What is the primary treatment for tinea faciei versus dermatophytosis?

Tinea Faciei vs Dermatophytosis: Treatment Approach

Understanding the Terminology

Tinea faciei IS dermatophytosis—specifically, it refers to a dermatophyte infection of the facial skin, excluding the beard area. Dermatophytosis is the umbrella term for all fungal infections caused by dermatophytes (Trichophyton, Microsporum, or Epidermophyton species), while tinea faciei describes the anatomical location 1, 2.

Primary Treatment for Tinea Faciei

For tinea faciei, oral antifungal therapy is the preferred treatment because topical drugs are difficult to apply adequately near the eyes, ears, and mouth, and oral therapy ensures complete eradication of the infection. 2

First-Line Oral Therapy

• Terbinafine 250 mg daily for 2-4 weeks is the preferred first-line agent for Trichophyton species infections due to its fungicidal activity and superior efficacy 3
• Griseofulvin 500 mg daily (or 15-20 mg/kg/day) for 2-4 weeks is the preferred choice for Microsporum species infections, as terbinafine fails against Microsporum because it cannot adequately reach the scalp surface where arthroconidia are located 3, 1

When to Start Treatment

• Begin treatment immediately if clinical features strongly suggest dermatophytosis (scaling, erythema with raised borders, or lymphadenopathy), even before mycology results return 3
• Collect specimens via skin scrapings for KOH preparation and fungal culture to confirm diagnosis and identify the causative organism 1

Second-Line Options

• Itraconazole 200 mg daily for 2-4 weeks is effective against both Trichophyton and Microsporum species and serves as an alternative when first-line agents fail 3
• Fluconazole may be used for refractory cases with favorable tolerability 3

Treatment Algorithm for All Dermatophytoses

Step 1: Determine Anatomical Location and Extent

• Tinea capitis (scalp): Oral therapy is mandatory; topical agents alone are ineffective 4, 3
• Tinea faciei (face): Oral therapy is necessary due to difficulty applying topicals near sensitive areas 2
• Tinea corporis/cruris (body/groin): Topical therapy is first-line for limited disease; oral therapy for extensive or chronic cases 5, 6, 7
• Tinea pedis/manuum (feet/hands): Topical therapy for mild cases; oral therapy for hyperkeratotic or extensive disease 6, 7
• Tinea unguium (nails): Oral therapy is primary treatment; terbinafine 250 mg daily for 12-16 weeks (toenails) or 6 weeks (fingernails) 4

Step 2: Identify the Causative Organism

• For Trichophyton species: Use terbinafine as first choice (shorter duration, better compliance) 3
• For Microsporum species: Use griseofulvin as first choice (terbinafine is ineffective) 3
• If organism unknown: Start empirically based on clinical presentation and local epidemiology, then adjust based on culture results 3

Step 3: Select Appropriate Therapy

Oral Antifungal Dosing:

• Terbinafine: 250 mg daily for 2-4 weeks (tinea corporis/cruris/faciei), 12-16 weeks (toenail onychomycosis) 4, 3
• Griseofulvin: 500 mg daily for adults; 2-4 weeks for tinea corporis, 4-6 weeks for tinea capitis 1
• Itraconazole: 200 mg daily for 12 weeks continuously, or pulse therapy 400 mg daily for 1 week per month (3 pulses for toenails) 4

Topical Antifungal Options (for limited disease):

• Terbinafine 1% cream once daily for 1 week is highly effective for tinea cruris 5
• Clotrimazole or butenafine applied twice daily for 2-4 weeks are alternatives 5

Step 4: Add Adjunctive Measures

• Use antifungal shampoos (ketoconazole 2%, selenium sulfide 1%, or povidone-iodine) to reduce spore transmission in tinea capitis 4
• Screen and treat family members and close contacts, especially for T. tonsurans infections 3
• Ensure proper hygiene: keep affected areas dry, use separate towels, discard contaminated footwear 4, 5

Common Pitfalls to Avoid

• Never use topical therapy alone for tinea capitis or tinea faciei—it cannot eradicate infection involving hair follicles or reach adequate depth 4, 2
• Do not use terbinafine for Microsporum infections—it has poor efficacy and will lead to treatment failure 3
• Avoid underdosing griseofulvin—higher doses (15-20 mg/kg/day) are needed due to increasing treatment failures with lower doses 3, 1
• Continue treatment until mycological cure is achieved, not just clinical improvement—relapse is common if organisms are not fully eradicated 4, 3, 6
• If treatment fails, consider poor compliance, suboptimal drug absorption, organism insensitivity, or reinfection; continue therapy for an additional 2-4 weeks if clinical improvement is seen but mycology remains positive 3, 5