Topical antifungal medications
What are topical antifungal medications?
Topical antifungal medications are creams, solutions, lotions, powders, gels, sprays and lacquers applied to the skin surface to treat fungal infections. They can often cure localised infections, although recurrence is common. Many suitable creams can be obtained over the counter without a doctor's prescription.
Many antifungal medications are suitable for both dermatophyte and yeast infections. Others are more specific to one or the other type of fungus. The medications available in New Zealand are listed below, with their trade names in parentheses.
Those unsuitable for dermatophyte fungal infections are marked with an asterix (*).
Preparations for general fungal skin infections
Topical antifungal creams can be used to treat:
- Dermatophyte infections such as tinea corporis, tinea cruris, tinea faciei, tinea manuum, tinea pedis.
- As an adjunct to oral therapy for tinea capitis and tinea barbae.
- Yeast infections such as candida intertrigo, pityriasis versicolor.
- Mould skin infections such as tinea nigra and nail plate infections.
The creams are applied to the affected area twice daily for two to four weeks, including a margin of several centimetres of normal skin. Continue for one or two weeks after the last visible rash has cleared. Repeated treatment is often necessary.
- Whitfield's ointment (benzoic acid)
- Undecylenic alkanolamide
- Ciclopirox olamine (Batrafen® cream, powder, solution)
- Polyenes *
- Nystatin (Nilstat® cream, ointment; Mycostatin® cream, ointment, paste)
- Bifonazole (Canesten® Once Daily Bifonazole Cream)
- Clotrimazole (Canesten® cream, solution; Clocreme® cream; Clomazol®, Fungizid® spray)
- Econazole (Ecreme® cream; Pevaryl® cream, powder, foaming solution)
- Ketoconazole (Nizoral® cream, Daktagold® cream)
- Miconazole (Daktarin® cream, lotion, dusting powder, spray powder; Micreme® cream, Resolve® solution, tinea cream, jock itch cream, thrush cream, powder; Tinasolve® Alpha cream)
- Allylamine (higher cure rates and more rapid responses than older topical antifungals for dermatophyte infections)
- Terbinafine (Lamisil® cream, gel, spray)
In other countries, additional antifungal agents include the azoles, bifonazole, tioconzaole, sulconazole, efinaconazole and luliconazole; naftifine; and a benzoxaborole, tavaborole.
Scalp antifungal agents
The most effective ingredients are ketoconazole (Daktagold® shampoo; Ketopine® shampoo, Nizoral® shampoo; Sebizole® shampoo), miconazole (HairScience® shampoo) and ciclopirox (Stieprox® liquid), but many other shampoos marketed for dandruff have antifungal properties.
Preparations for nail fold infections
- Thymol 3% in chloroform
- Sulfacetamide 15% in spirit
- Clotrimazole topical solution (Canesten®)
- Econazole solution (Pevaryl® solution)
- Miconazole (Daktarin® tincture; Fungo® solution)
Preparations for nail plate infections
Distal onychomycosis can be treated with antifungal lacquers applied once or twice weekly. The medication should be applied to the surface of the cleaned nail plate after it has been roughened using an emery board. Extra lacquer should be applied under the edge of the nail.
These can be expected to reduce and sometimes cure the infection provided:
- No more than 50% of the nail plate is infected
- The growing part of the nail plate (the matrix) is not involved
- There is no complicating internal disease (such as diabetes) or skin condition (such as psoriasis)
Available preparations are:
- The morpholine, amorolfine (Loceryl®, Nail lacquer)
- Ciclopirox (Nail Batrafen®)
- Bifonazole cream + urea ointment (Canesten Fungal Nail Treatment Set)
- Efinaconazole solution
- Tavaborole solution
Treatment needs to be undertaken for long periods (a year or longer) because nails take a long time to grow, especially in older individuals. Nail polish is not recommended, in case it interferes with the efficacy of the product, although this is not proven.
Preparations for oral infections
Oral candidiasis can be treated with:
- Nystatin * (Nilstat® oral drops, capsules, powder, tablets)
- Amphotericin B * (Fungilin® lozenges, oral suspension)
- Miconazole (Daktarin® oral gel)
Note: miconazole oral gel should not be usd in patients who are taking warfarin because it has been reported to cause a dangerous interaction, which could result in serious bleeding.
Preparations for vaginal infections
Vulvovaginal candidiasis can be treated with:
- Nystatin * (Nilstat® vaginal cream and pessaries)
- Clotrimazole (Canesten® vaginal cream and pessaries; Clocreme® pessary, vaginal cream; Clomazol® Vaginal cream; Clotrimaderm® vaginal cream)
- Econazole (Pevaryl® ovules)
* Unsuitable for dermatophyte fungal infections
Topical antifungals may be sold with an oral antifungal, e.g. Canesten® combination pack (fluconazole capsule and clotrimazole cream duo).
Antifungal creams are sometimes combined with:
- Hydrocortisone or other topical steroid (e.g. Resolve® Plus cream)
- Antibacterial agents
- Both topical steroid and antibacterial agent
Oral antifungal medications may be required for a fungal infection if:
- It is extensive or severe.
- It resists topical antifungal therapy.
- It affects hair-bearing areas (tinea capitis and tinea barbae).