Topical antifungal treatments

• CKS found evidence from randomized trials that topical imidazoles and topical terbinafine are effective for the treatment of fungal infections of the body and groin. They are also widely recommended by experts in reviews of the literature [Gupta et al, 2004; Loo, 2004; Andrews and Burns, 2008].
• There was insufficient trial evidence to recommend one preparation over another, but imidazoles are currently the most commonly used topical treatments for fungal infections of the skin [Havlickova and Friedrich, 2008].
• Topical antifungals have advantages over oral antifungals [Havlickova and Friedrich, 2008]:
• Less risk of adverse effects.
• Fewer drug interactions.
• No requirement for laboratory tests to monitor treatment.

Topical corticosteroids

• Expert opinion varies on the use of topical corticosteroids. Some prefer not to use them alone because of the potential for fungal proliferation, worsening of symptoms, and the development of tinea incognito (an atypical skin appearance due to local corticosteroid application, which may mask true dermatophyte infection) [Erbagci, 2004; Gupta et al, 2004].

Topical antifungal combined with corticosteroid

• The recommendation to consider using a topical antifungal combined with a mildly potent corticosteroid for severely inflamed and irritant infections is based on expert opinion that this will provide more rapid symptom relief than a topical antifungal alone [Erbagci, 2004; Havlickova and Friedrich, 2008].
• However, the studies providing evidence to support this approach investigated moderately potent and potent corticosteroids, rather than mildly potent corticosteroids [Weinstein and Berman, 2002].
• Some experts recommend avoiding treating areas of thin skin and naturally occluded body areas, such as the groin, with combination treatment [Weinstein and Berman, 2002] because of possible adverse effects from topical corticosteroids (for example skin thinning, telangiectasia and striae). Others recommend using short-term courses of combination products for this purpose. A combination of a mild topical corticosteroid with a topical antifungal is therefore offered as an option, but only for a short period of time, to minimize the potential for adverse effects.

Oral antifungal treatment

• Topical antifungal treatment is generally successful. However, if the infection covers an extensive area or is resistant to initial treatment, experts recommend oral antifungals [Weinstein and Berman, 2002; Gupta et al, 2004; Havlickova and Friedrich, 2008].
• Specialist advice is advised before prescribing an oral antifungal for a child less than 16 years of age because terbinafine and itraconazole are not licensed for this age group and there are a lack of suitable preparations available for children (even for griseofulvin, which is licensed).