, Volume 166, Issue 5–6, pp 353–367 | Cite as

Update in Antifungal Therapy of Dermatophytosis

  • Aditya K. GuptaEmail author
  • Elizabeth A. Cooper


Treatment of dermatophyte infection involves primarily oral and/or topical formulations of azoles or allylamines, particularly itraconazole and terbinafine. Topical medications applied once or twice daily are the primary treatment indicated for tinea corporis/cruris, and tinea pedis/manuum. Use of oral antifungals may be practical where the tinea involvement is extensive or chronic, or where application of a topical is not feasible. For tinea unguium (onychomycosis) and tinea capitis, oral therapies are the primary treatments provided. Recently, topical amorolfine and ciclopirox formulations have been approved for use in milder onychomycosis cases, and their role in the treatment of the different clinical forms of onychomycosis is currently being defined. Relapse of infection remains a problem, particularly with tinea pedis/unguium. Appropriate follow-up duration and education of patients on proper foot hygiene are also important components in providing effective therapy.


Fluconazole Itraconazole Terbinafine Griseofulvin Dermatophytosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Loo DS. Systemic antifungal agents: an update of established and new therapies. Adv Dermatol. 2006;22:101–24.PubMedCrossRefGoogle Scholar
  2. 2.
    Lecha M, Effendy I, Feuilhade de Chauvin M, Di Chiacchio N, Baran R. Treatment options—development of consensus guidelines. J Eur Acad Dermatol Venereol. 2005;19(Suppl 1):25–33.PubMedCrossRefGoogle Scholar
  3. 3.
    TARO Pharmaceuticals Inc. Clotrimazole cream USP, 1%. Prescribing information. Bramalea, Ontario, Canada, June 1996.Google Scholar
  4. 4.
    TARO Pharmaceuticals Inc. Econazole nitrate cream 1%. Prescribing information. Brampton, Ontario, Canada, September 2001.Google Scholar
  5. 5.
    Merz Pharmaceuticals. Naftin® Naftifine HCl 1% gel/cream. Prescribing information. Greensboro, NC, USA, May 2007.Google Scholar
  6. 6.
    McNeil Consumer & Specialty Pharmaceuticals. Nizoral® (ketoconazole) 2% shampoo. Prescribing information. Fort Washington, PA, USA, October 2003.Google Scholar
  7. 7.
    TARO Pharmaceuticals Inc. Ciclopirox olamine cream USP, 0.77%. Prescribing information. Brampton, Ontario, Canada, March 2005.Google Scholar
  8. 8.
    MEDICIS, The Dermatology Company. Loprox® Gel (ciclopirox) 0.77%. Prescribing information. Scottsdale, AZ, USA, July 2005.Google Scholar
  9. 9.
    BERTEK Pharmaceuticals Inc. Mentax®-TC (butenafine HCl) cream, 1%. Prescribing information. Research Triangle Park, NC, USA, October 2002.Google Scholar
  10. 10.
    GlaxoSmithKline Consumer Healthcare LP. Oxistat® (oxiconazole nitrate cream) cream 1%; Oxistat® (oxiconazole nitrate lotion) lotion 1%. Prescribing information. Pittsburgh, PA, USA, January 2004.Google Scholar
  11. 11.
    Gupta AK, Chow M, Daniel CR, Aly R. Treatments of tinea pedis. Dermatol Clin. 2003;21:431–62.PubMedCrossRefGoogle Scholar
  12. 12.
    Lamisil® (terbinafine hydrochloride tablets) Prescribing information. Novartis Pharmaceuticals Corporation. East Hanover, NJ, November 2005.Google Scholar
  13. 13.
    Sporanox® (itraconazole) Capsules prescribing information (Ortho-McNeil Inc). Janssen Pharmaceutica Products, L.P. Titusville, NJ, June 2006.Google Scholar
  14. 14.
    Diflucan® (fluconazole tablets) (fluconazole injection—for intravenous infusion only) (fluconazole for oral suspension) Prescribing information. Pfizer Inc, August 2004.Google Scholar
  15. 15.
    Griseofulvin (Systemic). In: Drug information for the health care professional, USP DI, The United States Pharmacopeial Convention, Inc., ed 24, Taunton MA, 2004, Micromedex, p. 1493–6.Google Scholar
  16. 16.
    Miscellaneous Antifungals—Griseofulvin. In: AHFS Drug Information® 2005. Bethesda, MD, 2005, American Society of Health-System Pharmacists, Inc., p. 535–7.Google Scholar
  17. 17.
    Azoles—Ketoconazole. In: AHFS Drug Information® 2005. Bethesda, MD, 2005, American Society of Health-System Pharmacists, Inc., p. 510–6.Google Scholar
  18. 18.
    Gupta AK, Cooper EA, Montero-Gei F. The use of fluconazole to treat superficial fungal infections in children. Dermatol Clin. 2003;21:537–42.PubMedCrossRefGoogle Scholar
  19. 19.
    Gupta AK, Cooper EA, Ginter G. Efficacy and safety of itraconazole use in children. Dermatol Clin. 2003;21:521–35.PubMedCrossRefGoogle Scholar
  20. 20.
    Gupta AK, Cooper EA, Lynde CW. The efficacy and safety of terbinafine in children. Dermatol Clin. 2003;21:511–20.PubMedCrossRefGoogle Scholar
  21. 21.
    Gupta AK, Ryder JE. The use of oral antifungal agents to treat onychomycosis. Dermatol Clin. 2003;21:469–79.PubMedCrossRefGoogle Scholar
  22. 22.
    Antifungals, Azole (Systemic). In: Drug information for the health care professional, USP DI, The United States Pharmacopeial Convention, Inc., ed 24, Taunton MA, 2004, Micromedex. p. 315–23.Google Scholar
  23. 23.
    Padhye AA, Weitzman I. The dermatophytes. In: Collier L, Balows A, Sussman M, Ajello L, Hay RJ, editors. Topley and Wilson’s medical mycology. New York: Oxford University Press; 1998. p. 215–36.Google Scholar
  24. 24.
    Noble SL, Forbes RC, Stamm PL. Diagnosis and management of common tinea infections. Am Fam Physician. 1998;58:163–8.PubMedGoogle Scholar
  25. 25.
    Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001434.Google Scholar
  26. 26.
    Gupta AK, Cooper EA, Ryder JE, et al. Optimal management of fungal infections of the skin, hair, and nails. Am J Clin Dermatol. 2004;5:225–37.PubMedCrossRefGoogle Scholar
  27. 27.
    Crawford F. Athlete’s foot. In: Williams H, Bigby M, Diepgen T, Herxheimer A, Naldi L, Rzany B, editors. Evidence based dermatology. London: BMJ Books; 2003. p. 436–40.Google Scholar
  28. 28.
    Gupta AK, Chaudhry M, Elewski B. Tinea corporis, tinea cruris, tinea nigra, and piedra. Dermatol Clin. 2003;21:395–400.PubMedCrossRefGoogle Scholar
  29. 29.
    Gupta AK, De Doncker P, Heremans A, et al. Itraconazole for the treatment of tinea pedis: a dose of 400 mg/day given for 1 week is similar in efficacy to 100 or 200 mg/day given for 2 to 4 weeks. J Am Acad Dermatol. 1997;36:789–92.PubMedCrossRefGoogle Scholar
  30. 30.
    Faergemann J, Mork NJ, Haglund A, et al. A multicentre (double-blind) comparative study to assess the safety and efficacy of fluconazole and griseofulvin in the treatment of tinea corporis and tinea cruris. Br J Dermatol. 1997;136:575–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Stary A, Sarnow E. Fluconazole in the treatment of tinea corporis and tinea cruris. Dermatology. 1998;196:237–41.PubMedCrossRefGoogle Scholar
  32. 32.
    Suchil P, Montero Gei F, Robles M, et al. Once-weekly oral doses of fluconazole 150 mg in the treatment of tinea corporis/cruris and cutaneous candidiasis. Clin Exp Dermatol. 1992;17:397–401.PubMedCrossRefGoogle Scholar
  33. 33.
    Haroon TS, Asghar HA, Aman S, et al. An open, non-comparative study for the evaluation of oral fluconazole in the treatment of tinea corporis. Specialist. 1997;13:417–23.Google Scholar
  34. 34.
    Papini M, Difonzo EM, Cilli P, et al. Itraconazole versus fluconazole, a double-blind comparison in tinea corporis. J Mycol Méd. 1997;7:77–80.Google Scholar
  35. 35.
    Kotogyan A, Harmanyeri Y, Tahsin Gunes A, et al. Efficacy and safety of oral fluconazole in the treatment of patients with tinea corporis, cruris or pedis or cutaneous candidiasis. A multicentre, open, non-comparative study. Clin Drug Investig. 1996;12:59–66.CrossRefGoogle Scholar
  36. 36.
    Gomez M, Arenas R, Salazar JJ, et al. Tinea pedis. A multicentre trial to evaluate the efficacy and tolerance of a weekly dose of fluconazole. Dermatol Rev Mex. 1996;40:251–5 (Spanish).Google Scholar
  37. 37.
    Del Aguila R, Montero Gei F, Robles M, et al. Once-weekly oral doses of fluconazole 150 mg in the treatment of tinea pedis. Clin Exp Dermatol. 1992;17:402–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Gupta AK, Ryder JE, Chow M, Cooper EA. Dermatophytosis: the management of fungal infections. Skinmed. 2005;4:305–10.PubMedCrossRefGoogle Scholar
  39. 39.
    Trent JT, Federman D, Kirsner RS. Common viral and fungal skin infections. Ostomy Wound Manage. 2001;47:28–34.PubMedGoogle Scholar
  40. 40.
    De Doncker P, Gupta AK, Marynissen G, et al. Itraconazole pulse therapy for onychomycosis and dermatomycoses: an overview. J Am Acad Dermatol. 1997;37:969–74.PubMedCrossRefGoogle Scholar
  41. 41.
    Parent D, Decroix J, Heenen M. Clinical experience with short schedules of itraconazole in the treatment of tinea corporis and/or tinea cruris. Dermatology. 1994;189:378–81.PubMedCrossRefGoogle Scholar
  42. 42.
    Gupta AK, Summerbell RC. Tinea capitis. Med Mycol. 2000;38:255–87.PubMedCrossRefGoogle Scholar
  43. 43.
    Roberts BJ, Friedlander SF. Tinea capitis: a treatment update. Pediatr Ann. 2005;34:191–200.PubMedGoogle Scholar
  44. 44.
    Lipozencic J, Skerlev M, Orofino-Costa R, et al. A randomized, double-blind, parallel-group, duration-finding study of oral terbinafine and open-label, high-dose griseofulvin in children with tinea capitis due to Microsporum species. Br J Dermatol. 2002;146:816–23.PubMedCrossRefGoogle Scholar
  45. 45.
    Gupta AK, Skinner AR. Onychomycosis in children: a brief overview with treatment strategies. Pediatr Dermatol. 2004;21:74–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Tosti A, Piraccini BM, Iorizzo M. Management of onychomycosis in children. Dermatol Clin. 2003;21:507–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Chan Y, Friedlander SF. New treatments for tinea capitis. Curr Opin Infect Dis. 2004;17:97–103.PubMedCrossRefGoogle Scholar
  48. 48.
    Haroon TS, Hussain I, Aman S, et al. A randomized double-blind comparative study of terbinafine for 1, 2 and 4 weeks in tinea capitis. Br J Dermatol. 1996;135:86–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Friedlander SF, Aly R, Krafchik B, et al. Terbinafine in the treatment of Trichophyton tinea capitis: a randomized, double-blind, parallel-group, duration-finding study. Pediatrics. 2002;109:602–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Lipozencic J, Skerlev M, Orofino-Costa R, et al. A randomized, double-blind, parallel-group, duration-finding study of oral terbinafine and open-label, high-dose griseofulvin in children with tinea capitis due to Microsporum species. Br J Dermatol. 2002;146:816–23.PubMedCrossRefGoogle Scholar
  51. 51.
    Gupta AK, Solomon RS, Adam P. Itraconazole oral solution for the treatment of tinea capitis. Br J Dermatol. 1998;139:104–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Dastghaib L, Azizzadeh M, Jafari P. Therapeutic options for the treatment of tinea capitis: griseofulvin versus fluconazole. J Dermatolog Treat. 2005;16:43–6.PubMedCrossRefGoogle Scholar
  53. 53.
    Montero Gei F. Fluconazole in the treatment of tinea capitis. Int J Dermatol. 1998;37:870–1.PubMedCrossRefGoogle Scholar
  54. 54.
    Gupta AK, Dlova N, Taborda P, et al. Once weekly fluconazole is effective in the treatment of tinea capitis: a prospective, multicentre study. Br J Dermatol. 2000;142:965–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Gupta AK, Scher RK. Management of onychomycosis: a North American perspective. Dermatol Ther. 1997;3:58–65.Google Scholar
  56. 56.
    Gupta AK, Ryder J, Bluhm R. Onychomycosis. In: Williams H, Bigby M, Diepgen T, Herxheimer A, Naldi L, Rzany B, editors. Evidence based dermatology. London: BMJ Books; 2003. p. 441–68.Google Scholar
  57. 57.
    Tavakkol A, Fellman S, Kianifard F. Safety and efficacy of oral terbinafine in the treatment of onychomycosis: analysis of the elderly subgroup in Improving Results in Onychomycosis-Concomitant Lamisil® and Debridement (IRONCLAD®), an open-label, randomized trial. Am J Geriatr Pharmacother. 2006;4:1–13.PubMedCrossRefGoogle Scholar
  58. 58.
    Potter LP, Mathias SD, Raut M, et al. The impact of aggressive debridement used as an adjunct therapy with terbinafine on perceptions of patients undergoing treatment for toenail onychomycosis. J Dermatolog Treat. 2007;18:46–52.PubMedCrossRefGoogle Scholar
  59. 59.
    Daniel CR III. Traditional management of onychomycosis. J Am Acad Dermatol. 1996;35:S21–5.PubMedCrossRefGoogle Scholar
  60. 60.
    King B. Pain at first dressing change after toenail avulsion: the experience of nurses, patients and an observer: 1. J Wound Care. 2003;12:5–10.PubMedGoogle Scholar
  61. 61.
    Seebacher C, Brasch D, Abeck O, et al. Onychomycosis. Mycoses. 2007;50:321–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Baran R, Hay RJ, Haneke E, Tosti A. Review of current antifungal treatment. Onychomycosis: the current approach to diagnosis and therapy. London: Martin Dunitz Ltd.; 1999. p. 44–69.Google Scholar
  63. 63.
    Hay RJ, Baran R, Haneke E. Fungal (onychomycosis) and other infections involving the nail apparatus. In: Baran R, Dawber RPR, de Berker DAR, Haneke E, Tosti A, editors. Baran and Dawber’s diseases of the nails and their management. Osney Mead, Oxford: Blackwell Science Ltd.; 2001. p. 129–71.CrossRefGoogle Scholar
  64. 64.
    Grover C, Bansal S, Nanda S, et al. Combination of surgical avulsion and topical therapy for single nail onychomycosis: a randomized controlled trial. Br J Dermatol. 2007;157:364–8.PubMedCrossRefGoogle Scholar
  65. 65.
    Baran R, Kaoukhov A. Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy. J Eur Acad Dermatol Venereol. 2005;19:21–9.PubMedCrossRefGoogle Scholar
  66. 66.
    Penlac® Nail Lacquer (ciclopirox) Topical Solution, 8% Prescribing information. Dermik Laboratories (a division of Sanofi-Aventis). Bridgewater, NJ, July 2006.Google Scholar
  67. 67.
    Gupta AK, Ryder JE, Skinner AR. Treatment of onychomycosis: pros and cons of antifungal agents. J Cutan Med Surg. 2004;8:25–30.PubMedCrossRefGoogle Scholar
  68. 68.
    Warshaw EM, St Clair KR. Prevention of onychomycosis reinfection for patients with complete cure of all 10 toenails: results of a double-blind, placebo-controlled, pilot study of prophylactic miconazole powder 2%. J Am Acad Dermatol. 2005;53:717–20.PubMedCrossRefGoogle Scholar
  69. 69.
    Daniel CR, Gupta AK, Daniel MP, Daniel CM. Two feet-one hand syndrome: a retrospective multicenter survey. Int J Dermatol. 1997;36:658–60.PubMedCrossRefGoogle Scholar
  70. 70.
    Sigurgeirsson B, Elewski BE, Rich PA, et al. Intermittent versus continuous terbinafine in the treatment of toenail onychomycosis: a randomized, double-blind comparison. J Dermatolog Treat. 2006;17:38–44.PubMedCrossRefGoogle Scholar
  71. 71.
    Finch JJ, Warshaw EM. Toenail onychomycosis: current and future treatment options. Dermatol Ther. 2007;20:31–46.PubMedCrossRefGoogle Scholar
  72. 72.
    Olafsson JH, Sigurgeirsson B, Baran R. Combination therapy for onychomycosis. Br J Dermatol. 2003;149(Suppl 65):15–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Evans EGV. Drug synergies and the potential for combination therapy in onychomycosis. Br J Dermatol. 2003;149(Suppl 65):11–3.PubMedCrossRefGoogle Scholar
  74. 74.
    Nandedkar-Thomas MA, Scher RK. An update on disorders of the nails. J Am Acad Dermatol. 2005;52:877–87.PubMedCrossRefGoogle Scholar
  75. 75.
    Gupta AK, Onychomycosis Combination Therapy Study Group. Ciclopirox topical solution, 8% combined with oral terbinafine to treat onychomycosis: a randomized, evaluator-blinded study. J Drugs Dermatol. 2005;4:481–5.PubMedGoogle Scholar
  76. 76.
    Baran R. Topical amorolfine for 15 months combined with 12 weeks of oral terbinafine, a cost-effective treatment for onychomycosis. Br J Dermatol. 2001;145(Suppl 60):15–9.PubMedGoogle Scholar
  77. 77.
    Lecha M. Amorolfine and itraconazole combination for severe toenail onychomycosis: results of an open randomized trial in Spain. Br J Dermatol. 2001;145(Suppl 60):21–6.PubMedGoogle Scholar
  78. 78.
    Binstock JM. Molecular biology techniques for identifying dermatophytes and their possible use in diagnosing onychomycosis in human toenails. J Am Podiatr Med Assoc. 2007;97:134–44.PubMedGoogle Scholar
  79. 79.
    de Assis Santos D, de Carvalho Araujo RA, Kohler LM, et al. Molecular typing and antifungal susceptibility of Trichophyton rubrum isolates from patients with onychomycosis pre- and post-treatment. Int J Antimicrob Agents. 2007;29:563–9.PubMedCrossRefGoogle Scholar
  80. 80.
    Brillowska-Dabrowska A, Saunte DM, Arendrup MC. Five-hour diagnosis of dermatophyte nail infections with specific detection of Trichophyton rubrum. J Clin Microbiol. 2007;45:1200–4.PubMedCrossRefGoogle Scholar
  81. 81.
    Savin C, Huck S, Rolland C, et al. Multicenter evaluation of a commercial PCR-enzyme-linked immunosorbent assay diagnostic kit (Onychodiag) for diagnosis of dermatophytic onychomycosis. J Clin Microbiol. 2007;45:1205–10.PubMedCrossRefGoogle Scholar
  82. 82.
    Gupta AK, Zaman M, Singh J. Fast and sensitive detection of Trichophyton rubrum DNA from the nail samples of patients with onychomycosis by a double-round polymerase chain reaction-based assay. Br J Dermatol. 2007;157:698–703.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2008

Authors and Affiliations

  1. 1.Division of Dermatology, Department of MedicineSunnybrook Health Sciences CenterTorontoCanada
  2. 2.University of TorontoTorontoCanada
  3. 3.Mediprobe Research IncorporatedLondonCanada

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