What treatment options are available for a 2-year case of tinea corporis that has not responded to Kennalog (triamcinolone)?

Treatment Options for Persistent Tinea Corporis

For a case of tinea corporis that has persisted for 2 years and not responded to triamcinolone (Kenalog), oral antifungal therapy is strongly recommended as the most effective approach to achieve mycological cure and prevent further complications.

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis:

• Perform skin scraping for KOH preparation and fungal culture
• Look for characteristic erythematous, scaly patches with central clearing
• Rule out other conditions that may mimic tinea corporis

First-Line Treatment

Oral Therapy

• Terbinafine 250 mg daily for 2-4 weeks is the recommended first-line treatment for persistent tinea corporis 1, 2
  • More effective than azoles for Trichophyton species
  • Shorter treatment duration needed compared to griseofulvin
  • Fungicidal rather than fungistatic action

Adjunctive Topical Therapy

• Add topical antifungal to accelerate clinical improvement:
  • Terbinafine 1% cream once daily 1
  • Azole cream (clotrimazole, miconazole) twice daily 3

Alternative Treatment Options

If terbinafine is contraindicated or unavailable:

Oral Alternatives

• Griseofulvin 500 mg daily for 2-4 weeks 4

  • FDA-approved for tinea corporis
  • Dosage: 0.5 g daily for adults (can be divided into 125 mg four times daily or 250 mg twice daily)
  • Take with fatty food to improve absorption

• Itraconazole 200 mg daily for 1 week 2

  • Effective alternative, especially for resistant cases
  • Consider SUBA-itraconazole formulation for better bioavailability in resistant cases 5

• Fluconazole 150 mg once weekly for 2-3 weeks 2

  • Convenient dosing schedule
  • Good option for patients who cannot tolerate daily medication

Important Considerations

1. Steroid-induced complications: The previous use of triamcinolone (Kenalog) may have caused:

   • Tinea incognito (altered presentation due to steroid use)
   • Deeper fungal invasion
   • Increased resistance to treatment

2. Treatment duration: Continue treatment for at least one week after clinical clearing of infection 6

3. Potential resistance: Consider terbinafine resistance testing if treatment fails, as resistant strains are emerging 5

4. Hygiene measures:

   • Wash clothing and bedding in hot water
   • Avoid sharing personal items
   • Keep affected areas clean and dry

Follow-up and Monitoring

• Evaluate clinical response after 2 weeks of therapy
• If no improvement, consider:
  • Confirming diagnosis with repeat culture
  • Switching to an alternative antifungal agent
  • Extending treatment duration
  • Testing for antifungal resistance

Special Considerations

• For extensive or inflammatory lesions, a longer course of therapy may be needed
• Avoid combination antifungal/steroid preparations as they may worsen the condition
• The goal of treatment should be complete mycological cure, not just clinical improvement 7

If the infection still persists after appropriate oral therapy, consider referral to a dermatologist for further evaluation and management of potential resistant infection or alternative diagnoses.