Approach

The main goal of treatment is eradication of the dermatophyte fungal infection of the scalp, beard, skin, or nails as indicated by the site of presentation.

Skin infections are typically treated based on clinical appearance. In some instances, confirmatory tests (potassium hydroxide microscopy, fungal culture, or periodic acid-Schiff test stain of nail clipping) might also be used; in particular, fungal nail infection must be confirmed by laboratory investigation prior to treatment.[13]

Choice of topical or oral therapy depends on pharmacologic properties, history of prior exposure to antifungals, the site and extent of the infection, the skin area involved (dry/sebum rich), and the age of the patient.[21] Consider issues of safety of oral therapy, although there is low incidence of adverse events in the immunocompetent population.[31]

The minimum treatment duration should be 2 to 4 weeks in simple cases, and >4 weeks in resistant or unresponsive cases.[21]

Tinea capitis

Systemic antifungals are the mainstay of therapy, and the optimal treatment regimen varies according to the dermatophyte involved. Duration of treatment varies, depending on the agent chosen, from 2 to 8 weeks. Safety issues, cost, and differences in duration of treatment may influence choice of agent. [ Cochrane Clinical Answers logo ]

Griseofulvin, an older oral agent, and newer agents such as terbinafine, which can be effective when used for shorter periods, are first-line options.[32] Griseofulvin is considered the gold standard treatment for Microsporum infections and terbinafine is considered the gold standard treatment for Trichophyton infections.[30][33][34] 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]

Although itraconazole, ketoconazole, and fluconazole have been studied for tinea capitis and have been found to be effective, fluconazole and itraconazole are not approved for this indication and ketoconazole is not recommended as it is hepatotoxic.[30] However, fluconazole 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.[30] In infants, itraconazole is safe and effective in short-duration therapy for superficial fungal infections and systemic fungal infections.[35]

Ketoconazole may cause severe liver injury and adrenal insufficiency. The Food and Drug Administration (FDA) recommends that oral ketoconazole should only be used for life-threatening fungal infections where alternative treatments are not available or tolerated, and when the potential benefits of treatment outweigh the risks. Its use is contraindicated in patients with liver disease. If used, monitor liver and adrenal function before and during treatment.[36] This recommendation does not apply to topical formulations of ketoconazole.

Topical antifungal shampoos reduce fungal spread and risk of transfer to others through direct contact or by transfer of shared articles of clothing or grooming; they do not treat the infection.

Treatment failure is unusual with correct diagnosis. Failure of scalp lesions to resolve with adequate course of therapy at appropriate dosage would prompt a search for other diagnoses, noncompliance with treatment, immunosuppression, or a request for dermatologic consultation.

Tinea barbae, tinea manuum, Majocchi granuloma, extensive tinea corporis

Each of these infections involves deeper skin structures, and requires systemic rather than topical antifungal therapy for successful treatment. Terbinafine, itraconazole, and fluconazole are good first-line options. Ketoconazole is not recommended because it may cause severe liver injury and adrenal insufficiency.

Treatment failure is unusual with correct diagnosis, and failure of lesions to resolve with an adequate course of therapy at appropriate dosage would prompt a search for other diagnoses, noncompliance with treatment, immunosuppression, or a request for dermatologic consultation.

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

These types of dermatophytosis are generally found in superficial skin structures and are responsive to topical therapy. There is limited evidence to favor the allylamine group (e.g., naftifine, terbinafine, butenafine) for topical therapy.[37][38] Topical azoles, ciclopirox, or tolnaftate are less preferred and are typically second-line agents. 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]

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.

If the patient has vesiculobullous tinea pedis, use topical aluminum acetate soaks as an adjunct to other antifungal therapy.

In moccasin-type tinea pedis also spread the topical agent along the sole and sides of the feet. Systemic antifungal therapy may also 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.[43]

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

Tinea unguium (onychomycosis)

Do not start treatment before mycologic 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 ] Itraconazole and fluconazole are second-line options; adverse-effect profile and cost determine which is the most appropriate choice.[13] Ketoconazole is not recommended because it may cause severe liver injury and adrenal insufficiency.

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 mycologic cure than continuous itraconazole for 12 weeks or weekly fluconazole for 9 to 12 months.[47]

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]

Topical treatment for onychomycosis

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 randomized, vehicle-controlled trials.[51][52][53] Both are approved by the FDA for the treatment of toenail distal subungual onychomycosis due to T 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] 

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