What treatment options are available for a patient with tinea versicolor who responded better to ketoconazole (ketoconazole) 2% shampoo than fluconazole (fluconazole) 100mg tablets and has elevated liver function tests (LFTs)?

Treatment Options for Tinea Versicolor with Elevated LFTs

For a patient with tinea versicolor who responded better to topical ketoconazole 2% shampoo than oral fluconazole and has elevated liver function tests, topical ketoconazole 2% cream applied once daily for two weeks is the recommended treatment.

Rationale for Topical Treatment

• Ketoconazole 2% cream is FDA-approved for tinea versicolor and should be applied once daily to cover the affected and immediate surrounding area for two weeks 1
• Topical ketoconazole formulations do not have significant systemic absorption when applied to intact skin, making them safe options for patients with elevated LFTs 2
• Oral ketoconazole has been associated with hepatotoxicity in 10-20% of patients, with the FDA issuing a black box warning regarding its potential for serious liver damage 3
• Hepatotoxicity from oral ketoconazole typically appears within the first 6 months of treatment and may not be dose-dependent 3

Treatment Protocol

• Apply ketoconazole 2% cream once daily to affected areas for two weeks 1
• Clinical improvement may be seen fairly soon after treatment begins, but complete the full two-week course to reduce possibility of recurrence 1
• For more widespread disease, ketoconazole 2% shampoo can be used as an adjunct treatment, applied to affected areas and left on for 5 minutes before rinsing 4

Alternative Topical Options

• Topical alternatives if ketoconazole cream is not available or not tolerated:
  • Miconazole cream 3
  • Clotrimazole cream 3
  • Selenium sulfide 2.5% lotion (applied for 10 minutes daily for 7 days) 4

Cautions Regarding Oral Antifungals

• Oral ketoconazole should be avoided due to the patient's elevated LFTs and previous poor response to oral fluconazole 3
• The FDA has restricted oral ketoconazole use due to risk of hepatotoxicity, which has been estimated to occur in 1:10,000 to 1:15,000 exposed persons 3
• Oral itraconazole also carries a risk of hepatotoxicity and should be used with caution in patients with pre-existing liver disease 3

Prevention of Recurrence

• Advise patient to:
  • Keep skin dry, especially in hot, humid weather 3
  • Wear loose-fitting, cotton clothing 3
  • Apply antifungal powders containing miconazole or clotrimazole to susceptible areas 3
  • Consider discarding old footwear or treating it with antifungal powders 3

Follow-up Recommendations

• Evaluate clinical response after two weeks of treatment 1
• If hypopigmented or hyperpigmented patches persist after treatment, reassure patient that these may take several months to resolve despite successful eradication of the fungus 5
• For patients with frequent recurrences, consider maintenance therapy with ketoconazole 2% shampoo used once weekly 4

Special Considerations

• Monitor LFTs periodically if patient requires any systemic antifungal therapy in the future 3
• Topical therapy is preferred for patients with liver disease due to minimal systemic absorption 2
• Educate patient that tinea versicolor has a high recurrence rate, and preventive measures may be necessary long-term 5