Principles of Therapy

Topical Antifungals

Topical medications have better pharmacokinetics than their systemic counterparts. Hence, the combination is expected to have better mycological clearance than systemic and topical alone.

The combination should be from different groups for wide coverage and also to prevent the emergence of resistance.

Drugs are given for shorter duration with higher doses there has less chance of development of resistance compared to lower doses for a longer duration.

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Most tinea corporis, cruris and pedis infections can be treated topically.

Choice of agent will depend on cost, physician and patient preference.

There are few direct comparison studies between agents of different groups; it is difficult to   justify choice of one agent over another.

For tinea pedis, treatment is targeted towards control of symptoms and spread to other parts of the body.

Tinea corporis, tinea cruris, and tinea pedis are generally responsive to topical creams such as terbinafine and butenafine.

Topical antifungals Luliconazole, an azole antifungal has fungicidal action against Trichophyton species similar to or more than that of terbinafine. Available in 1% cream formulation, it is effective as once daily application for 1–2 weeks for dematophytic infection.

Tinea pedis is usually treated with a topical antifungal cream for 4 weeks; interdigital tinea pedis may only require 1 week of therapy.

Treatment with terbinafine or naftifine produces a slightly higher cure rate than treatment with an azole in tinea pedis.

Topical Corticosteroids

Should only be used in combination with antifungal and limited only to confirmed fungal infections in patients suffering from symptomatic inflammation, itching, erythema and burning sensation.

Regarding combination therapy of topical steroids and antifungals though there is no standard guideline. There is insufficient evidence to confidently assess relapse rates in the individual or combination treatments.

Should be used only for a short time in inflamed lesions.

Use with caution when treating areas of thin skin and naturally occluded body areas (eg groin, axillae, breast and face).

Combination topical corticosteroids with antifungal should not be administered in children <12 years.

Steroids may be helpful in initial improvement in symptoms but chronic use lead to a complication like atrophy, telangiectasia which is more prominent when lesions are present in flexures. 

Topical antifungals with potent anti-inflammatory action such as sertaconazole or luliconazole may be a better option than an antifungal-steroid combination in inflamed lesions.

Oral Antifungals

Oral antifungals (Terbinafine, Fluconazole, Griseofulvin, Itraconazole) may be considered in patients with extensive disease, unresponsive to treatments, immunocompromised, or severe moccasin-type tinea of the plantar surface.

Out of the various systemic antifungals, terbinafine, and itraconazole are commonly prescribed.

Griseofulvin and fluconazole are also effective but require long-term treatment. 

In a systematic review of the efficacy of oral antifungals, terbinafine was found to be more effective than griseofulvin, whereas the efficacy of terbinafine and itraconazole were similar.

Pulse doses of Fluconazole, Itraconazole and Terbinafine have been shown effective.