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Topical Antifungal Agents at a Glance
  • Preferred treatment for superficial fungal infection of limited extent.
  • Low cost, low incidence of drug interactions, few side effects and complications, ease of use.
  • Use systemic agent when superficial fungal infection affects large surface area, involves terminal hair or nails, or is resistant to topical management.
  • Topical antifungal classes: imidazoles, allylamines, benzylamines, polyenes.
  • Ciclopirox olamine: unique topical antifungal with broad-spectrum activity, variety of indications.
  • Side effects: irritant dermatitis, allergic contact dermatitis, urticarial reactions.
  • Combination agents (antifungal and steroid): watch for side effects due to glucocorticoids.
  • Combination agents: higher rate of treatment failure, disease relapse.

Superficial fungal infections, including dermatophytoses, candidiasis, and pityriasis versicolor, are most often restricted to the epidermis. In treating these infections, the clinician must select between topical or systemic management. Factors guiding management include, but are not limited to, the:

  • extent and severity of the infection,
  • site of involvement,
  • comorbid conditions or potential drug interactions, if any,
  • anticipated efficacy of treatment,
  • cost and access to medication, and
  • ease of use.

Patients with limited fungal infections confined to glabrous skin are usually best treated with topical agents. Conversely, those with extensive or recalcitrant disease, or with involvement of terminal hair or nails, may be better suited for systemic management. In some cases, either treatment option may be reasonably chosen.

Treatment with topical antifungal therapy enjoys several advantages over systemic management, including:

  • fewer side effects,
  • fewer drug interactions,
  • localization of treatment, and
  • generally lower cost.

Numerous topical antifungal medications are available (Table 219-1). For the most part, specific antifungal agents have replaced nonspecific topical treatments, such as keratolytics (salicylic acid) or antiseptics (gentian violet or Castellani paint), which were once the cornerstones of management.

Table 219-1 Topical Antifungal Agents Commonly Used in Dermatology

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