Treatment for tinea
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Here is a comprehensive overview of tinea treatment organized by type:
Treatment of Tinea (Dermatophytosis)
Overview
Tinea refers to superficial fungal infections caused by dermatophytes (genera Trichophyton, Microsporum, and Epidermophyton). The term is used with the body site - tinea capitis (head), tinea corporis (body), tinea cruris (groin), tinea pedis (feet), and tinea unguium/onychomycosis (nails).
Treatment choice depends on the site, extent of infection, and whether hair/nails are involved (which always require systemic therapy).
Treatment by Site
1. Tinea Corporis (body) and Tinea Cruris (groin)
Localized:
- Topical therapy is first-line
- Allylamines: terbinafine, naftifine
- Benzylamines: butenafine
- Azoles: econazole, luliconazole, miconazole, clotrimazole
- Ciclopirox
- Allylamines/benzylamines may provide a more sustained cure compared to azoles
- For tinea cruris, keep the area as dry as possible; lotions or sprays are easier to apply than creams on large areas
Widespread/Extensive:
- Oral therapy required:
- Terbinafine 250 mg/day for 1-2 weeks
- Itraconazole 200 mg/day for 1-2 weeks
- Alternatives: fluconazole, griseofulvin
- Terbinafine is generally preferred as it has fewer drug interactions than itraconazole
2. Tinea Pedis (athlete's foot)
- Topical: azoles, allylamines, benzylamines (same agents as above)
- Systemic (for extensive or refractory cases): terbinafine, itraconazole, fluconazole, griseofulvin
- Note: tinea pedis can be complicated by bacterial superinfection (streptococci/staphylococci entering through toe-web fissures); agents like econazole and ciclopirox have some additional antibacterial coverage and may be useful in those situations
3. Tinea Capitis (scalp)
- Always requires systemic therapy - topical agents do not penetrate the hair shaft
- Griseofulvin has been the traditional agent; treatment failure is often due to inadequate dose or duration
- Terbinafine may be more effective for Trichophyton tonsurans (most common cause in the US)
- Fluconazole and itraconazole are also effective alternatives
4. Onychomycosis (nail, tinea unguium)
- Always requires systemic therapy (topical agents generally ineffective alone)
- Confirm fungal infection before starting oral therapy (about 1/3 of clinically suspected cases are not fungal)
First-line oral agents:
| Agent | Dosing - Fingernails | Dosing - Toenails |
|---|---|---|
| Terbinafine (preferred for dermatophytes) | 250 mg/day x 6 weeks | 250 mg/day x 12 weeks |
| Itraconazole (preferred for Candida) | 200 mg/day x 6 weeks OR 400 mg/day x 1 wk/month x 2 months | 200 mg/day x 12 weeks OR 400 mg/day x 1 wk/month x 3 months |
| Fluconazole | Alternative if above not tolerated | Alternative if above not tolerated |
- Terbinafine is slightly superior to itraconazole for dermatophyte onychomycosis; monitor for hepatotoxicity with both
- Itraconazole has frequent drug interactions; use with caution in heart failure
Topical agents for onychomycosis (for mild-moderate disease, no nail matrix involvement, or patients not candidates for systemic therapy):
-
Ciclopirox lacquer
-
Efinaconazole (topical solution, applied for up to 1 year - shown beneficial in trials)
-
Tavaborole
-
All require ~48 weeks of treatment
-
Griseofulvin is no longer preferred for onychomycosis (less efficacious, longer courses)
Summary Table
| Condition | Topical | Oral |
|---|---|---|
| Tinea corporis, localized | Azoles, allylamines, benzylamines | - |
| Tinea corporis, widespread | - | Terbinafine, itraconazole, fluconazole, griseofulvin |
| Tinea capitis | Not effective alone | Griseofulvin, terbinafine, itraconazole, fluconazole |
| Tinea pedis | Azoles, allylamines, benzylamines | Terbinafine, itraconazole, fluconazole, griseofulvin |
| Onychomycosis | Ciclopirox, efinaconazole, tavaborole (mild only) | Terbinafine (preferred), itraconazole, fluconazole |
| Tinea versicolor, localized | Azoles, allylamines | - |
| Tinea versicolor, widespread | - | Itraconazole, fluconazole |
Important Notes
- Ketoconazole (systemic) is not recommended for superficial infections due to risk of severe hepatotoxicity and QT prolongation
- Relapse of tinea cruris and tinea pedis is common; treat early with topical agents
- Onychomycosis relapses occur in 25-30% of cases after treatment
- Itraconazole capsules require food and gastric acid for absorption; the solution is taken on an empty stomach
Emerging Resistance - 2025 Alert
A recent systematic review (PMID: 39082800) documents terbinafine-resistant Trichophyton indotineae emerging in Europe. This is an important development for refractory tinea cases - particularly extensive or persistent infections that fail standard terbinafine therapy. In such cases, itraconazole or other azoles may need to be substituted.
Sources: Harrison's Principles of Internal Medicine 22E (2025); Goodman & Gilman's Pharmacological Basis of Therapeutics
Fluconazole tablet dosage
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Fluconazole Tablet - Dosage
Available Formulations
- Tablets: 50 mg, 100 mg, 150 mg, 200 mg
- Oral suspension: 10 mg/mL and 40 mg/mL
- IV solution: 2 mg/mL (in saline or dextrose)
Dosage by Indication
| Indication | Dose | Duration |
|---|---|---|
| Vaginal candidiasis (uncomplicated) | 150 mg single dose | Once |
| Oropharyngeal candidiasis | 100-200 mg/day | 7-14 days |
| Esophageal candidiasis | 200 mg/day (loading 400 mg day 1) | 14-21 days |
| Candidemia (non-immunocompromised) | 800 mg loading, then 400 mg/day | Per response |
| Cryptococcal meningitis (consolidation, AIDS) | 400 mg/day x 8 weeks, then 200 mg/day maintenance | Indefinitely (or until CD4 >200 for ≥6 months) |
| Tinea corporis / tinea pedis / tinea barbae | 150 mg once weekly | 2-4 weeks |
| Tinea cruris / tinea capitis | 150 mg once weekly | 4-6 weeks |
| Onychomycosis - fingernails | 150-450 mg once weekly | 3 months |
| Onychomycosis - toenails | 150-450 mg once weekly | 6 months |
| Tinea versicolor (pityriasis versicolor), widespread | 300 mg/wk | 2 weeks |
| Coccidioidal meningitis | 400-800 mg/day | Long-term |
General Dosing Rules
- General range: 50-400 mg once daily (oral or IV)
- Loading dose: On day 1, give twice the maintenance dose
- Maximum studied dose: Up to 1200 mg/day has been used in cryptococcal meningitis trials
Pediatric Dosing
- General infections: 12 mg/kg once daily (max 600 mg/day), no loading dose
- Onychomycosis: 3-6 mg/kg/week
- Fingernails: 6-12 weeks
- Toenails: 9-15 weeks
Renal Dose Adjustment
- Fluconazole is primarily renally eliminated (poorly metabolized by liver)
- Dose adjustment required in renal insufficiency
- For patients on dialysis: give full dose after each dialysis session
Key Pharmacokinetic Points
- Oral bioavailability ~90% (nearly equivalent to IV)
- Long half-life: 25-30 hours (allows once-daily or once-weekly dosing)
- Absorption is NOT affected by food, gastric acidity, or disease
- Good CSF and tissue penetration (skin, nail, vitreous)
Important Cautions
- Drug interactions: Fluconazole inhibits CYP3A4 and CYP2C9 - interacts with warfarin, phenytoin, cyclosporine, statins, and many others. Fatal arrhythmias possible with cisapride, pimozide, astemizole
- QT prolongation: Cardiac monitoring if risk factors present
- Pregnancy: Avoid high doses (associated with tetralogy of Fallot and skeletal/cardiac defects in neonates)
- Hepatotoxicity: Rare but serious; reversible alopecia with prolonged high-dose use
Sources: Goodman & Gilman's Pharmacological Basis of Therapeutics; Fitzpatrick's Dermatology
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