Chapter 16

Fungal Skin Infections

Lebanese International University
School of Pharmacy
Non-Prescription Drugs
Fall 2013 - 2014

Katia Iskandar, PharmD, MHM (Course coordinator)

Samar Younes, PharmD
Fouad Sakr, PharmD
Introduction
 Known as dermatomycoses

 Often referred to as ringworm

◦ Because of the characteristic ring-shaped lesions

◦ With clear centers and red scaly margins

◦ But the shape may be variable from a ring

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Risk Factors
 Skin trauma of the Malnutrition and poor
skin (e.g., tight- hygiene
fitting shoes)
Warm humid climates
 Diabetes mellitus
Skin occlusion
 Immune deficiency
Use of public pools
 Circulation disorders and bathing facilities
 Old age

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Types
 Tinea capitis (ringworm of the scalp)
 Tinea corporis (ringworm of the body)
 Tinea cruris (ringworm of the groin)
◦ Most common during warm weather (warm and humid)

 Tinea pedis (ringworm of the feet) or athlete’s

foot
◦ Most prevalent

 Tinea unguium (ringworm of the nails) or

onychomycosis

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Transmission
 All dermatophytes are transmitted to humans
through: Contaminated objects
◦ Contact with infected: or like:
 People Combs

Towels
 Animals

Clothes
 Water
Bedlinen
 Soil

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Clinical Presentation
 Variable from:
◦ Mild itching and scaling

◦ To severe exudative inflammatory process

characterized by:
 Fissuring

 Crusting

 Discoloration of the infected skin

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Clinical Presentation
 Pruritus is the most common complaint

 Fissures
 Painful stinging

and burning
 Abrasion
may also occur
 Oozing
 Appearance of

small vesicular lesions

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Complications
 Secondary infections
may occur if tinea
 Permanent hair loss infections are not
effectively treated
 Scarring

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Goals of Therapy
 Provide symptomatic relief

 Eradicate existing infection

 Prevent future infections

The recommended treatment period for self-

therapy of dermatomycoses is a minimum of 2
to 4 weeks

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Exclusions for Self Treatment
 Causative factor unclear Excessive and
continuous exudation
 Unsuccessful initial
treatment or worsening
Condition extensive,
condition
seriously inflamed, or
 Nails or scalp involved debilitating

 Signs of possible DM, systemic infection,

secondary bacterial
immune deficiency
infection (oozing
purulent material)
Fever, malaise, or both

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General Treatment Approach
 Tinea pedis, tinea corporis, and tinea cruris
can be effectively treated with
nonprescription topical antifungals and
nonpharmacologic measures
◦ Tinea unguium or tinea capitis  referred to a
primary care provider
 Before recommending therapy, the provider
must be reasonably sure that the lesions are
consistent with a tinea infection
◦ In case of doubt  consult a primary care provider
or dermatologist

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Nonpharmacologic Therapy
 Prevent spreading of the Wash the skin thoroughly
infection to other body with soap and water, and
parts pat dry
◦ Using a separate towel
to dry the affected area Avoid wearing wool,
synthetic fabrics, clothes or
footwear that prevent
 Avoid sharing of towels
optimal air circulation or
or clothes with others
occlude the skin
 Launder contaminated Allow shoes to dry well, or
cloth in hot water and dust them with foot powder
dry (talc) to keep them dry

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Pharmacologic Therapy
Clioquinol
 FDA approved clioquinol 3% for

nonprescription use

 But no commercially available nonprescription

topical antifungals currently contain this
agent

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Pharmacologic Therapy
Haloprogin
 FDA approved haloprogin 1% for

nonprescription use

 But no commercially available nonprescription

topical antifungals currently contain this
agent

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Pharmacologic Therapy
Clotrimazole and Miconazole Nitrate
 Inhibit fungal biosynthesis of ergosterol

◦  resulting in damage of the fungal cell membrane

and alteration of permeability
◦ With subsequent loss of intracellular contents

 Applied topically twice daily up to 4 weeks

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Pharmacologic Therapy
Clotrimazole and Miconazole Nitrate
Side Effects (rare)
 Skin burning
 Irritation
 Stinging

◦ No significant drug-drug interactions have been

reported

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Pharmacologic Therapy
Terbinafine Hydrochloride (Lamisil®)
 Available as 1% cream and spray

 Inhibits the fungal enzyme squalene

epoxidase
◦ A key enzyme in fungal sterol biosynthesis

 Applied to the affected area twice daily up to

4 weeks

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Pharmacologic Therapy
Terbinafine Hydrochloride (Lamisil®)
Side Effects (low incidence)
 Irritation
 Burning
 Itching
 Dryness

◦ No significant drug-drug interactions with topical

use

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Pharmacologic Therapy
Butenafine
Hydrochloride Applied to the affected
 Similar mechanism of area twice daily for 1
action of terbinafine week, then once daily
for 4 weeks
 Available as a cream
Low incidence of side
 Effective for treatment effects
of athlete’s foot
No reported drug
interactions with topic
use
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Pharmacologic Therapy
Tolnaftate
 Exact mechanism of action  Applied twice daily after
has not been described effective cleaning of the
affected area for 2 – 4 weeks
 The only nonprescription
antifungal available for both  Well tolerated, but may
prevention and treatment of slightly sting the skin when
athlete’s foot applied

 Available as 1% solution,  No drug-drug interactions

cream, gel, powder, and with topical use are known
spray

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Pharmacologic Therapy
Undecylenic Acid
 FDA approved undecylenic acid and

undecylenate salts for nonprescription use

 But no commercially available nonprescription

topical antifungals currently contain this
agent

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Pharmacologic Therapy
Salts of Aluminum
 Not FDA approved antifungals

 Approved to treat inflammatory skin

conditions like those in athlete’s foot
◦ Do not treat athlete’s foot if applied alone

◦ But help in drying skin  make the condition easier

to treat with other topical antifungals

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Pharmacologic Therapy
Salts of Aluminum
Mechanism of Action (two-way effect)
 Astringent

◦ Complex with proteins  reduce edema,

inflammation, and cellular permeability

 Antibacterial
◦ At concentration above 20%
◦  prevent the development of secondary bacterial
infections

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Pharmacologic Therapy
Salts of Aluminum
 Contraindicated in severely eroded or deeply

fissured skin due to risk of irritation and

toxicity

 Prolonged use precipitates tissue necrosis

◦  should not be used for than one week
◦ Should be discontinued if signs of inflammation
abruptly develop or worsen

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Pharmacologic Therapy
Salts of Aluminum
 Aluminum acetate solution is used to

immerse the feet or as a wet dressing 3 times

per day

 Aluminum chloride is applied twice daily

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Dosage Form Selection
Creams and Solutions
 Most effective and efficient dosage forms for

delivery of active ingredients into the epidermis

Sprays and Powders

 Less effective because they are not rubbed into

the skin
 Probably more useful as adjuncts to a cream or a

solution
 Prophylactic agents that prevent new or recurrent

infections

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Patient Counseling for Fungal
Skin Infections
 Proper application technique for topical
antifungals to prevent over- or undermedication
 Expected duration of therapy
 Applying the medication regularly throughout a

complete course of therapy

 Proper care of the infected skin site
 Appropriate laundry techniques and products
 Minimal use of occlusive clothing
 Avoidance of habits or behavior that may lead

to recurring infections

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Outcome Evaluation
 Tinea infections start to improve within about
1 week of topical product use

◦ If this is the condition  treatment should be

continued up to 4 weeks

◦ If the condition has not improved or worsened

during self-therapy  the patient should be
referred to the PCP

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Key Points for Fungal Skin Infections
 Effectiveness of topical antifungals will be limited
unless the patient eliminates other predisposing
factors to tinea infections
 Drugs are effective in all their delivery vehicles, but
the powder forms should be reserved only for
extremely mild conditions or as adjunctive therapy
 Because solutions and creams are spreadableshould
be used sparingly
 Drugs should be used twice daily (morning and night)
 Treatment should be continued for 2 to 4 weeks
depending on the symptoms
◦ After that time evaluate the effectiveness of the therapy.

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Key Points for Fungal Skin Infections
 To minimize noncompliance advise patients
that alleviation of symptoms will not occur
overnight
 Frequent recurrence indication to consult a

PCP
 Immunocompromised patients and those with

diabetes or circulatory problems  treated by

a PCP

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