Treatment of Common Fungal Skin Infections with Antifungal Cream
For dermatophyte infections (tinea corporis, tinea cruris, tinea pedis), use topical allylamine antifungals like terbinafine 1% cream twice daily for 1 week, which provides superior mycological cure rates compared to azole creams. 1
Algorithmic Approach by Infection Type
Dermatophyte Infections (Tinea)
First-line topical therapy:
- Terbinafine 1% cream twice daily for 1 week achieves 93.5% mycological cure rates and 89.7% effective treatment rates, significantly superior to clotrimazole (73.1% and 58.7% respectively). 1
- Naftifine 1-2% cream is an alternative allylamine with fungicidal activity and documented sustained clearance after therapy completion. 2
Alternative topical azoles (if allylamines unavailable):
- Ketoconazole 2% cream is FDA-approved for tinea corporis, tinea cruris, and tinea pedis caused by Trichophyton rubrum, T. mentagrophytes, and Epidermophyton floccosum. 3
- Clotrimazole 1% cream requires 4 weeks of twice-daily application (longer than allylamines). 1
Key distinction: Allylamines are fungicidal (kill fungi), while azoles are fungistatic (inhibit growth), making allylamines preferable when patients may discontinue treatment early. 4
Cutaneous Candidiasis
First-line topical therapy:
- Topical azoles (clotrimazole, miconazole) or nystatin are effective for candidal skin infections and paronychia. 5
- Ketoconazole 2% cream is FDA-approved for cutaneous candidiasis caused by Candida species. 3
- Nystatin topical powder applied 2-3 times daily until healing is complete for candidal lesions. 6
Critical adjunct: Keep infected areas dry, especially in skin folds (intertrigo) common in obese and diabetic patients. 5
Tinea (Pityriasis) Versicolor
Topical options:
- Ketoconazole 2% cream (FDA-approved for this indication). 3
- Topical allylamines have proven efficacious in some cases despite being less active against yeasts than azoles. 2
Common Clinical Pitfalls
Duration of therapy matters: Patients often stop treatment when skin appears healed (typically after 1 week), leading to higher recurrence rates with fungistatic azoles versus fungicidal allylamines. 4
Keeping areas dry is mandatory: For intertrigo and skin fold infections, topical antifungals alone are insufficient without addressing moisture. 5
Very moist lesions: Use topical dusting powder formulations rather than creams for optimal penetration and moisture control. 6
Paronychia requires drainage: The most important intervention for candidal paronychia is drainage, with topical antifungals as adjunctive therapy. 5
When Topical Therapy is Insufficient
Oral therapy required for:
- Tinea capitis (scalp infections). 7, 8
- Onychomycosis (nail infections) - topical agents penetrate poorly through nail plates. 5, 4, 8
- Widespread infections covering large body surface areas. 7, 4
- Hair follicle infections. 4
Vehicle Selection
Match vehicle to lesion characteristics: