Treatment for Fungal Skin Infections
Topical antifungal agents are the first-line treatment for most fungal skin infections, with systemic therapy reserved for nail infections, scalp involvement, or extensive/resistant disease. 1
Initial Approach by Infection Type
Candidal Skin Infections (Intertrigo, Skin Folds)
- Topical azoles (clotrimazole, miconazole) or polyenes (nystatin) are the treatments of choice for candidal skin infections, particularly in skin folds of obese and diabetic patients 1
- Keeping the infected area dry is absolutely critical for treatment success 1
- Failure to maintain dryness, especially in intertrigo, is a common pitfall that leads to treatment failure 1
- For peristomal fungal infections associated with feeding tubes, topical antifungal agents can be applied to the affected area 2
Dermatophyte Infections (Tinea Corporis, Cruris, Pedis)
- Topical azoles or allylamines (terbinafine, naftifine, butenafine) are effective for localized dermatophyte infections 3, 4
- Fungicidal agents (allylamines) are often preferred over fungistatic agents (azoles) because they kill fungi rather than just inhibiting growth, allowing for shorter treatment courses (as brief as 1 week) 4
- Topical therapy alone is appropriate only when infections are localized and not extensive 5, 6
Candida Paronychia (Nail Fold Infection)
- Drainage is the most important intervention, followed by antifungal therapy 1
- This is distinct from nail infections themselves, which require different management 1
Nail Infections (Onychomycosis)
Oral systemic therapy is required for nail infections; topical agents are ineffective 1, 5
For Dermatophyte Onychomycosis:
- Terbinafine or itraconazole are preferred over griseofulvin 1
- Treatment duration: fingernails require at least 4 months; toenails require at least 6 months 5
- Griseofulvin dosing (if used): Adults 0.5g daily; pediatric patients >2 years: 10 mg/kg daily 5
For Candida Onychomycosis:
- Azoles are preferred because terbinafine has limited activity against Candida species 1
Scalp Infections (Tinea Capitis)
- Systemic oral therapy is required; topical therapy alone is not recommended 1, 5
- Griseofulvin treatment duration: 4-6 weeks 5
- Concomitant topical therapy may be used as adjunctive treatment 5
Mucocutaneous Candidiasis (Oropharyngeal/Esophageal)
While not strictly "skin," these guidelines are relevant for completeness:
Oropharyngeal Candidiasis:
- Fluconazole 100-200 mg daily for 7-14 days is first-line 2
- Alternatives include nystatin suspension, itraconazole 200 mg daily, or topical agents 2
Esophageal Candidiasis:
- Fluconazole 200-400 mg daily for 14-21 days 2
- For fluconazole-refractory disease: itraconazole solution 200 mg daily OR voriconazole 200 mg twice daily 2
- Echinocandins or amphotericin B are alternatives for refractory cases 2
Key Principles and Common Pitfalls
When Topical Therapy is Insufficient:
- Do not use topical therapy alone for nail infections or tinea capitis 1
- Widespread infections, resistant infections, or those involving hair/nails require systemic treatment 5, 6
Importance of Moisture Control:
- Failure to keep infected areas dry will undermine treatment effectiveness, particularly for intertrigo and skin fold infections 1
Confirmation of Diagnosis:
- Prior to initiating systemic therapy, appropriate specimens (KOH preparation, fungal culture, or nail biopsy) should be obtained to confirm the diagnosis 5
- Accurate identification of the organism is essential before starting treatment 5
Duration of Treatment:
- Medication must be continued until the infecting organism is completely eradicated, not just until symptoms resolve 5
- Clinical relapse will occur if medication is stopped prematurely 5