Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

tinea capitis

1st line – systemic antifungal therapy

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ACUTE
|
tinea capitis
1st line – 

systemic antifungal therapy

Oral systemic antifungal therapy is necessary. Topical agents are not effective as they do not penetrate the hair shaft, where the fungal infection resides.

Griseofulvin is considered the gold standard treatment for Microsporum infections and terbinafine is considered the gold standard treatment for Trichophyton infections.[23][31][32] In the case of Trichophyton rubrum syndrome, antifungals are to be used for a longer period, and can go up to 3 months. Sometimes they may have to be combined with other antifungals.[21]

Griseofulvin is better absorbed with a fatty meal and is taken once daily, but is fungistatic and requires 8 to 10 weeks of therapy for cure.[23][30][56][57]

Fluconazole is not approved for tinea capitis; however, it is sometimes used off-label in refractory cases in exceptional circumstances. Its use is limited by adverse effects. It may cause abdominal adverse effects and rare hepatotoxicity in children.[23]

Primary options

griseofulvin microsize: children ≥2 years of age: 10-20 mg/kg/day orally given in 1-4 divided doses for 4-6 weeks, maximum 1000 mg/day; adults: 500-1000 mg/day orally given in 1-4 divided doses for 4-6 weeks

OR

terbinafine: children ≥4 years of age and body weight <25 kg: 125 mg orally once daily for 6 weeks; children ≥4 years of age and body weight 25-35 kg: 187.5 mg orally once daily for 6 weeks; children ≥4 years of age and body weight >35 kg: 250 mg orally once daily for 6 weeks; adults: 250 mg orally once daily for 6 weeks

Secondary options

itraconazole: children: 5-10 mg/kg/day orally given in 1-2 divided doses for 4-6 weeks, maximum 600 mg/day; adults: 200 mg orally once or twice daily for 4-6 weeks

OR

fluconazole: children: 3-6 mg/kg/day orally for 6 weeks; adults: 200 mg orally once daily for 6 weeks

Consider – topical antifungal shampoo

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ACUTE
|
tinea capitis
Consider – 

topical antifungal shampoo

Additional treatment recommended for SOME patients in selected patient group

Topical therapy is useful to reduce the likelihood of spread of tinea capitis to siblings or classmates; in situations where a widespread daycare or school outbreak occurs, topical therapy may shorten the time in which viable dermatophytes may be spread through use of shared clothing or grooming items.

Primary options

selenium sulfide topical: (1 to 2.5% shampoo) children and adults: apply to scalp twice weekly for 2 weeks, leave each application on scalp for 2-3 minutes then rinse

OR

ketoconazole topical: (1-2% shampoo) children: apply to scalp two to three times weekly for 2-4 weeks, leave each application on scalp for 5 minutes then rinse; adults: apply to scalp twice weekly for 4 weeks, leave each application on scalp for 5 minutes then rinse

tinea barbae, tinea manuum, or Majocchi's granuloma

1st line – systemic antifungal therapy

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ACUTE
|
tinea barbae, tinea manuum, or Majocchi's granuloma
1st line – 

systemic antifungal therapy

Similar to tinea capitis, systemic therapy is needed to deliver effective antifungal therapy to the hair shaft, where the infection resides in tinea barbae, or the thick, keratinised skin of the palmar surface of the hand(s).

When tinea manuum is associated with tinea unguium of the fingernails, longer treatment times of 8 to 12 weeks are necessary.

Majocchi's granuloma is a fungal infection in hair, hair follicles, and surrounding skin that also requires systemic antifungal therapy for cure.

Primary options

griseofulvin: adults: 500-1000 mg/day orally given in 1-2 divided doses for 4-8 weeks

OR

terbinafine: adults: 250 mg orally once daily for 6 weeks

OR

itraconazole: adults: 200 mg orally once daily for 2-4 weeks

Secondary options

fluconazole: adults: 200 mg orally once daily for 2-4 weeks

tinea faciale, tinea corporis, tinea cruris, or tinea pedis

1st line – topical allylamine antifungal therapy

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ACUTE
|
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
1st line – 

topical allylamine antifungal therapy

These types of dermatophytosis are generally found in superficial skin structures and are usually responsive to topical therapy.

There is limited evidence to favour the allylamine group (e.g., terbinafine, naftifine, butenafine) for topical therapy.[37][38] A higher-strength formulation of naftifine has been tried for tinea cruris and tinea pedis.[39][40][41][42] Two weeks of treatment with the 2% strength was as effective as 4 weeks of treatment with the 1% formulation in the management of tinea pedis.[40]

Apply topical agents until no further infection is visible and for 1 to 2 weeks after, generally a total treatment time of 2 to 6 weeks, depending on the topical agent.

Tinea pedis can be difficult to eradicate or may easily recur if there is a reservoir of infection in the toenails, or inadequate application of antifungal therapy to the entire surface of the foot and sides in moccasin-type tinea pedis. Disinfection of footwear or replacement footwear at the time of treatment may reduce recurrence of tinea pedis. In moccasin-type tinea pedis also spread the topical agent along the sole and sides of the feet.

Primary options

terbinafine topical: (1%) children ≥12 years of age and adults: apply to the affected area(s) once daily (tinea corporis or tinea cruris) or twice daily (tinea pedis) for 1-4 weeks

OR

naftifine topical: (1% gel) adults: apply to the affected area(s) twice daily for up to 4 weeks; (1% cream) adults: apply to the affected area(s) once daily for up to 4 weeks; (2% cream or gel) children ≥12 years of age and adults: apply to the affected area(s) once daily for 2 weeks

OR

butenafine topical: (1%) children ≥12 years of age and adults: apply to the affected area(s) once or twice daily for 1-2 weeks

Consider – topical aluminium acetate

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ACUTE
|
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
Consider – 

topical aluminium acetate

Additional treatment recommended for SOME patients in selected patient group

If the patient has vesiculobullous tinea pedis, recommend the application of topical aluminium acetate soaks several times daily for relief of pain and tenderness until the resolution of bullae and open skin with serous discharge.

Primary options

aluminium acetate topical: children and adults: soak twice daily for 15-30 minutes for 7 days

2nd line – other topical antifungal therapy

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ACUTE
|
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
2nd line – 

other topical antifungal therapy

Topical azoles, ciclopirox, or tolnaftate are less preferred and are typically second-line agents.

Azole therapy has been demonstrated to be better than placebo in tinea pedis.[58][59]

Apply topical agents until no further infection is visible and for 1 to 2 weeks after, generally a total treatment time of 2 to 6 weeks depending on the topical agent.

Tinea pedis can be difficult to eradicate or may easily recur if there is a reservoir of infection in the toenails, or inadequate application of antifungal therapy to the entire surface of the foot and sides in moccasin-type tinea pedis. Disinfection of footwear or replacement footwear at the time of treatment may reduce recurrence of tinea pedis. In moccasin-type tinea pedis also spread the topical agent along the sole and sides of the feet.

Primary options

miconazole topical: (2%) children ≥2 years of age and adults: apply to the affected area(s) twice daily for 2-4 weeks

OR

clotrimazole topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily for 2-4 weeks

OR

econazole topical: (1%) children and adults: apply to the affected area(s) once daily for 2 weeks

OR

ketoconazole topical: (2%) children and adults: apply to the affected area(s) once daily for 2-6 weeks

OR

luliconazole topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) once daily for 1-2 weeks

OR

tolnaftate topical: (1%) children and adults: apply to the affected area(s) twice daily for 2-4 weeks

OR

ciclopirox topical: (0.77%) children ≥10 years of age and adults: apply to the affected area(s) twice daily for 1-4 weeks

Consider – topical aluminium acetate

Back
ACUTE
|
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
Consider – 

topical aluminium acetate

Additional treatment recommended for SOME patients in selected patient group

If the patient has vesiculobullous tinea pedis, recommend the application of topical aluminium acetate soaks several times daily for relief of pain and tenderness until the resolution of bullae and open skin with serous discharge.

Primary options

aluminium acetate topical: children and adults: soak twice daily for 15-30 minutes for 7 days

3rd line – systemic antifungal therapy

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ACUTE
|
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
3rd line – 

systemic antifungal therapy

Systemic antifungal therapy may be needed, particularly in immunosuppressed individuals with extensive tinea pedis.

In case of systemic antifungal agents, terbinafine is recommended in treatment-naive cases of tinea pedis, while itraconazole is recommended in recalcitrant and severe cases. The minimum treatment duration should be 2 to 4 weeks in treatment-naive tinea pedis and >4 weeks in recalcitrant cases.[21] 

Evidence suggests that systemic therapy with terbinafine, itraconazole, griseofulvin, or fluconazole may be considered as alternative treatment for patients with tinea corporis with extensive skin involvement, or patients who are refractory to topical therapy. Treatment duration is usually 2 to 4 weeks but depends on response. A longer course may be required in recalcitrant cases.[43]

Failure of treatment of tinea faciale or faciei, tinea cruris, tinea pedis, or tinea corporis may be due to patient non-adherence to treatment recommendations, misdiagnosis, or immunosuppressive illness or therapy. With treatment failure, a search for these possibilities and/or dermatological consultation may be warranted.

Primary options

terbinafine: children ≥2 years of age: consult specialist for guidance on dose; adults: 250 mg orally once daily

OR

itraconazole: children: consult specialist for guidance on dose; adults: 200-400 mg/day orally given in 1-2 divided doses

OR

griseofulvin microsize: children ≥2 years of age: consult specialist for guidance on dose; adults: 500-1000 mg/day orally given in 1-4 divided doses

OR

fluconazole: children: consult specialist for guidance on dose; adults: 150-200 mg orally once weekly

Consider – topical aluminum acetate

Back
ACUTE
|
tinea faciale, tinea corporis, tinea cruris, or tinea pedis
Consider – 

topical aluminum acetate

Additional treatment recommended for SOME patients in selected patient group

If the patient has vesiculobullous tinea pedis, recommend the application of topical aluminium acetate soaks several times daily for relief of pain and tenderness until the resolution of bullae and open skin with serous discharge.

Primary options

aluminium acetate topical: children and adults: soak twice daily for 15-30 minutes for 7 days

tinea unguium (onychomycosis)

1st line – systemic terbinafine therapy

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ACUTE
|
tinea unguium (onychomycosis)
1st line – 

systemic terbinafine therapy

Do not start treatment before mycological confirmation of infection.[13] 

Systemic antifungal treatment is recommended for most patients. Both terbinafine and azoles have been found to be effective in achieving a normal-looking nail and curing the toenail infection, with terbinafine being more effective than azoles; therefore, consider terbinafine as first-line treatment.[44][45][46] [ Cochrane Clinical Answers logo ]

Toenail infections require a longer duration of therapy than fingernails due to the slower rate of nail growth. One systematic review found that continuous terbinafine for 24 weeks, but not 12 weeks, was significantly more likely to result in mycological cure than continuous itraconazole for 12 weeks or weekly fluconazole for 9 to 12 months.[47]

Patient expectations regarding the success of therapy should be discussed before starting treatment. Counsel patients about regularly alternating footwear, avoiding walking barefoot in public bathing areas, and avoiding trauma to the infected nail.[13]

Primary options

terbinafine: children: consult specialist for guidance on dose; adults: 250 mg orally once daily for 12 weeks (toenails) or 6 weeks (fingernails)

2nd line – systemic azole therapy or topical treatment

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ACUTE
|
tinea unguium (onychomycosis)
2nd line – 

systemic azole therapy or topical treatment

Do not start treatment before mycological confirmation of infection.[13]

Systemic treatment is recommended for most patients. Itraconazole and fluconazole are second-line options; adverse-effect profile and cost determine which is the most appropriate choice.[13] Toenail infections require a longer duration of therapy than fingernails due to the slower rate of nail growth. 

For a small number of patients with very distal infection or superficial white onychomycosis, mechanical debridement followed by topical treatment may suffice.[49] Although some evidence supports the use of topical treatments for fungal infections of the toenails, complete cure rates are relatively low.[50] Efinaconazole and tavaborole topical solutions have been reported to effectively treat toenail onychomycosis in randomised, vehicle-controlled trials.[51][52][53] Both are approved by the US Food and Drug Administration for the treatment of toenail distal subungual onychomycosis due to Trichophyton rubrum or Trichophyton mentagrophytes. One Cochrane review confirmed the effectiveness of efinaconazole and tavaborole topical solutions, and that of ciclopirox nail lacquer.[50] The effectiveness of ciclopirox nail lacquer is enhanced when delivered in a water-soluble biopolymer vehicle.[50][54] Ciclopirox nail lacquer requires debridement of hyperkeratotic nail for best effect.[55]

Patient expectations regarding the success of therapy should be discussed before starting treatment. Counsel patients about regularly alternating footwear, avoiding walking barefoot in public bathing areas, and avoiding trauma to the infected nail.[13]

Primary options

itraconazole: children: consult specialist for guidance on dose; adults: 200 mg orally twice daily for 7 days, followed by no treatment for 21 days, then 200 mg twice daily for 7 days (fingernails); adults: 200 mg orally once daily for 12 weeks (toenails)

OR

fluconazole: children: consult specialist for guidance on dose; adults: 150-450 mg orally once weekly for 6-12 months (toenails) or 3-6 months (fingernails)

Secondary options

ciclopirox topical: (8%) children ≥12 years of age and adults: apply to affected nail(s) once daily, remove with acetone every 7 days and repeat application cycle

OR

efinaconazole topical: (10%) children ≥6 years of age and adults: apply to the affected nail(s) once daily for 48 weeks

OR

tavaborole topical: (5%) children ≥6 years of age and adults: apply to the affected nail(s) once daily for 48 weeks

3rd line – additional course of alternative systemic therapy

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ACUTE
|
tinea unguium (onychomycosis)
3rd line – 

additional course of alternative systemic therapy

Only 30% to 60% of people will report a clinical cure following treatment with oral antifungals.[48]

Review diagnostic findings to ensure that a differential diagnosis or concomitant condition does not explain nail change. Only consider a second course of oral treatment after confirming diagnosis, and ensure that an agent other than the one used for initial treatment is used.

Patient expectations regarding the success of therapy should be discussed before starting treatment. Counsel patients about regularly alternating footwear, avoiding walking barefoot in public bathing areas, and avoiding trauma to the infected nail.[13]

Primary options

terbinafine: children: consult specialist for guidance on dose; adults: 250 mg orally once daily for 12 weeks (toenails) or 6 weeks (fingernails)

Secondary options

itraconazole: children: consult specialist for guidance on dose; adults: 200 mg orally twice daily for 7 days, followed by no treatment for 21 days, then 200 mg twice daily for 7 days (fingernails); adults: 200 mg orally once daily for 12 weeks (toenails)

OR

fluconazole: children: consult specialist for guidance on dose; adults: 150-450 mg orally once weekly for 6-12 months (toenails) or 3-6 months (fingernails)

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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