What is the treatment for a patient with a Tinea infection on the bilateral lower breast?

Treatment of Tinea Infection on Bilateral Lower Breast

For tinea infection affecting the bilateral lower breast (tinea corporis), initiate topical antifungal therapy for 2 weeks as first-line treatment, reserving oral antifungals for extensive, resistant, or treatment-refractory cases. 1

First-Line Treatment: Topical Antifungals

• Topical terbinafine is the preferred initial therapy, applied to affected areas for 2 weeks, as it cures most ringworm (tinea corporis) and relieves associated itching, burning, cracking, and scaling 2
• Topical azole antifungals are equally effective alternatives, though they require application for the full 2-week duration 3
• Continue treatment for at least 1 week after clinical clearing of the infection to prevent recurrence 3

When to Escalate to Oral Therapy

Oral antifungal therapy is indicated when: 1

• The infection is resistant to topical treatment
• The infected area is extensive or covers large body surface areas 4
• The skin is macerated with secondary bacterial infection 4
• The patient is immunocompromised 4, 5

Oral Antifungal Options (If Needed)

Terbinafine 250 mg daily for 1-2 weeks is the preferred oral agent, particularly effective against Trichophyton species that commonly cause tinea corporis 1

Alternative oral options include:

• Itraconazole 100 mg daily for 15 days, which has an 87% mycological cure rate and superior efficacy compared to griseofulvin 1
• Fluconazole can be considered as third-line therapy, though it has limited comparative efficacy data and is less cost-effective than terbinafine 1

Critical Management Considerations

Confirm the diagnosis before treatment through potassium hydroxide (KOH) preparation or fungal culture, as accurate diagnosis is essential for effective therapy 1, 3

Address moisture and skin occlusion, which are key exacerbating factors in inframammary areas:

• Keep the skin dry and cool at all times 4
• Reduce moisture accumulation under the breast folds 3

If inflammation is prominent, consider using a combination antifungal/steroid agent, though use with caution due to potential for skin atrophy and steroid-associated complications 3

Prevention of Recurrence and Transmission

• Avoid sharing towels, clothing, and personal items with others 1, 4
• Clean contaminated personal items with disinfectant or 2% sodium hypochlorite solution 1
• Screen and treat household contacts if anthropophilic species are identified 1
• Cover lesions to prevent transmission 1

Monitoring and Follow-Up

• The definitive endpoint should be mycological cure, not just clinical response 1
• Follow-up should include both clinical and mycological assessment until clearance is documented 1
• If no clinical improvement occurs after initial therapy, switch to oral antifungal treatment 1
• For ongoing positive mycology despite clinical improvement, continue current therapy for an additional 2-4 weeks 6

Common Pitfalls to Avoid

• Do not discontinue treatment when lesions appear clinically clear—continue for at least 1 week beyond clinical resolution 3
• Avoid using topical therapy alone for extensive disease, as this leads to treatment failure 1
• Do not overlook the need for mycological confirmation, as misdiagnosis can lead to inappropriate treatment 1, 4