Fungal Infection

5/23/2018 Fungal Infection

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FUNGAL INFECTIONS

Fungal infection Treatment


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Most common fungal

infections

1- Candidiasis

It is caused by infection with species of the

genus Candida, predominantly with Candidaalbican

Types:

candidiasisVaginal-a

Presentation:-

1- Itching and irritation in the vaginal area.


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1- Candidiasis

2-A burning sensation, especially during intercourse orwhile urinating

3-Redness and swelling of the area

4-Vaginal pain and soreness

5-Thick, white, odor-free vaginal discharge with acottage cheese appearance

1-Treatment:

1- mild to moderate symptoms and infrequentepisodes of infection

a-Short-course vaginal therapy:


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Candidiasis

- one-to-three-day regimen of an antifungal cream,

ointment, tablet or suppository

-The medication of choice is azole antifungal

family:butoconazole, clotrimazole ,miconazole and

terconazole .

The oil-based nature of these agents in cream

and suppository form can weaken latex condoms

and diaphragms

-Side effects :

A- sli ht burnin or irritation durin a lication


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Candidiasis

B- Single-dose oral medication fluconazole (Diflucan) to

be taken by mouth.

2- Treatment for a complicated cases

a- Long-course vaginal therapy includes an azole

medication in the form of a vaginal cream, ointment,

tablet or suppository. The duration of treatment is

usually seven to 14 days.b- Multidose oral medication instead of vaginal

therapy: two or three doses of fluconazole to be taken

by mouth.

***this therapy isn't recommended for pregnant


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Candidiasis

c- Maintenance therapy: For recurrent infections

- It starts after the initial treatment clears infection

-It include:I-fluconazole tablets taken by mouth once a week for

six months.

II- Clotrimazole as a vaginal tablet (suppository) used

once a week instead of an oral medication


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Candidiasis

b- Oropharyngeal candidiasis

Presentation

I-Children and adults

a-Creamy white lesions on tongue, inner cheeks

and on the roof of mouth, gums and tonsils

b-Lesions with a cottage cheese-like appearance

c-Pain

d-Slight bleeding if the lesions are rubbed orscraped


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Candidiasis

e- Cracking and redness at the corners of the mouth

f- Loss of taste

II- Infants and breast-feeding mothers

a- white mouth lesions

b- infants may have trouble feeding or and irritable.

c- Unusually red, sensitive or itchy nipples

d- Unusual pain during nursing or painful nipplesbetween feedings


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Candidiasis

Treatment

A- For infants and nursing mothers

1- A mild topical antifungal medication for baby andmother.

Example: miconazole

2- If baby uses a pacifier or feeds from a bottle, rinsenipples

and pacifiers in a solution of equal parts water andvinegar

daily and allow them to air dry to prevent fungus growth.


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Candidiasis

B- For healthy adults and children

1-Eating unsweetened yogurt

2-Taking acidophilus capsules or liquidYogurt and acidophilus don't destroy the fungus,

but they can help restore the normal bacterial flora

in the body.

3-If infection persists, Topical antifungal medication

can be used


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Candidiasis

C- For adults with weakened immune systems

1-Antifungal medication ( lozenges, tablets or a

liquid that can be swish in mouth and then

swallow). Example: nystatin.

2-Amphotericin B that can be used when other

medications aren't effective.


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Candidiasis

C- skin lesion

-Presentation:

1-itching

2- Red and growing skin rash. This rash withdiscrete

borders

3- Rash usually appear on the skin

folds, genitals, middle of the body,

buttocks, and under the breasts


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Candidiasis

-Treatment:

1-Topical azole antifungal: clotrimazole

(Canesten ), econazole (Pevaryl),

ketoconazole( Nizoral), miconazole (Dactarin )

2-topical terbinafine (Lamisil )

3-Topical nystatin

4-Refractory cases: need systemic treatment withazole ( fluconazole)


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1. Candidiasis

D- Disseminated candidiasis:

This is frequently associated with multiple deep

organ infections or may involve single organinfection.


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2- Dermatophytoses

2-Dermatophytoses

a-tinea capitis :Superficial fungal infection of the

skin of the scalp, eyebrows, and eyelashes,

- Presentation

1-One or more round

patches of scaly skin

2-Scaly, gray or reddened

areas


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2- Dermatophytoses

3-Patches have small black dots where the

hair has broken off at the scalp

4-Tender or painful areas on the scalp

- Treatment:

1-Drug of choice : Systemic administration of

Griseofulvin

Recommend dose:

20-25 mg/kg/d for 6-8 weeks


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2- Dermatophytoses

2-Topical treatment alone is not recommended

because it is ineffective

3-alternative systemic therapy:ketoconazole, itraconazole, terbinafine, and

fluconazole (itraconazole and terbinafine are used

most commonly)

4-Selenium sulfide shampoo may reduce the riskof

spreading the infection


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2- Dermatophytoses

b-Tinea coropris ( ringworm infection of thebody )

it is a superficial dermatophyte on the on the

top layer of your skin (skinregions other than the scalp,

groin, palms, and soles).

Presentation

1- A ring-shaped rash that is

itchy, red, scaly and slightly

raised.


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2- Dermatophytoses

2- The rings usually flat scaly area on the skin,

which

may be red and itchy.

- Treatment

1- antifungal lotion or cream

***Topical therapy should be applied to the

lesion and at least 2 cm beyond this area once

or twice a day for at least 2 weeks


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2- Dermatophytoses

a- The topical azoles (econazole, ketoconazole,

clotrimazole, miconazole, oxiconazole,

sulconazole, sertaconazole)

b-Luliconazole (Luzu) is an imidazole topical

cream approved by the FDA in November 2013 for

treatment tinea corporis

FDA approves luliconazole for treatment of tinea

corporis


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2- Dermatophytoses

FDA recently approved the azole antifungal

luliconazole 1% cream the first topical azole

antifungal

agent with a 1-week (rather than 2-week), once-daily

treatment regimen for the management of tinea

cruris

and tinea corporis in adults aged 18 years or

older.

Luliconazole was also approved for the treatment

of

interdi ital tinea edis in adults a re imen that


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2- Dermatophytoses

Allylamines (eg, naftifine, terbinafine)-c

2- Severe cases need systemic therapy: griseofulvin, Systemic azoles (eg, fluconazole,

itraconazole, ketoconazole)

(athlete's foot )pedisTinea-c

It is a dermatophyte infection ofthe soles of the feet and the

interdigital spaces


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Athlete's foot


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2- Dermatophytoses

It occurs most commonly in people whose feet

have become very sweaty while confined within

tight-fitting shoes.

- Presentation

1- Scaly rash that usually causes itching, stinging and

burning.

2- Some cases: blisters or ulcers.

3- Some cases: chronic dryness and scaling on the

soles that extends up the sides of the feet


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2- Dermatophytoses

- Treatment:

1- Topical treatment:

a- imidazole:clotrimazole, econazole, miconazole,

ketoconazole and luliconazole) "Luliconazole, an

imidazole topical cream, is applied once daily for 2

weeks "b- Ciclopirox cream

c- terinafine and naftitine


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2- Dermatophytoses

2-oral drugs in severe cases : Itraconazole,

Terbinafine, and fluconazole

3-Topical urea to decrease scaling.

3 Pit i i i l ( Ti


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3- Pityriasis versicolor ( Tinea

versicolor)

- Presentation

- Hypopigmented or hyperpigmented macules

and

patches on the chest and the back.

- The color of each lesion varies

from almost white to reddishbrown or fawn colored. A fine,

dustlike scale covers the lesions.

3 Pit i i i l ( Ti


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3- Pityriasis versicolor ( Tinea

versicolor)

- Treatment:

1-Clotrimazole cream or lotion

2-Miconazole cream

3- Ketoconazole and Selenium sulfide shampoo

4- Terbinafine (Lamisil) cream or gel

- InstructionsA thin layer of the topical agent applied once or twice

a day on affected area for at least two weeks.

4 F l il i f ti


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4- Fungal nail infections

(onychomycosis)

Onychomycosis is a fungal infection of thetoenails or

fingernails.

Causes:

1-Most common cause is Dermatophytes ( Tinea

ungum )

2-Candida (yeasts )

3- molds

4 F l il i f ti


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(onychomycosis)

- Presentation:

There are different classifications

of nail fungus depending on type

of fungus and manifestation.

- Common symptoms:

1- A painful and erythematous area

around and underneath the nail

and nail bed

2- Nail thickening, ridging, discoloration, and

occasional nail loss

4 Fungal nail infections


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(onychomycosis)

3-Infected nails may separate from the nail bed.

- Treatment :

1-Topical antifungal:

-Topical treatment used for mild to moderate cases

-Agents: Amorolfine (Loceryl), Ciclopirox (Mycoster) .

2-Oral medication:

Most effective treatments are terbinafine (Lamisil)

and itraconazole (Sporanox)

4 F l il i f ti


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(onychomycosis)

Oral medication recommended for:

1- DM patients

2- If patient has cellulitis or history of cellulitis3- If patient has pain or discomfort from nail infection

- These Drugs help growing a new nail free of

infection,slowly replacing the infected portion of nail. these

medications will be taken for six to 12 weeks, andthe end

result of treatment seen after the nail grows back

4 Fungal nail infections


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(onychomycosis)

To decrease the adverse effects and duration of

oral therapy, topical treatments may becombined with oral antifungal management

M t f l


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Most common fungal

infection s5- Aspergillosis

- Commonly affects respiratory tract

- Invasive forms can affect heart, brain and skin- Drug of choice: Voriconazole

6- Cryptococcosis

- Most common form: cryptococcal meningitis

Treatment : amphotericin B and flucytocine for 2

weeks then followed by fluconazole for 8 weeks or

until culture is positive

M t f l


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Most common fungal

infection s

7-histoplasmosis

Histoplasmosis is an infection caused by

breathing in

spores of a fungus often found in bird and bat

droppings


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Antifungal Drugs

I-Azole family:

- M.O.A

-Inhibit sterol synthesis in fungal cell membranes,

thislead to increase cell permeability and osmotic

pressure

- Drugs:

1-ketoconazole (Nizoral)

- System ic Ketoconazole

It has slow onset of action and need long durationof


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1- ketoconazole

- Off-label use :

1- Cushing syndrome :ketoconazole Inhibits

steroidogenes process through inhibiting P450enzymes includes the first step in cortisol

synthesis, cholesterol side-chain cleavage, and

conversion of 11-deoxycortisol to cortisol

2- Dose Range : 600-800 mg/day PO


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1- ketoconazole

Tablets are not recommended as first-line

treatment; should be used only when other

effective antifungal therapy is not effective or

tolerated and the potential benefits areconsidered to outweigh the potential of

hepatotoxicity

Usual dose range:-200-400 mg/day PO


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1- ketoconazole

Black Box Warnings

A-Hepatotoxicity has occurred with oral use,

including some fatalities or requiring liver

B-May cause QT prolongation

- Coadministration with dofetilide, quinidine,

pimozide, cisapride, methadone, disopyramide,

dronedarone, and ranolazine is contraindicated


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1- ketoconazole

- Ketoconazole can cause elevated plasma

concentrations of these drugs (by CYP3A4

inhibition)and may prolong QT intervals, sometimes

resulting in

life-threatening ventricular dysrhythmiassuch as

torsades de pointes


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Most common side effects:

- Nausea,vomiting,diarrhea, constipation, and

abdominal pain

- Rare : hepatotoxicity

Drugs interaction:

Enhance anticoagulant effects of warfarin

1- ketoconazole

Ketoconazole( nizoral) Potentially Fatal


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Ketoconazole( nizoral) Potentially Fatal

Liver Injury, Risk of Drug Interactions and

Adrenal Gland Problems

July 26, 2013Audience: Internal Medicine, Infectious Disease.

ISSUE: FDA is taking several actionsrelated to Nizoral

(ketoconazole) oral tablets, including limiting the drugsuse,

warning that it can cause severe liver injuries and adrenalgland

problems, and advising that it can lead to harmful drug

interactions with other medications. FDA has approvedlabel

changes and added a new Medication Guide to addressthese

safety issues. As a result, Nizoral oral tablets should not be

a-


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1- Ketoconazole

Topical Ketoconazole

- Indication and dose

1-Seborheic Dermatitis

a-Foam: apply to affected area q12hr for 4 wk

b-Cream: apply q12hr for 4 wk or until clear

c-Shampoo: apply twice weekly for 4 wk with at

least 3 days between each shampoo


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2-Tinea Versicolor

a-Shampoo: twice weekly for 4 wks allowing 3

days between shampoo

3-Tinea corporis, Tinea Cruris, Tinea pedis

Cream: Apply once daily to cover affected area for

2

weeks (6 weeks for tinea pedis)

1- Ketoconazole


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1- Ketoconazole

*** When combined with corticosteroid ,

ketoconazole is useful in treating :

Atopic dermatitis, diaper rash, eczema, and

psoriasis


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2-Fluconazole (Diflucan)

-It achieves good penetration into cerebrospinal fluidso can be used for treating fungal meningitis

- It excreted largely in the urine and can be used for

treating candiduria

Drugs interaction:-

1- Avoid concomitant use with cisapride andterfenadine

2- It increases level of phenytoin, warfarin,sulfonylurea and cyclosporine


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- Dose:

1-Oropharyngeal & esophageal candidiasis:

200mg , orally on first day then continue 100mg,

orally , daily

2-Vaginal candidiasis: 150mg as single dose

3-Cryptoccocal meningitis: 400mg, orally on day 1

then 200mg, orally daily4-Candida UTI: 50-200mg, orally, qday


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- Caution

1- Hepatotoxicity reported with use; use with

caution in patients with hepatic impairment

2- When driving vehicles or operating machines,

it should be taken into account that dizziness or

seizures may occasionally occur


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3- Itraconazole (Sporanex)

-Need acid media for optimal absorption

-It is potent CYP4503A4 inhibitor

* Doses

-Onychomycosis:

1-Fingernails: pulse dose regimen: 200mg, twice

daily

for 1 week, repeat the course after 3 week off-time

2-toenails with or without fingernails involvement:


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3- Oral candidiasis: oral solution: 100-200 mg/dayfor at least 3 weeks, continued for 2 weeks aftersymptom resolution

Drugs interaction:- avoid co-administration with antacids, H2-

blockers

and proton pump inhibitors

- Containdicated with cisapride, dofetilide, ergot

derivatives, lovastatin, simvastatin, quinidine, and

triazolam


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Black Box Warning

Congestive heart failure-1

Negative inotropic effects reported with IVadministration; reassess therapy if signs or

symptoms of CHF occur during administration

Onychomycosis-2

Onychomycosis treatment contraindicated in

patients with ventricular dysfunction or history

of heart failure.


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Caution

-Discontinue if liver disease develops, and perform

liver

function tests; readministration discouraged

" Itraconazole is contraindicated for treating

onychomycosis in pregnant or intend on becoming

pregnant "

Most common side effects

- Nausea


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4-Voriconazole (Vfend)

- Broad spectrum antifungal and used in lifethreatening infection and refractory cases

Dose:

Esophageal candidiasis: 200mg, orally, q12hrs

*** Take oral form 1 hr before or after meal

Most common side effects:

Visual changes (photophobia, color changes,increased

or decreased visual acuity, or blurred vision occurin


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4-Voriconazole (Vfend)

Warning:

Avoid intense or prolonged exposure to direct

sunlight; in patients with photosensitivity skinreactions, squamous cell carcinoma of the skin

and melanoma have been reported during long-

term therapy


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5- Posaconazole

- licensed for treatment of invasive cases

unresponsive to conventional therapy

-Food increases oral availability so preferred to take

the dose with full meal

-Most common side effects

nausea & headache

-Drugs interactions:

1-avoid concomitant use with cimetidine, phenytoin,

and rifbutin


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5- Posaconazole

2- Coadministration with sirolimus; increases

sirolimus

blood concentrations

Dose

oropharyngeal candidiasis

-oral suspension: 100 mg , PO BID on Day 1, then

100

mg PO qDay for 13 days

-Refractory to itraconazole and/or fluconazole: 400

m

Newly approved formulation of


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Newly approved formulation ofPosaconazole

1-FDA has approved a new formulation of posaconazole

(Noxafil,

Merck), The agency approved posaconazole 100-mg delayed-

release

tablets, given as a loading dose of 300 mg (three 100-mg

delayed-

release tablets) twice daily on the first day, followed by a once-

daily

maintenance dose of 300 mg (three 100-mg delayed-release

tablets)

on the second day of therapy. Merck also markets posaconazole

(also



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Posaconazole

2-FDA has approved an intravenous (IV) formulation of the

posaconazole (Noxafil, Merck), according to the company.

Posaconazole injection is indicated in patient at least 18 years

of age, whereas the delayed-release tablets and oralsuspension are

indicated in patients aged 13 years and older. Posaconazole is

indicated for prophylaxis of invasiveAspergillusand Candida

infections in patient who are at high risk of developing these

infections because of being severely immunocompromised,

such as

hematopoietic stem cell transplant recipients with graft-vs-host

6 Cl t i l (C ti )


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6-Clotrimazole (Canestin)

IndicationFor fungal skin infection, vaginal candidiasis and otitis

externa

Dose

1-vaginal cream:

a- 1 %: insert 1 applicatorfulvaginal cream at bedtime

for 7 consecutive daysb- 2 %: insert 1 applicatorfulvaginal cream at bedtime

for 3 consecutive days

2-topical cream and solution: apply to affected area twice


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7-Econazole (Pevaryl)

Indicationtinea pedis, Tinea cruris, Tinea corporis, Tinea

versicolor and cutaneous candidiasis

Dose1-Tinea pedis, cruris, corporis, versicolor: apply cream

to

affected area qDay

2-Cutaneous candidiasis:apply cream to affected area,BID

Treatment duration

Tinea cruris, corporis, versicolor, cutaneous candidiasis:

for 2


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8-Miconazole ( Dactarin )

- Used for:

Tinea-1

a-Tinea cruris, corporis & cutaneous

canidiasis: apply to affected area BID for 2 weeks

b-Tinea versicolor: apply once daily to affectedarea

for 2 weeks

c-Tinea pedis: apply BID to affected area for 4weeks


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8-Miconazole ( Dactarin )

2-Vulvovaginal candidiasis

a-Vaginal 2% cream : once daily , before sleep

for 7days.

b-100 mg vaginal suppository once daily , before

sleep for 7days .

c- 200 mg vaginal suppository once daily , before

sleep for 3 day


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Polyene Antifungals

Polyene Antifungal

It binds to sterols in fungal cell membrane,

leading to alterations in cell permeability and

celldeath

1-Amphoter ic in B

- It is most effective antifungal agents in thetreatment of systemic fungal infection,especially in immunocompromised patients


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Type Advantage Disadvantage

Conventional cheap Toxic and side effectscommon

Lipid formulation Less toxic and side effects

Given when conventional

thearapy contraindicated

because of toxicity especially

nephrotoxicity or when

respone inadequate

Expensive

- Types

1-Amphotericin B

1 A h i i B


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1-Amphotericin B

Precaution

1-infusion-related reaction: fever, chills, vomiting,

nausea, headache, hypotension, dyspnea,tachypnea (need test dose before start Infusion)

" A test dose is advisable before the firstinfusion, the patient should be observed for at

least 30 min after the test dose "Premedication with acetaminophen,

diphenhydramine,hydrocortisone should be usedfor patient who have previously experienced acute

adverse reaction

1 A h t i i B


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1-Amphotericin B

2- Nephrotoxicity: need dose adjustmentor drug D/C or change to liposomal form

3-electrolyte abnormalities :Hypokalemia, hypomagnesemia, and

hypocalcemia

4-CNS effects: headache, peripheralneuropathy,

malaise, depression, seizure, hallucination

2 N t ti ( M t t)


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2-Nystatin( Mycostat)

2-nystatinIndication and Dose

1-Cutaneous or mucocutaneous Candidainfections:

apply 2-3 times daily for 2 weeks

2-vaginal infections: I tab daily at bedtime for 2weeks

3- GI candidal infection:

a- oropharngeal candidiasis :

Oral suspension: 400,000-600,000 units PO q6hr;

N t ti


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Nystatin

b-Intestinal candidiasis

-Oral tablets: 500,000-1,000,000 units q8hr

-Powder: 1/8 to 1/4 teaspoonful in 1/2 cup of water

(500,000-1,000,000 units) PO q8hr

Fl t i


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Flucytosine

Flucytocin

M.O.A

It penetrates fungal cells and converted tofluorouracil, then incorporated to the RNA offungal cell. This action leads to defect proteinsynthesis

Indications-Used alone not recommended

-It is used with amphotericin B in synergistic

combination for treatment of severe systemic

fungal

Fl t i


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Flucytosine

Dose-Candidiasis & Cryptococcus infection : 50-150

mg/kg/dose, orally, q6hr

CautionBone marrow depression can occurs

Black Box Warnings

Use extreme caution in patients with renalimpairment

Monitor hematologic, renal, and hepatic function

Review instructions thoroughly beforeadministration

G i f l i


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Griseofulvin

GriseofulfinM.O.A

-It inhibits fungal cell activity by interfering withmitotic

spindle structure

- it deposit in keratin precursor cells and is tightly

bound to new keratin, and this increases resistance

to

fungal invasion

-It is mechanism of action similar to colchicines it

G i f l i


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Griseofulvin

IndicationTreatment of susceptible tinea infections of

skin,body,hair and nails

Dosea- Microsize (orally)

1-Tinea corporis, cruris, or capitis: 500 mg/day

2-Tinea pedis: 1000 mg/day

b-Ultramicrosize (orally)

1-Tinea corporis, cruris, or capitis: 375 mg/day

2-Tinea pedis : 250 mg, q8hr

G i f l i


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Griseofulvin

Duration of treatment Dependent oninfection site

1-Tinea corporis: 2-4 weeks

2-Tinea capitis: 4-6 weeks; may be up to 8-12weeks

3-Tinea pedis: 4-8 weeks

"Absorption increased with fatty meals"

G i f l i


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Griseofulvin

Most common Side effects

- Headache, lethargy, syncope, confusion,

lethargy,

impaired performance, and skin rash

Severe skin reactions (eg, Stevens-Johnson

syndrome,

toxic epidermal necrolysis) and erythema

multiforme

reported, some resulting in hospitalization or

death;

G i f l i


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Griseofulvin

Drugs interaction

1-it increases the metabolism of warfarin and

lead to decrease prothrombin time

2-Oral contraceptive may increase amenorrhea

or increase breakthrough bleeding

E hi di


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Echinocandins

Echinocandins1-caspofungin

2-micafungin

3-anidulafungin

-They cause cell wall lysis

-have activity againt candida spp and aspergillus

species

-available as Injection dosage form

S nthetic all lamine


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Synthetic allylamine

M.O.AInhibits squalene monooxygenase and this lead to

interruption of fungal sterol biosynthesis

1-Terbinafine ( Lamisil )

Oral sys tem ic p reparation

Indication and dose1-Onychomycosis

250 mg (1 tablet) PO daily for 6 weeks (fingernail)or

12 weeks (toenail)

Terbinafine ( Lamisil )


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2- Tinea pedis ( off-label use ) 250 mg/day PO for2- 6 weeks

3- Tinea corporis and tinea crusis 250 mg/day PO

for 2-4 weeks

Common side effects

1-headache

2-taste disturbances

3-visual disturbances

4-skin rash



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Top ical preparat ion

Indication and dose

1- Tinea PedisApply to affected area BID until significant

clinical improvement (no more than 4 weeks)

2-Tinea corporis and crurisApply daily for 1 week (no more than 4 weeks)

Terbinafine cutaneous solution


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Terbinafine cutaneoussolution

( Lamisil once)

Indication

It is a single dose treatment for tinea pedis

Side effect

burning, dryness, pruritis, rash, irritation

Terbinafine cutaneoussolution


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( Lamisil once)

- How to use: apply to both feet, even ifsigns

are visible only on one foot. When applied

to

the feet, the medication dries quickly to a

colourless film. The drug delivers into the

skin

where it lasts for a number of days to kill the

fungus .after applying the drug, patient must

Naftifine ( Exodril)


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2-Naftifine ( Exodril)

Indication & Dose

1- 1% cream treatment

-Used for treatmen of tinea pedis, tinea cruris,and tinea corporis

-apply BID to the affected areas plus a 0.5-inch

margin of healthy surrounding skin for 4 weeks



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2- 2% cream or gel

-Used for treatment of interdigital tinea pedis,

tinea cruris, and tinea corporis

-Apply daily to the affected areas plus a 0.5-inchmargin of healthy surrounding skin for 2 weeks

CautionAvoid use of occlusive dressings

Amorolfine ( Loceryl)


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Amorolfine ( Loceryl)

Amorolfine

IndicationTopical treatment of nail infections caused by fungi

(onychomycosis)

DoseApply to affected toenails or fingernails once or twice

weekly

Duration

- - -

Ciclopirox ( Mycoster)


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CiclopiroxM.O.A

Synthetic benzylamine

It inhibits intermediary in synthesis of ergosterol, an

essential component of fungal cell membranes

Indication and dose

1-Mild to moderate onychomycosis of fingernails &toenails:

1- topical solution: apply over entire nail plate dailybefore sleep or 8 hours before washing to all affectednails



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2-Tinea pedis, Tinea corporis, Tinea cruris, Tineavesicolor, and cutaneous candidiasis :

Cream and suspension: apply BID; gentlymassage into affected areas; if noimprovement after 4 weeks re-evaluatediagnosis

3-Seborrheic dermatitis:

-Gel: Apply BID; gently massage into affectedareas; if no improvement after 4 weeks re-evaluate diagnosis

Tolnaftate


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Tolnaftate

Tolnaftate

M.O.A

distort the hyphae and stunt mycelial growth in

susceptible fungiIndication & Dose

Superficial fungal infection

apply BID for 2-3 weeks

Clioquinol


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Clioquinol

Clioquinol

It is used for fungal skin infection : apply two tofour times a day up to 4 weeks

Newly approved drugs:


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Newly approved drugs:

1-Luliconazole ( Luzu)

- FDA has approved the azole antifungal

luliconazole

1% cream to treat fungal infections

- Luliconazole 1% cream is indicated for the

topical

treatment of interdigital tinea pedis (athlete's foot),tinea cruris and tinea corporis , in adults aged 18

years

and older.



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It is the first topical azole antifungal agent

approved to treat tinea cruris and tinea corporis

with a 1-week, once-daily treatment regimen. All

other currently approved treatments require 2weeks of treatment. For interdigital tinea pedis,

the treatment period is 2 weeks, once daily

2 Efinaconazole


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2- Efinaconazole

Efinaconazole

- It is used for the topical treatment of

onychomycosis.

- Efinaconazole is an inhibitor of sterol 14-

demethylase and is more effective in vitro than

terbinafine, itraconazole, ciclopirox and amorolfine

against dermatophytes, yeasts and non-

dermatophyte

molds.

2 Efi l


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similar to the oral antifungal itraconazole andexceeds

the efficacy of topical ciclopirox

- efinaconazole 10% nail solution is an effectivetopical monotherapy for distal and lateral

subungual onychomycosis (


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feeding

Breast feedingPregnancy categoryDrugEnters breast milkCKetoconazole

use caution as topical,

vaginal not known

CMiconazole

Not recommendedCFluconazole

Enter breast milk so

weigh risk against

benefits

CItraconazole

not known if excreted in

breast milk, weighrisk/benefit

DVoriconazole

unknown; weigh

risk/benefit

CPosaconazole

Pregnancy category and


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breast feeding

Breast feedingPregnancyDruguse with cautionBClotrimazole

-Conventional:

contraindicated

-liposomal: not

recommended

BAmphotericin B

1-systemicNot known if

excreted in breast milk; use

caution

2-Topical: no studies

3-vaginal: Poorly

distributed in breast milk

1-systemic: c

2-topical: B

3-vaginal:A

Nystatin

not recommendedcFlucytocin

Avoid useXGriseofulvin

Avoid useBterbinafine

Pregnancy category and


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breast feeding

Breast feedingPregnancyDrugavoid unless

potential benefit

outweigh risk

avoid unless

potential benefit

outweigh risk

Amorolfin

not known ifdistributed in breast

milk

BCiclopirox

Use cautionBNaftifine

UnknownCTolnaftate

Fungal Infection

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