What is the treatment for a fungal rash?

Treatment of Fungal Rash

For superficial fungal skin infections (dermatophytosis), topical antifungal agents are the first-line treatment, with allylamines (terbinafine, naftifine) preferred over azoles due to their fungicidal activity and shorter treatment duration. 1, 2

Initial Assessment and Treatment Selection

For Mild to Moderate Superficial Fungal Rash (Tinea Corporis/Cruris)

Topical therapy is sufficient and should be the initial approach:

• Topical allylamines (terbinafine 1% or naftifine 1-2%) applied once or twice daily for 1-2 weeks are preferred due to their fungicidal activity, which kills organisms rather than just inhibiting growth 2, 3
• Topical azoles (clotrimazole, miconazole, ketoconazole) applied twice daily for 2-4 weeks are effective alternatives, though they are fungistatic and require longer treatment courses 4, 3
• The fungicidal nature of allylamines allows for treatment courses as short as 1 week with high cure rates, reducing the risk of recurrence when patients stop treatment early 3

For Extensive or Resistant Superficial Fungal Rash

Oral antifungal therapy is indicated when:

• Terbinafine 250 mg daily for 1-2 weeks is highly effective for dermatophyte infections (tinea corporis/cruris) 1
• Fluconazole 50-100 mg daily or 150 mg once weekly for 2-3 weeks is an alternative 1
• Itraconazole 100 mg daily for 2 weeks or 200 mg daily for 7 days is also effective 1

For Candida (Yeast) Skin Infections

Azole antifungals are preferred over allylamines for yeast infections:

• Topical azoles (clotrimazole, miconazole, ketoconazole) applied twice daily are first-line for cutaneous candidiasis 2, 3
• Allylamines have reduced efficacy against Candida species and should be avoided for confirmed yeast infections 2, 3

For Vulvovaginal Candidiasis

Single-dose oral therapy or short-course topical therapy are equally effective:

• Fluconazole 150 mg as a single oral dose is recommended for uncomplicated vulvovaginal candidiasis 5, 6
• Any topical azole antifungal agent applied intravaginally for 1-7 days is equally effective, with no single agent superior to another 5
• For severe acute vulvovaginal candidiasis, fluconazole 150 mg every 72 hours for 2-3 doses is recommended 5

For Recurrent Vulvovaginal Candidiasis

• 10-14 days of induction therapy with topical azole or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months is recommended 5

For Azole-Resistant C. glabrata Vulvovaginitis

• Intravaginal boric acid 600 mg daily in a gelatin capsule for 14 days is the alternative of choice 5
• Nystatin intravaginal suppositories 100,000 units daily for 14 days is another option 5

For Oropharyngeal Candidiasis (Oral Thrush)

Mild Disease

• Clotrimazole troches 10 mg 5 times daily for 7-14 days 5, 7
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 5, 7
• Nystatin suspension (100,000 U/mL) 4-6 mL 4 times daily for 7-14 days 5, 7

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days is recommended 5, 7

Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily or posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 5, 7
• For severe refractory cases, intravenous echinocandin or amphotericin B deoxycholate 0.3 mg/kg daily 5, 7

Chronic Suppression

• Fluconazole 100 mg 3 times weekly for patients with recurrent infection 5, 7

For Severe or Disseminated Candida Infections

Systemic therapy with echinocandins is first-line:

• An echinocandin (caspofungin 70 mg loading dose then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading dose then 100 mg daily) is recommended for severe skin fungal infections 8
• Fluconazole (800 mg loading dose, then 400 mg daily) can be used for less critically ill patients without recent azole exposure 8
• Treatment should continue for at least 2 weeks after documented clearance and resolution of symptoms 8

For Tinea Capitis (Scalp Ringworm)

Oral therapy is always required as topical agents cannot penetrate hair follicles:

• Griseofulvin 20-25 mg/kg daily for 6-8 weeks remains the only licensed treatment for children in the UK 5
• Terbinafine is highly effective for Trichophyton species but less effective for Microsporum species 5
• Treatment protocols should reflect local epidemiology based on the most likely causative organism 5

Critical Pitfalls to Avoid

• Never use allylamines for confirmed Candida infections as they have poor activity against yeasts 2, 3
• Fungistatic agents (azoles) require completion of the full treatment course to prevent recurrence, as they depend on skin turnover to shed living organisms 3
• Topical therapy alone is inadequate for tinea capitis, nail infections, or widespread infections requiring systemic treatment 5, 3
• For denture-related candidiasis, disinfection of the denture is essential in addition to antifungal therapy 5, 7
• In HIV-infected patients with recurrent candidiasis, antiretroviral therapy is strongly recommended to reduce recurrence 5, 7

When to Add Topical Corticosteroids

Short-term combination therapy may be beneficial when significant inflammation is present:

• Adding a corticosteroid at treatment initiation can attenuate inflammatory symptoms and potentially increase compliance 9
• However, incorrect or prolonged use may be associated with treatment failure and adverse effects 9
• Limit corticosteroid use to the initial phase of treatment only when inflammation is prominent 9