How Can Fungal Infections Be Managed?
Both prevention and pharmacological treatment are equal partners in patients who have fungal infections. For treatment, there are many antifungal medications available, both topical and systemic.
Topical Management and Therapy
For superficial skin involvement with the dermatophytes (T. capitis, T. corporis, T. cruris, and Tenia pedis), antifungal sprays, powders, and solutions containing azoles, allylamines, butenafine, ciclopirox, and tolnaftate can be used. These are available in various prescription and over-the-counter commercial products and many have systemic versions for widespread or severe involvement.
- Azoles: fluconazole (Diflucan) , itraconazole (Sporanox), voriconazole (Vfend), posaconazole (Noxafil), isavuconazole (Cresemba), and ketoconazole (Nizoral).
Hepatotoxicity can occur with systemic azoles, so therapy should be accompanied by liver function studies.
- Allylamines: naftifine 2% cream (Naftin) and terbinafine 1% cream (Lamisil)
- Ciclopirox (Ciclodan, Loprox)
- Butenafine (Lotrimin)
- Tolnaftate (LamISIL, Tinactin)
Systemic Management and Therapy
Many of the active ingredients in the topical antifungal preparations have systemic counterparts that can be used when indicated, but with caveats:
- Nail involvement (onychomycosis): due to dermatophyte infections and Candida esophagitis as a complication of thrush are difficult to successfully treat with topical preparations. Systemic antifungal approaches are typically used. Nail involvement (T. unguium onychomycosis) has better success with systemic terbinafine (LamISIL) than griseofulvin (Grisfulvin); griseofulvin also has the disadvantage of requiring prolonged courses that increase the risk of hepatotoxicity and side effects.
- Azoles: cannot be used in pregnancy during the first trimester, since they are teratogenic. Amphotericin B is the suggested alternative.
- Hepatotoxicity: Concerns should prompt pre-therapy, concomitant, and post-therapy liver function testing with systemic antifungal therapy, especially when it is prolonged.
Antifungal therapy is associated with GI upset, rashes, and–specifically with the azole, voriconazole–unusual visual disturbances and photosensitivity. Rarer side effecs include headaches, dizziness, and unusual tastes in the mouth.