

Contraindications:
- Hypersensitivity,
-
 AMOROLFINE
Adverse Effects: hypersensitivity reactions, skin irritation, erythema,
pruritus, contact dermatitis, urticaria, blisters

Pregnancy Category: C

Local product: Locetar 5% nail lacquer

Amorolfine 5% Nail Lacquer 2.5mL

Rose Pharmacy P2866/2.5mL

 CONTENTS OF THIS TEMPLATE
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 INTRODUCTION
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 MISSION
Mercury is the closest planet to
the Sun and the smallest one in
the Solar System. It’s only larger
than the Moon
VISION
Venus has a beautiful name and
is the second planet from the
Sun. It’s terribly hot, even hotter
than Mercury
01 OUR CENTER
You can enter a subtitle here if you need it
 OUR CENTER
Venus has a beautiful name and is the
second planet from the Sun. It’s terribly
hot—even hotter than Mercury—and its
atmosphere is extremely poisonous
 “This is a quote, words full of wisdom
that someone important said and can
make the reader get inspired.”

—SOMEONE FAMOUS
 KEY NUMBERS

20,000
This is the number
of patients we had
+50% last month +68%
Increase in the Increase in the
number of patients number of visitors we
we had last month had last month
 THIS IS A GRAPH

16% 34%
Jupiter is the biggest Venus has a beautiful
planet of them all name, but it’s hot

22% 28%
Mercury is the closest Despite being red,
planet to the Sun Mars is a cold place

To modify this graph, click on it, follow the link, change

the data and paste the new graph here
 A BRIEF STORY

MARS NEPTUNE
Despite being red, It’s the farthest
Mars is cold from the Sun

2014 2016 2017 2018 2020

JUPITER MERCURY VENUS

Jupiter is the Mercury is the Venus has a
biggest of them all closest to the Sun beautiful name
 MILESTONES REACHED
2016 2020
Despite being red, Venus has a
Mars is a cold place beautiful name

01 02 03 04

2014 2018
Jupiter is the biggest Mercury is the
planet closest to the Sun
 OUR PROCESS

01 02
Jupiter is the biggest Venus has a beautiful
planet of them all name, but it’s hot

03 04
Mercury is the closest Despite being red,
planet to the Sun Mars is a cold place
PATIENT CARE
Mercury is the closest planet to the
Sun and the smallest one in the Solar
System—it’s only a bit larger than the
Moon. The planet’s name has nothing
to do with the liquid metal
 AREAS WE COVER

VENUS
Venus has a beautiful
name, but it’s hot

MERCURY MARS
Mercury is the closest Despite being red,
planet to the Sun Mars is a cold place
SYSTEMIC
ANTIFUNGALS
 SERVICES

A B C D
Mercury is the It has a beautiful Despite being Saturn is a gas
closest planet to name, but it’s red, Mars is a giant and has
the Sun hot cold place several rings
KEY ACCOMPLISHMENTS

A
JUPITER
Jupiter is the biggest planet of them all

B
VENUS
Venus has a beautiful name, but it’s hot

C MARS
Despite being red, Mars is a cold place
 PATIENT SATISFACTION

95% Mercury is the closest

planet to the Sun and the
smallest one in the Solar
System. It’s only a larger
than the Moon
 INNOVATIONS

MERCURY VENUS MARS

Mercury is the closest Venus has a beautiful Despite being red, Mars
planet to the Sun name, but it’s very hot is a cold place
 QUALITY IMPROVEMENT MEASURES

Mercury is the closest Venus has a beautiful Despite being red, Mars
planet to the Sun name, but it’s very hot is a cold place

Saturn is a gas giant It’s the biggest planet It’s the farthest planet
and has several rings in the Solar System from the Sun
 TESTIMONIALS

JENNA DOE, 25 JOHN JAMES, 36

“Neptune is the fourth-largest planet “Mercury is the closest planet to the
by diameter in the Solar System” Sun and the smallest one”

FRED BLOGGS, 31 HELENA SMITH, 58

“Despite being red, Mars is actually a “Saturn is composed mostly of
very cold place” hydrogen and helium”
 AWARDS

2004 2010 2014 2018

+ 5000 + 80,000 + 6,000 + 50,000

Mercury is the Saturn is a gas Venus has a Jupiter is the

smallest planet giant and has rings beautiful name biggest of them all
 WHERE ARE WE?

Despite being red, Mars is a very cold place

 OUR TEAM

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