Treatment of Fungal Skin Infections with Antifungal Ointments
For uncomplicated superficial fungal skin infections, apply topical azole antifungals (clotrimazole or miconazole cream) twice daily for 2-4 weeks as first-line therapy. 1
Topical Treatment Selection by Infection Type
Dermatophyte Infections (Tinea)
- Allylamines (naftifine, terbinafine) are superior to azoles for dermatophyte infections due to their fungicidal activity, allowing treatment durations as short as once daily for 1 week with high cure rates 2, 3
- Azole antifungals (clotrimazole, miconazole, ketoconazole) are fungistatic alternatives that require longer treatment courses (2-4 weeks) but remain clinically effective 1, 3
- Apply twice daily to affected areas and extend 1-2 cm beyond visible margins 2
Candida (Yeast) Infections
- Azole antifungals are preferred over allylamines for Candida infections because allylamines have reduced activity against yeasts 2, 3
- Clotrimazole or miconazole cream applied twice daily for 2-4 weeks is first-line 1
- Nystatin cream serves as an alternative polyene option if azoles are not tolerated 1
- Keep infected areas dry throughout treatment, as moisture promotes fungal growth 1
Facial Fungal Infections
- Apply topical azole antifungals (clotrimazole or miconazole cream) twice daily for 2-4 weeks 1
- Address predisposing factors such as diabetes, immunosuppression, or excessive moisture to prevent recurrence 1
When Topical Therapy is Insufficient
Indications for Oral Antifungals
- Escalate to oral fluconazole 100-200 mg daily for 7-14 days if:
Specific Oral Regimens
- For dermatophyte infections: Terbinafine 250 mg daily for 1-2 weeks is highly effective 6
- For Candida infections: Fluconazole 100-200 mg daily for 7-14 days 4, 1
- For pityriasis versicolor: Fluconazole 400 mg as a single dose or itraconazole 200 mg daily for 5-7 days 6
Nail Infections (Onychomycosis)
Topical Options (Limited Role)
- Topical therapy is only appropriate for superficial white onychomycosis or early distal lateral subungual onychomycosis affecting <80% of nail plate without lunula involvement 7
- Amorolfine 5% lacquer applied once or twice weekly for 6-12 months after filing diseased nail areas achieves approximately 50% efficacy 7
- Ciclopirox 8% lacquer applied once daily for up to 48 weeks shows 34% mycological cure versus 10% with placebo 7
- Tioconazole 28% solution has only 22% cure rates and is less preferred 7
Systemic Therapy (Preferred for Most Cases)
- Terbinafine 250 mg daily is first-line for dermatophyte onychomycosis with the highest cure rates 7
- Duration: 6 weeks for fingernails, 12 weeks for toenails 7
- For Candida onychomycosis: Itraconazole 200 mg daily or pulse therapy (400 mg daily for 1 week each month) for minimum 4 weeks (fingernails) or 12 weeks (toenails) 7
- Fluconazole 50 mg daily or 300 mg weekly is an alternative for Candida 7
Critical Pitfalls to Avoid
- Do not use allylamines as monotherapy for Candida infections—they have poor activity against yeasts despite being superior for dermatophytes 2, 3
- Do not stop treatment when skin appears healed—fungi recur more often with premature discontinuation, especially with fungistatic agents 3
- Do not rely on topical therapy alone for nail infections—products penetrate poorly through the nail plate and systemic therapy is usually required 3, 5
- Do not use terbinafine for pityriasis versicolor—it is ineffective for this Malassezia infection 6
Adjunctive Measures
- Eradicate predisposing factors: control diabetes, address immunosuppression, reduce moisture exposure 1, 5
- For lip involvement with Candida: apply white soft paraffin ointment immediately and every 2 hours to protect vermillion border 4
- Investigate and treat other sites of infection and potential sources of reinfection 5