What is the workup for dryness and cracked skin surrounding the right pinky finger due to a fungal infection, which has worsened at night since starting ketoconazole (ketoconazole) 2% cream two months ago, and has persisted after discontinuation 3-4 days ago?

From the Guidelines

For a skin condition involving dryness and cracking around a finger due to fungal infection, I recommend switching to a different antifungal medication since ketoconazole 2% appears to have caused irritation. Consider using clotrimazole 1% cream or terbinafine 1% cream applied twice daily for 2-4 weeks, as suggested by general dermatological guidelines 1. These alternatives are often better tolerated while still effectively treating fungal infections. Additionally, apply a fragrance-free moisturizer like CeraVe or Eucerin several times daily after the antifungal cream has dried to help repair the skin barrier. Overnight application of petroleum jelly with cotton gloves can provide intensive moisture. The worsening symptoms at night may be due to decreased awareness of scratching or lower cortisol levels which can increase inflammation and itching. If symptoms don't improve within two weeks with this regimen, or if there's increasing redness, swelling, or drainage, consult a healthcare provider as bacterial superinfection may have developed, as indicated by guidelines for skin and soft tissue infections 1. The irritation you're experiencing could be either a reaction to the ketoconazole or a sign that the fungal infection is causing more inflammation as it responds to treatment. Some key points to consider in managing fungal infections include keeping the affected area clean and dry, avoiding sharing personal items, and wearing protective footwear to prevent reinfection, as emphasized in the British Association of Dermatologists' guidelines for the management of onychomycosis 1. It's also essential to note that antifungal treatment should be continued for an adequate duration to ensure complete resolution of the infection, and in some cases, may require oral antifungal agents, as outlined in the practice guidelines for the diagnosis and management of skin and soft tissue infections 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION SECTION Cutaneous candidiasis, tinea corporis, tinea cruris, tinea pedis and tinea (pityriasis) versicolor: It is recommended that Ketoconazole Cream 2% be applied once daily to cover the affected and immediate surrounding area Clinical improvement may be seen fairly soon after treatment is begun; however, candidal infections and tinea cruris and corporis should be treated for two weeks in order to reduce the possibility of recurrence. Patients with tinea versicolor usually require two weeks of treatment. Patients with tinea pedis require six weeks of treatment

The patient has been using ketoconazole 2% for two months and has stopped using it 3-4 days ago. The patient is experiencing dryness and cracked skin surrounding a finger due to a fungal infection, which has worsened at night.

• The ketoconazole 2% was likely prescribed for a fungal infection, given its indications for use 2.
• The treatment duration for tinea pedis is six weeks 2, which the patient has exceeded.
• The dryness and cracked skin may be a symptom of the underlying fungal infection or a separate condition.
• Given the patient has stopped using the ketoconazole 2% 3-4 days ago, it is unlikely that the medication is the cause of the worsening symptoms.
• A workup for the skin dryness and cracked skin surrounding the finger may include:
  • Assessing the affected area for signs of infection or other conditions
  • Reviewing the patient's medical history and current medications
  • Considering alternative treatments for the fungal infection or separate conditions contributing to the dryness and cracked skin 2

From the Research

Skin Dryness Surrounding a Finger due to Fungus

• The patient is experiencing dryness and cracked skin around the pinky finger, which has worsened since starting ketoconazole 2% treatment two months ago, with increased dryness and stinging, particularly at night 3, 4.
• The patient stopped using ketoconazole 2% 3-4 days ago, which may help alleviate some of the symptoms, but the dryness and cracking persist.

Treatment Options

• Topical antifungal agents such as clotrimazole, nystatin, and miconazole have been shown to be effective in treating fungal infections, including those causing skin dryness and cracking 5, 4, 6.
• Ketoconazole 2% was initially used to treat the fungal infection, but its effectiveness in preventing recurrence is limited, and it may cause skin dryness and irritation as a side effect 3, 4.
• Terbinafine, an allylamine antifungal drug, has been shown to be effective in treating dermatophyte skin infections and onychomycosis, with a lower recurrence rate compared to other antifungal agents 7.

Management of Skin Dryness

• Keeping the affected area clean and dry can help prevent the growth of fungus and reduce skin dryness and cracking 5.
• Using a moisturizer can help alleviate skin dryness and irritation, but it is essential to choose a moisturizer that is fragrance-free and hypoallergenic to avoid further irritating the skin.
• Applying a topical antifungal agent, such as clotrimazole or miconazole, can help treat the underlying fungal infection and reduce skin dryness and cracking 4, 6.