What's the next step for a patient with a persistent groin rash, slightly improved with Nystatin (nystatin) cream, despite prior treatment with topical steroids, oral Diflucan (fluconazole), and topical Nystatin (nystatin) cream, after starting Jardiance (empagliflozin)?

Management of Persistent Groin Rash Associated with Jardiance

For a persistent groin rash that started after Jardiance initiation and has only partially responded to nystatin, the next step should be to discontinue Jardiance if possible and add combination therapy with an oral antihistamine and a different topical antifungal agent.

Understanding the Cause

The groin rash is likely a fungal infection (candidiasis) secondary to Jardiance (empagliflozin) use. SGLT2 inhibitors like Jardiance increase urinary glucose excretion, creating favorable conditions for fungal growth in the genital region.

Treatment Algorithm:

1. Address the underlying cause:

   • Consider discontinuing Jardiance if clinically appropriate
   • If Jardiance must be continued, implement more aggressive antifungal therapy

2. Optimize current antifungal therapy:

   • Continue topical nystatin since partial improvement was noted 1
   • Add a different class of topical antifungal (azole-based) such as clotrimazole or ketoconazole cream 2
   • Apply twice daily to affected areas after gentle cleansing

3. Add symptomatic treatment:

   • Oral antihistamine (cetirizine 10mg daily or diphenhydramine 25-50mg every 6 hours) for itch relief 3
   • Consider adding famotidine 20mg twice daily to enhance antihistamine effect 3

4. Modify local environment:

   • Keep area clean and dry
   • Use soap-free cleansers and pat dry thoroughly after bathing
   • Wear loose-fitting cotton underwear
   • Apply powder (non-medicated) to reduce moisture

5. If no improvement within 2 weeks:

   • Consider oral fluconazole 200mg once weekly for 2-4 weeks 4
   • For fluconazole-resistant cases, consider alternative oral antifungals

Rationale for Treatment

The partial response to nystatin suggests a fungal etiology, but the persistence indicates either:

• Ongoing exposure to the causative factor (Jardiance)
• Inadequate treatment regimen
• Possible mixed infection or steroid-induced dermatitis from prior topical steroid use 5

Topical nystatin has shown efficacy against Candida species, including some fluconazole-resistant strains 6. However, combination therapy with different antifungal classes may provide better coverage.

Important Considerations

• Avoid reintroducing topical steroids as they may worsen fungal infections and can cause steroid-induced rosacea-like dermatitis with prolonged use 5
• If the rash persists despite these measures, consider dermatology referral for further evaluation
• Ensure proper application of topical medications (thin layer, extending slightly beyond visible rash)
• Patient should be instructed to continue treatment for 1-2 weeks after visible resolution to prevent recurrence 1

This approach addresses both the underlying cause and provides symptomatic relief while targeting the likely fungal infection with appropriate antifungal agents.