Current Trends In Antifungal Therapy

Author(s): 
Panelists: Warren Joseph, DPM, Aditya Gupta, MD, PhD, Benjamin Overley, DPM, Richard Pollak, DPM and Jack Rubinlicht, DPM

Should you use a topical, an oral therapy or a combination of both? This is one of many questions that came up during an intriguing discussion of antifungals. Drawing upon their clinical experience, the panelists discuss their approaches to treating tinea pedis and onychomycosis, indications and contraindications for oral drugs, and other important aspects of prescribing appropriate, effective therapy.

Q: What do you use to treat different presentations of tinea pedis, including moccasin variety, acute vesicular and dermatophytosis complex (severe interdigital tinea)?
Warren Joseph, DPM, says moccasin variety tinea pedis has always been difficult to treat, due to the chronic nature of the condition. He also points out that the body has a blunted immune response to the fungus (almost always T. Rubrum), which causes the chronicity and prevents the natural immune defenses from helping to eliminate the infection.

Traditionally, doctors could only treat this condition with systemic medications but Dr. Joseph notes that with the advent of terbinafine cream (Lamisil), he had his “first real successes in treating the condition topically.” However, lately with the terbinafine cream only being available OTC, Dr. Joseph says he has reverted back to using ciclopirox cream or gel (Loprox) and has been impressed with its ability to treat moccasin tinea. Richard Pollak, DPM, also prescribes Loprox gel bid for two months while Benjamin Overley, DPM, uses Oxistat 1% cream and may also use a topical steroid cream to treat this condition.
In his opinion, Dr. Joseph believes terbinafine and ciclopirox creams are effective for moccasin tinea because, unlike the azoles, they are fungicidal. Due to the fact that the skin needs time to completely turn over and shed the fungus, Drs. Joseph and Pollak note that it usually takes at least a month before you see results.
When it comes to treating acute vesicular tinea, Dr. Joseph says combining a short course of oral therapy with aggressive topical therapy seems to be the best course. Aditya Gupta, MD, PhD, notes that he leans toward using oral antifungals for this condition. Dr. Pollak says he initially uses Domeboro soaks bid, Spectazole cream or Loprox gel, and tinactin powder in the shoes.
If the tinea is acute and aggressive, Jack Rubinlicht, DPM, says he will use a topical, such as Spectazole, and add either Lamisil (250mg 1qd) or one Sporanox pulse pack. If the condition is severe, Dr. Pollak may consider prescribing an oral antifungal for two weeks in addition to Domeboro soaks. If there is a secondary bacterial infection, Dr. Pollak says he does not hesitate to consider an appropriate oral antibiotic.
Given the intense inflammatory response generated by T. mentagrophytes, the usual cause of acute vesicular tinea, topical steroids can also be useful, according to Dr. Joseph. Dr. Overley concurs, noting that he uses Oxistat 1% lotion and may also opt for a topical steroid cream.

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