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Fungal skin infection - body and groin - Management
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What advice should I give about fungal infections of the body and groin?
- Advise the person to:
- Wash the affected skin daily and dry thoroughly afterwards, particularly in the skin folds.
- Wash clothes and bed linen frequently to eradicate the fungus.
- Not share towels, and to wash them frequently.
- Wear loose-fitting clothes made of cotton or a material designed to wick moisture away from the skin.
- It is not necessary to keep children away from school. However, to ensure that the infection is not transmitted to others, carefully follow the recommendations on hygiene and treatment.
Basis for recommendation
How should I treat fungal infections of the body and groin?
- Treat with a topical imidazole (clotrimazole, econazole, ketoconazole, or miconazole) or topical terbinafine (not licensed for use in children younger than 12 years of age).
- The timing of application and duration of treatment depends on the drug used. For more information, see Prescriptions.
- For skin that is particularly inflamed, consider prescribing a topical antifungal combined with a mildly potent corticosteroid for a maximum of seven days.
- Do not give a corticosteroid preparation alone.
- Use a combination preparation with caution on fungal infection of the groin, because of the increased risk of adverse effects with topical corticosteroids in occluded areas.
- Consider oral antifungal treatment in adults if severe or extensive disease is present (referral is often indicated) or if topical treatment has failed.
- A positive microscopy or a positive culture of skin scrapings is recommended before starting treatment.
- If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat the sample and start treatment.
- If oral antifungal treatment is being considered in children, seek specialist advice.
- If there is infection of the nails, treatment should be considered to prevent re-infection. See the CKS topics on Fungal nail infection and Fungal skin infection - foot.
Basis for recommendation
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).
Which oral antifungal should I prescribe?
- If an oral antifungal is appropriate (see Treatment), prescribe terbinafine, griseofulvin, or itraconazole.
- Oral terbinafine:
- Treatment duration is often shorter than with griseofulvin.
- There are fewer drug interactions with terbinafine than with itraconazole.
- Adverse effects are usually mild or transient, although there are concerns about liver toxicity.
- Oral griseofulvin (licensed):
- Is used less commonly following the introduction of newer, safer azoles (itraconazole and fluconazole) and terbinafine.
- Women of childbearing age should be advised to avoid pregnancy during, and for 1 month after, treatment with griseofulvin. Men should ensure contraceptive precautions are taken during, and for the 6 months after, their own treatment due to potential adverse effects on the male reproductive system.
- Griseofulvin is a fungistatic drug. It must be given continuously for a relatively long period of time, which may contribute to reduced compliance and decreased effectiveness.
- Oral itraconazole:
- Itraconazole is not recommended for use in children or elderly people because of a lack of data on its safety and efficacy in these groups.
- Rare cases of serious hepatotoxicity have been reported.
- The Committee on Safety of Medicines has advised caution when prescribing itraconazole to people at high risk of heart failure (for example older people, those with cardiac disease, people receiving negative inotropic drugs such as calcium-channel blockers, and people receiving high doses or long treatment courses of itraconazole).
- Oral fluconazole and oral ketoconazole are not recommended.
Basis for recommendation
Recommended treatments
- There is evidence that oral griseofulvin, terbinafine, and itraconazole are effective for the treatment of fungal infections of the body and groin, but CKS found insufficient evidence to recommend one oral antifungal in preference to another.
- The information to guide the choice of oral antifungal was largely based on expert opinion and manufacturers' information [Gupta et al, 2004; Chemidex Pharma Ltd., 2005; Aronson, 2006; HPA, 2007; Andrews and Burns, 2008; BNF for Children, 2008; ABPI Medicines Compendium, 2009; BNF 57, 2009].
Treatments not recommended
- Oral fluconazole: there is evidence that fluconazole is effective for treating fungal infections of the body and groin. However, there is more evidence to support the use of griseofulvin, terbinafine, and itraconazole.
- Oral ketoconazole: this should only be initiated by a physician who is experienced in the management of fungal infections because of the risk of serious hepatotoxicity. Oral ketoconazole should only be prescribed for the treatment of dermatophytosis that cannot be treated topically because of the site, extent of the lesion, or deep infection of the skin, in people resistant to or intolerant of both fluconazole and itraconazole [MHRA, 2008].
How should I prescribe oral antifungal treatment?
The following information is a guide only. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk) or the British National Formulary (BNF) (www.bnf.org).
Oral griseofulvin
- Treat for at least 4 weeks and continue treatment for 2 weeks after all signs of infection have disappeared.
- For adults, prescribe 500 mg once a day or 250 mg twice a day.
Oral terbinafine (not licensed for children)
- For ringworm, treat for 4 weeks. For fungal infection of the groin, treat for 2–4 weeks.
- For adults, the recommended dosage is 250 mg once per day.
Oral itraconazole
- Itraconazole is not recommended for use in children or the elderly.
- In adults, treat with either:
- 100 mg daily for 15 days, or
- 200 mg twice daily for 7 days.
Basis for recommendation
The recommended doses are based on the British National Formulary [BNF 57, 2009] and the manufacturer's information for griseofulvin [Chemidex Pharma Ltd., 2005].
- Doses for children have not been included because in most cases specialist advice will be needed. Also, terbinafine is not licensed for this purpose and there is no UK-approved liquid paediatric formulation of griseofulvin.
When should I refer to dermatology?
- Consider referral to dermatology if:
- The diagnosis is uncertain.
- There is no response to primary care management.
- Infection is severe or extensive.
- Infection is recurrent.
- The person is immunocompromised.
Basis for recommendation
CKS found no evidence or expert reviews on referral, and has therefore based this recommendation on common clinical practice.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Topical imidazole
Age from 1 month onwards
Clotrimazole 1% cream: apply two to three times a day
Clotrimazole 1% cream
Apply to the affected area 2 to 3 times a day. Continue for at least 2 weeks after the affected area has healed.
Supply 20 grams.
Econazole 1% cream: apply twice a day
Econazole 1% cream
Apply to the affected area twice a day. Continue for 2 to 3 days after the affected area has healed.
Supply 30 grams.
Ketoconazole 2% cream: apply once or twice a day
Ketoconazole 2% cream
Apply to the affected area(s) once or twice a day. Continue for a few days after the affected area has healed.
Supply 30 grams.
Miconazole 2% cream: apply twice a day
Miconazole 2% cream
Apply to the affected area twice a day. Continue for 10 days after the affected area has healed.
Supply 30 grams.
Topical terbinafine
Age from 12 years onwards
Terbinafine 1% cream: apply twice a day
Terbinafine 1% cream
Apply thinly to the affected area and the surrounding skin twice a day for 7-14 days.
Supply 15 grams.
Topical antifungal + hydrocortisone
Age from 1 month onwards
Clotrimazole 1% + hydrocortisone 1% cream
Clotrimazole 1% / Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Miconazole 2% + hydrocortisone 1% cream
Miconazole 2% / Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Oral antifungal
Age from 16 years onwards
Terbinafine tablets: 250mg once a day for 2-4 weeks
Terbinafine 250mg tablets
Take one tablet once a day.
Supply 28 tablets.
Griseofulvin tablets: 250mg twice a day for 4 weeks
Griseofulvin 125mg tablets
Take two tablets twice a day.
Supply 112 tablets.
Griseofulvin tablets: 500mg once a day for 4 weeks
Griseofulvin 500mg tablets
Take one tablet once a day.
Supply 28 tablets.
Itraconazole capsules: 100mg once a day for 15 days
Itraconazole 100mg capsules
Take one capsule once a day for 15 days.
Supply 15 capsules.
Itraconazole capsules: 200mg once a day for 7 days
Itraconazole 100mg capsules
Take two capsules once a day for 7 days.
Supply 14 capsules.
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