antifungals (topical)

butenafine: byoo-TEN-a-feen

ciclopirox: sye-kloe-PEER-ox

clotrimazole: kloe-TRYE-ma-zole

econazole: ee-KON-a-zole

efinaconazole: eff-in-a-KON-a-zole

ketoconazole: kee-toe-KOE-na-zole

luliconazole: loo-li-KON-a-zole

miconazole: mye-KON-a-zole

naftifine: NAFF-ti-feen

nystatin: nye-STAT-in

oxiconazole: ox-i-KON-a-zole

sertaconazole: ser-ta-KON-a-zole

sulconazole: sul-KON-a-zole

tavaborole: ta-va-BOR-ole

terbinafine: ter-BIN-a-feen

tolnaftate: tol-NAFF-tate

Classifications ⬆ ⬇

Therapeutic Classification: antifungals (topical)

Indications ⬆ ⬇

REMS

Treatment of a variety of cutaneous fungal infections, including cutaneous candidiasis, tinea pedis (athlete’s foot), tinea cruris (jock itch), tinea corporis (ringworm), tinea versicolor, seborrheic dermatitis, dandruff, and onychomycosis of fingernails and toenails.

Action ⬆ ⬇

Butenafine, nystatin, clotrimazole, econazole, efinaconazole, ketoconazole, luliconazole, miconazole, naftifine, oxiconazole, sertaconazole, sulconazole, and terbinafine affect the synthesis of the fungal cell wall, allowing leakage of cellular contents. Tolnaftate distorts the hyphae and stunts mycelial growth in fungi. Ciclopirox inhibits the transport of essential elements in the fungal cell, disrupting the synthesis of DNA, RNA, and protein. Tavaborole inhibits fungal protein synthesis via inhibition of aminoacyl-transfer ribonucleic acid (tRNA) synthetase.

Therapeutic effects:

Decrease in symptoms of fungal infection.

Pharmacokinetics ⬆ ⬇

Absorption: Absorption through intact skin is minimal.

Distribution: Distribution after topical administration is primarily local.

Metabolism/Excretion: Metabolism and excretion not known following local application.

Half-Life: Butenafine: 35 hr; Ciclopirox: 5.5 hr (gel); Efinaconazole: 29.9 hr; Terbinafine: 21 hr.

Time/Action Profile ⬆ ⬇

( resolution of symptoms/lesions‡)

ROUTE	ONSET	PEAK	DURATION
Butenafine	unknown	up to 4 wk	unknown
Luliconazole	unknown	3–4 wk	unknown
Tolnaftate	24–72 hr	unknown	unknown

‡Only the drugs with known information included in this table.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity to active ingredients, additives, preservatives, or bases;
Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance.

Use Cautiously in:

Nail and scalp infections (may require additional systemic therapy);
OB: Safety not established in pregnancy;
Lactation: Safety not established in breastfeeding.

Adv. Reactions/Side Effects ⬆ ⬇

Local: burning, itching, local hypersensitivity reactions, redness, stinging

Interactions ⬆ ⬇

Drug-drug:

Econazole may ↑ levels of and risk of bleeding from warfarin.

Route/Dosage ⬆ ⬇

Butenafine

(Adults and Children >12 yr): Apply once daily for 2 wk for tinea corporis, tinea cruris, or tinea versicolor. Apply once daily for 4 wk or once daily for 7 days for tinea pedis.

Ciclopirox

(Adults and Children >10 yr): Cream/lotion: Apply twice daily for 2–4 wk; Topical solution (nail lacquer): Apply to nails at bedtime or 8 hr prior to bathing for up to 48 wk. Each daily application should be made over the previous coat and then removed with alcohol every 7 days; Gel: Apply twice daily for 4 wk; Shampoo: 5–10 mL applied to scalp; lather and leave on for 3 min; rinse; repeat twice weekly for 4 wk (≥3 days between applications).

Clotrimazole

(Adults and Children >3 yr): Apply twice daily for 1–4 wk.

Econazole

(Adults and Children ): Apply once daily for tinea pedis (for 4 wk), tinea cruris (for 2 wk), tinea corporis (for 2 wk), or tinea versicolor (for 2 wk). Apply twice daily for cutaneous candidiasis (for 2 wk).

Efinaconazole

(Adults and Children ≥6 yr): Apply to affected toenails once daily for 48 wk.

Ketoconazole

(Adults ): Apply cream once daily for cutaneous candidiasis (for 2 wk), tinea corporis (for 2 wk), tinea cruris (for 2 wk), tinea pedis (for 6 wk), or tinea versicolor (for 2 wk). Apply cream twice daily for seborrheic dermatitis (for 4 wk). For dandruff, use shampoo twice weekly (wait 3–4 days between treatments) for 4 wk and then intermittently.

Luliconazole

(Adults and Children ≥12 yr): Interdigital tinea pedis: Apply to affected and surrounding areas once daily for 2 wk; Tinea cruris: Apply to affected and surrounding areas once daily for 1 wk.
(Adults and Children ≥2 yr): Tinea corporis: Apply to affected and surrounding areas once daily for 1 wk.
(Adults ): Interdigital tinea pedis: Apply to affected and surrounding areas once daily for 2 wk; Tinea cruris and tinea corporis: Apply to affected and surrounding areas once daily for 1 wk.

Miconazole

(Adults and Children >2 yr): Apply twice daily. Treat tinea cruris for 2 wk and tinea pedis or tinea corporis for 4 wk.

Naftifine

(Adults ): Interdigital tinea pedis: Apply cream or gel once daily for 2 wk; Tinea cruris or tinea corporis: apply cream once daily for 2 wk.
(Children ≥12 yr): Interdigital tinea pedis: Apply cream or gel once daily for 2 wk.
(Children ≥2 yr): Tinea corporis: Apply cream once daily for 2 wk.

Nystatin

(Adults and Children ): Apply 2–3 times daily until healing is complete.

Oxiconazole

(Adults and Children ): Apply 1–2 times daily for tinea pedis (for 4 wk), tinea corporis (for 2 wk), or tinea cruris (for 2 wk). Apply once daily for tinea versicolor (for 2 wk).

Sertaconazole

(Adults and Children >12 yr): Apply twice daily for 4 wk.

Sulconazole

(Adults ): Apply 1–2 times daily (twice daily for tinea pedis). Treat tinea corporis, tinea cruris, or tinea versicolor for 3 wk, and tinea pedis for 4 wk.

Tavaborole

(Adults and Children ≥6 yr): Apply to affected nail once daily for 48 wk.

Terbinafine

(Adults ): Apply twice daily for tinea pedis (for 1 wk) or daily for tinea cruris or tinea corporis for 1 wk.

Tolnaftate

(Adults ): Apply twice daily for tinea cruris (for 2 wk), tinea pedis (for 4 wk), or tinea corporis (for 4 wk).

Availability ⬆ ⬇

Butenafine

(Generic available)

Cream: 1%^{Rx, OTC}

Ciclopirox

(Generic available)

Cream: 0.77%
Gel: 0.77%
Lotion: 1%
Nail lacquer: 8%
Shampoo: 1%
Suspension: 0.77%

Clotrimazole

(Generic available)

Cream: 1%^OTC
Ointment: 1%^OTC
Solution: 1%^OTC
In combination with:
betamethasone.

Econazole

(Generic available)

Cream: 1%
Foam: 1%

Efinaconazole

(Generic available)

Solution: 10%

Ketoconazole

(Generic available)

Cream: 2%
Foam: 2%
Shampoo: 2%

Luliconazole

(Generic available)

Cream: 1%

Miconazole

(Generic available)

Cream: 2%^{Rx, OTC}
Ointment: 2%^OTC
Powder: 2%^OTC
Solution: 2%^OTC
Spray powder: 2%^OTC
In combination with:
zinc oxide (Vusion). See Combination Drugs.

Naftifine

Cream: 1%; 2%
Gel: 2%

Nystatin

(Generic available)

Cream: 100,000 units/g^{Rx, OTC}
Ointment: 100,000 units/g^{Rx, OTC}
Powder: 100,000 units/g^{Rx, OTC}
In combination with:
triamcinolone.

Oxiconazole

(Generic available)

Cream: 1%

Sertaconazole

Cream: 2%

Sulconazole

(Generic available)

Cream: 1%

Tavaborole

(Generic available)

Solution: 5%

Terbinafine

(Generic available)

Cream: 1%^OTC

Tolnaftate

(Generic available)

Cream: 1%^OTC
Powder: 1%^OTC
Solution: 1%^OTC
Spray powder: 1%^OTC

Assessment ⬆ ⬇

Assess involved areas of skin and mucous membranes before and frequently during therapy. ↑ skin irritation may indicate need to discontinue medication.

Implementation ⬆ ⬇

Do not confuse Lamisil with Lamictal.
Consult health care provider for proper cleansing technique before applying medication.
- Choice of vehicle is based on use. Ointments, creams, and liquids are used as primary therapy. Lotion is usually preferred in intertriginous areas; if cream is used, apply sparingly to avoid maceration. Powders are usually used as adjunctive therapy but may be used as primary therapy for mild conditions (especially for moist lesions).
Topical Apply small amount to cover affected area completely. Avoid use of occlusive wrappings or dressings unless directed by health care provider.
Nail lacquer: Avoid contact with skin other than skin immediately surrounding treated nail. Avoid contact with eyes or mucous membranes. Removal of unattached, infected nail, as frequently as monthly, by health care provider is needed with use of this medication. Up to 48 wk of daily application and provider removal may be required to achieve clear or almost clear nail. 6 mo of treatment may be required before results are noticed.
Ciclopirox or ketoconazole shampoo: Moisten hair and scalp thoroughly with water. Apply sufficient shampoo to produce enough lather to wash scalp and hair and gently massage it over the entire scalp area for approximately 1 min. Rinse hair thoroughly with warm water. Repeat process, leaving shampoo on hair for an additional 3 min. After the 2nd shampoo, rinse and dry hair with towel or warm air flow. Shampoo twice a week for 4 wk with >3 days between each shampooing and then intermittently as needed to maintain control.
Ketoconazole or econazole foam: Hold container upright and dispense foam into cap of can or other smooth surface; dispensing directly on to hand is not recommended as the foam begins to melt immediately on contact with warm skin. Pick up small amounts with fingertips and gently massage into affected areas until absorbed. Move hair to allow direct application to skin.

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of medication to patient. Advise patient to read Patient Information before starting therapy. Instruct patient to apply medication as directed for full course of therapy, even if feeling better. Emphasize the importance of avoiding the eyes.
Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care provider before taking other medications.
Advise patient that some products may stain fabric, skin, or hair. Check label information. Fabrics stained from cream or lotion can usually be cleaned by handwashing with soap and warm water; stains from ointments can usually be removed with standard cleaning fluids.
Patients with athlete’s foot should be taught to wear well-fitting, ventilated shoes; to wash affected areas thoroughly; and to change shoes and socks at least once a day.
Advise patient to report ↑ skin irritation or lack of response to therapy to health care provider.
Nail lacquer: File away loose nail and trim nails every 7 days after solution is removed with alcohol. Do not use nail polish on treated nails. Inform health care provider if patient has diabetes mellitus before using.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or breastfeeding.

Evaluation/Desired Outcomes ⬆ ⬇

Decrease in symptoms of fungal infection.

US Brand Names ⬆ ⬇

butenafine: Lotrimin Ultra,

ciclopirox: Ciclodan,

clotrimazole: Alevazol,

econazole: Ecoza,

efinaconazole: Jublia,

ketoconazole: Ketodan,

luliconazole: Luzu,

miconazole: Fungoid, Lotrimin AF, Micatin, Zeasorb-AF,

naftifine: Naftin,

nystatin: Klayesta, ~~Mycostatin,~~ Nyamyc, Nystop,

oxiconazole: Oxistat,

sertaconazole: Ertaczo,

sulconazole: Exelderm,

tavaborole: ~~Kerydin,~~

terbinafine: Lamisil AT,

tolnaftate: Tinactin

section name header

Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆