From the Guidelines
Terbinafine is not the preferred treatment for cutaneous candidiasis, and azole antifungals such as clotrimazole, miconazole, or fluconazole are generally more effective against Candida infections. The mechanism of action of terbinafine, which involves inhibiting squalene epoxidase and disrupting ergosterol synthesis in fungi, is more effective against dermatophytes (causing tinea infections) rather than yeasts like Candida 1.
Treatment Options
For cutaneous candidiasis, the following treatment options are recommended:
- Topical azole treatments such as clotrimazole 1% cream applied twice daily for 2-4 weeks
- In more extensive cases, oral fluconazole 150-300mg weekly for 2-4 weeks may be necessary It is essential for patients to keep affected areas clean and dry, as Candida thrives in warm, moist environments. If terbinafine is used for presumed dermatophyte infection and symptoms do not improve, reassessment for possible Candida infection is warranted, as misdiagnosis between these fungal infections is common and treatment approaches differ significantly 1.
Key Considerations
When considering treatment for cutaneous candidiasis, it is crucial to:
- Choose the most effective treatment based on the type of fungal infection
- Monitor patient response to treatment and adjust as necessary
- Prevent misdiagnosis and ensure proper treatment of Candida infections, as they require different treatment approaches than dermatophyte infections.
From the FDA Drug Label
Terbinafine has been shown to be active against most strains of the following microorganisms both in vitro and in clinical infections: ... The following in vitro data are available, but their clinical significance is unknown In vitro, terbinafine exhibits satisfactory MIC’s against most strains of the following microorganisms; however, the safety and efficacy of terbinafine in treating clinical infections due to these microorganisms have not been established in adequate and well-controlled clinical trials: Candida albicans
- Terbinafine is active against Candida albicans in vitro, but
- The safety and efficacy of terbinafine in treating clinical infections due to Candida albicans (cutaneous candidiasis) have not been established in adequate and well-controlled clinical trials 2.
- Therefore, terbinafine is not recommended for treating cutaneous candidiasis due to the lack of clinical evidence.
From the Research
Terbinafine Efficacy
- Terbinafine is an allylamine antifungal agent with fungicidal activity against dermatophytes, molds, and certain dimorphic fungi, and fungistatic activity against Candida albicans 3.
- Topical terbinafine 1% formulations are effective in treating cutaneous candidiasis, achieving mycological cure in > 80% of patients 3.
- Oral terbinafine 250 mg/day is effective in treating superficial dermatophyte infections, but its efficacy in cutaneous candidiasis is also notable, with mycological cure rates of 82% in one study 4.
Comparison with Other Antifungals
- Terbinafine has been compared to ketoconazole in the treatment of cutaneous candidosis, with terbinafine showing slightly higher mycological cure rates (82% vs 73%) 4.
- Terbinafine has also been shown to be effective against certain species of Candida, including Candida parapsilosis, with an MIC90 of 0.125 microg/ml 5.
- In vitro studies have demonstrated terbinafine's activity against a range of pathogenic fungi, including dermatophytes, molds, and yeasts 5.
Clinical Use
- Terbinafine is considered a first-line treatment option for dermatophyte onychomycosis and cutaneous mycoses that warrant systemic treatment 3.
- Topical terbinafine is a treatment of choice for less extensive mycoses, including cutaneous candidiasis 3.
- Guidelines for the diagnosis and treatment of mucocutaneous candidiasis recommend the use of topical antifungal agents, including terbinafine, for cutaneous candidiasis 6.