Topical Antifungal Agents for Tinea Infections

Fungal (tinea) skin infections are common. These infections are usually classified by the site of infection (tinea capitis [scalp], tinea cruris [groin area or jock itch], tinea corporis [ringworm], tinea pedis [athlete’s foot], and tinea unguium [fingernails or toenails]). The goals of therapy are to alleviate symptoms, treat the existing infection, and prevent recurrences. In general, topical treatment is effective for tinea pedis, cruris, and corporis, but systemic therapy is usually needed for tinea capitis and unguium.1 Systemic therapy may also be needed for patients with certain comorbidities (e.g., diabetes, immunocompromised) or when the infection is chronic, widespread, or has failed topicals. Topical antifungal products for the treatment of tinea infections are available in a number of dosage forms (e.g., cream, gel, liquid spray, powder spray, powders, etc). When choosing a formulation consider efficacy, site of infection, cost, and patient preference.1 Proper application of topical antifungals is important. Patients should apply the antifungal product to the lesion as well as one to two inches around the visible lesion. This will treat any fungus which has spread around the visible lesion. Antifungals should be continued for a week or so after lesions clear to reduce the rate of recurrence.2 In general, itching resolves with antifungal treatment, but if an antipruritic is necessary, a non-steroid agent such as Sarna Sensitive (pramoxine) is preferred. For most tinea infections, avoid topical corticosteroids because use can lead to treatment failures. In cases of severe inflammation, a low-potency steroid (OTC hydrocortisone, etc) can be used. If no clinical improvement is noted within four weeks, the diagnosis should be reevaluated. The following chart provides information about the use of TOPICAL antifungals to treat common fungal skin infections such as jock itch, ringworm, and athlete’s foot. See our PL Chart, Comparison of Pharmacotherapy for Onychomycosis, for information about treating fungal infections of nails.

Drug

Dosage Forms

Dosing Frequency/Duration of Therapya,3-8

Comments

Allylamine and allylamine derivatives

Terbinafine (Lamisil, Lamisil AT)
OTC

Cream 1%
Spray pump Solution 1%
Gel 1%

Tinea pedis:
Cream – Twice daily for 1 week (between toes) or 2 weeks (bottom or sides of feet)
Gel – At bedtime for 1 week (between toes)
Spray – Twice daily for 1 week (between toes)


Tinea cruris:
Spray or cream – once daily for 1 week


Tinea corporis:
Spray, cream, gel – once daily for 1 week

Allylamine antifungals are fungicidal and are considered slightly more effective than imidazole agents.3-8

Terbinafine may be preferred due to shorter duration of use than other agents.4

OTC Lamisil products are inexpensive (WAC less than $20/30 g) compared with Rx products (Naftin, Mentax).






Lotrimin brands contain different active ingredients including clotrimazole, miconazole, and butenafine. For more information see our PL Chart, OTC Brand Name Extensions.

Although not indicated by the FDA for the treatment of tinea versicolor, topical terbinafine has been successfully used.9,10

Naftifine (Naftin)
Rx

Cream 2%
Gel 2%

Tinea pedis, cruris, corporis:
Once daily for 2 weeks

Butenafine (Mentax [Rx], Lotrimin Ultra [OTC])

Cream 1%

Tinea corporis, cruris, versicolor:
Once daily for 2 weeks


Tinea pedis:
Twice daily for 7 days OR
Once daily for 4 weeks

Imidazoles

Clotrimazole (Lotrimin, others)
Rx/OTC


Cream 1%
Solution 1%

Tinea cruris, corporis:
Twice daily for 2 weeks


Tinea pedis:
Twice daily for 4 weeks


Imidazole antifungal agents are fungistatic and therefore require longer duration of therapy compared to allylamine (e.g., terbinafine, others) antifungals.3-8

Lotrimin brands contain different active ingredients including clotrimazole, miconazole, and butenafine. For more information see our PL Chart, OTC Brand Name Extensions.

Nizoral AD (1% ketoconazole) OTC shampoo approved for seborrheic dermatitis.

Luzu, Oxistat, and Ertaczo are expensive (WAC greater than $300/60 g) vs OTC options or generic Rx options including econazole and ketoconazole.

Econazole
(Ecoza [foam]; generic only [cream])
Rx

Cream 1%
Foam 1%

Tinea cruris, corporis, versicolor:
Cream – Once daily for 2 weeks


Tinea pedis:
Cream or foam – Once daily for 4 weeks


Ketoconazole (Nizoral, others)
Rx

Cream 2%
Shampoo 2%

Cream
Tinea cruris, corporis, versicolor:
Once daily for 2 weeks
Tinea pedis:
Once daily for 6 weeks


Shampoo
Tinea versicolor:
Apply to damp skin, leave for 5 minutes, then rinse. One application usually sufficient.

Luliconazole (Luzu)
Rx

Cream 1%

Tinea pedis:
Once daily for 2 weeks


Tinea cruris, corporis:
Once daily for 1 week

Miconazole
OTC

Powder spray 1%
Liquid spray 1%

Tinea pedis, cruris, corporis:
Twice a day for up to 4 weeks

Oxiconazole (Oxistat)
Rx

Cream 1%
Lotion 1%

Tinea cruris, corporis, versicolor:
Once daily for 2 weeks


Tinea pedis:
Once daily for 1 month

Sertaconazole (Ertaczo)
Rx

Cream 2%

Tinea pedis:
Twice daily for 4 weeks

Others

Ciclopirox
(Penlac, Loprox, others)
Rx

Cream 0.77%
Topical suspension 0.77%
Topical gel 0.77%

Tinea pedis, cruris, corporis:
Apply twice daily for up to 4 weeks

Ciclopirox is also available in a nail lacquer formulation for the treatment of fungal nail infections and a 1% shampoo for seborrheic dermatitis.

Other agents preferred due to shorter treatment regimens and greater efficacy. 3-8

Tolnaftate (Tinactin, others)
OTC

Cream 1%
Spray 1%
Powder spray 1%
Powder 1%

Tinea cruris, corporis:
Twice daily for 2 weeks


Tinea pedis:
Twice daily for 4 weeks
  1. The following U.S. product labeling was used for the above chart: Lamisil products (www.lamisilat.com; Accessed April 8, 2014), Naftin cream/gel (January 2012), Lotrimin website (www.lotrimin.com; Accessed April 8, 2014), econazole (Perrigo, October 2012), Ecoza (October 2013), ketoconazole 2% cream (Fougera Pharmaceuticals, November 2011), Nizoral 2% shampoo (October 2013), Luzu (November 2013), Oxistat cream/lotion (January 2004), Ertaczo (January 2014), Mentax (June 2001), Penlac (December 2004), Loprox cream/suspension/gel (June 2013), Loprox shampoo (May 2013), Tinactin product website (www.tinactin.com; Accessed April 8, 2014).

Project Leader in preparation of this PL Detail-Document: Neeta Bahal O’Mara, Pharm.D., BCPS, Drug Information Consultant

References

  1. Newton GD, Popovich NG. Chapter 41 Fungal skin infections. In: Handbook of Nonprescription Drugs. 17th ed. Krinsky DL, Berardi RR, Ferreri SP, et al, (eds). Washington DC: American Pharmaceutical Association. 2012.
  2. Huang DB, Ostrosky-Zeichner L, Wu JJ, et al. Therapy of common superficial fungal infections. Dermatol Ther 2004;17:517-22.
  3. Gupta AK, Chaudhry M, Elewski B. TInea corporis, tinea cruris, tinea nigra, and piedra. Dermatol Clin 2003;21:395-400.
  4. Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 2007;(3):CD001434.
  5. Gupta AK, Chow M, Daniel CR, Aly A. Treatments of tinea pedis. Dermatol Clin 2003;21:431-62.
  6. Hart R, Bell-Syer SE, Crawford F, et al. Systematic review of topical treatments for fungal infections of the skin and nails of the feet. BMJ 1999;319:79-82.
  7. Nadalo D, Montoya C, Hunter-Smith D. What is the best way to treat tinea cruris? J Fam Pract 2006;55:256-8.
  8. Rotta I, Otuki MF, Sanches AC, Correr CJ. Efficacy of topical antifungal drugs in different dermatomycoses: a systematic review with meta-analysis. Rev Assoc Med Bras 2012;58:308-18.
  9. Faergemann J. Management of seborrheic dermatitis and pityriasis versicolor. Am J Dermatol 2000;1:75-80.
  10. Sunenshine PJ, Schwartz RA, Janniger CK. Tinea versicolor. Int J Dermatol 1998;37:648-55.

Cite this document as follows: PL Detail-Document, Topical Antifungal Agents for Tinea Infections. Pharmacist’s Letter/Prescriber’s Letter. May 2014.

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