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Topical antifungaldrugs are used to treat fungal infections on the skin, scalp, nails, vagina or inside the mouth. These medications come as creams, gels, lotions, ointments, powders, shampoos, tinctures and sprays. Most antifungal drugs induce fungal cell death by destroying the cell wall of the fungus. These drugs inhibit the production of ergosterol, which is a fundamental component of the fungal cell membrane and wall.
The general mechanism of action for topical antifungal drugs is the disruption of the cell membrane. The unique components found in fungal cell membranes are usually the drug targets of antifungal drugs, in particular ergosterol. It is a sterol, which is important in maintaining proper membrane fluidity and normal functions of the cell membrane. Ergosterol replaces cholesterol found in the cell membranes of mammalian cells. Antifungal medications that target ergosterol synthesis are selectively toxic to the fungi, hence, killing and stopping the growth of fungi in the body. When ergosterol is damaged, it causes the contents inside the fungal cells to leak out, preventing further reproduction of fungal cells. Lastly, antifungal agents contribute to fungal cell death.
Topical antifungals are generally safe to use in adults, seniors and children, Different dosages may be required for patients of different age groups. Discuss with healthcare professionals before the use of topical antifungal agents.
Prior to using topical antifungals, wash the affected area with soap and water and dry it completely, Wash both hands thoroughly after applying topical preparations. Apply a thin layer of topical antifungals to the area of infection. Avoid using occlusive dressings or wrappings unless otherwise directed by a clinician.
Topical antifungal medications usually come with side effects. Some patients may develop itching or local irritations after the application of these products. Consult a pharmacist or clinician if the treated area shows signs of increased irritation or possible sensitization such as erythema, pruritus, burning, blistering, swelling, or oozing. These drugs can also interact with food and various medications. Inform pharmacists or clinicians of existing or contemplated concomitant therapy, including prescription and Over-the-counter drugs, dietary or herbal supplements and any concomitant illnesses. Therefore, topical antifungals should be used with caution after seeking advice from medical professionals.
Clotrimazole is widely used to treat fungal infections on different parts of the body, including infections in the otitis externa (ear), the skin, regions of the vagina, and vulva. It is available in the form of pessaries, liquid, creams, and spray. Common side effects of clotrimazole are skin irritations, itchiness or redness in areas where the drug is applied.
Econazole in the form of creams and nail lacquers is often used to treat fungal skin and nail infections respectively. It can also be used to treat vaginal and vulval candidiasis by administering creams or pessaries vaginally. Some patients may experience skin reactions such as itchiness and redness after application.
Patients with acute porphyrias should avoid using Miconazole and Ketoconazole.
Miconazole is a widely used topical antifungal medication for the treatment of many fungal infections, namely skin infections, nail infections and vaginal candidiasis. The drug is usually formulated in creams, powders and sprays. However, it is suggested that patients developing acute porphyrias should avoid using this drug. Miconazole can also be used for both prevention and treatment of oral candidiasis which the drug is formulated as oromucosal gel. It is suggested that the usage of Miconazole for oral lesions in infants with swallowing reflexes should be avoided.File:Cushing's Syndrome.webpThe symptoms of Cushing's syndrome. Patients with this condition could only use oral Ketoconazole.
Ketoconazole is majorly used topically to treat fungal skin infections such as tinea pedis (Athlete's foot), seborrhoeic dermatitis, dandruff, and pityriasis versicolor. It can also be used to prevent the recurrence of fungal infections. The drug comes in the form of creams, shampoos, and tablets. Other than treating the infection, ketoconazole may cause skin reactions at the site of application, including skin rash and itching. Ketoconazole is contraindicated in patients with acute porphyrias, where patients may present with shortness of breath and seizures. If not treated promptly, acute porphyrias can be life-threatening.
In July 2013, the European Medicines Agency's Committee on Medicinal Products for Human Use (CHMP) advised that oral medicines containing Ketoconazole should be suspended due to the high risk of hepatotoxicity outweighing its benefits. The advice does not affect topical ketoconazole products, and the oral use of the drug for Cushing's syndrome.
Cautions
Avoid contact with eyes and mucous membranes using topically. Avoid intravaginal preparations (particularly those that require the use of an applicator) in young girls who are not sexually active, unless there is no alternative (in children).
Polyene antifungals do not work well orally so they are mostly seen as a solution or given topically or intravenously as a systemic antifungal. They are not suitable for dermatophyte fungal infections.
Nystatin is commonly used in treatment of lesions of the mouth caused by oral candidiasis. The drug can be formulated in pastilles or suspensions and is directly applied to the affected area. After application, patients should avoid taking food or drink for an hour to allow sufficient time for the drug to exert its effect locally. Oral irritation or sensitisation may occur in some patients after applying the drug to the oral mucous membrane.
Nystatin in the forms of creams, ointments or powders can also be used to treat fungal infections of the skin. The medication is directly applied to the affected area at around the same times on a daily basis. Some patients may experience itchiness, pain or burning sensations in the area where the drug is applied, while some may develop rashes or hives. On rare occasions, patients may have difficulty breathing or swallowing after topical use of Nystatin.
Nystatin is also used to treat fungal infections in the vaginal area. It is commonly formulated into pessaries or vaginal cream for application. Ointments, gels, creams or dusting powder may be used when patients develop cutaneous lesions. Skin irritations may occur in some patients after applying the medication vaginally.
Patients who are concurrently using latex contraceptives should be reminded that some intravaginal preparations of nystatin may damage the contraceptive. Additional contraceptive measures may be needed during the treatment duration.
Allylamines are a new type of antifungal drug that is highly selective for the fungal enzyme but has a minimal effect on humans. They work in a similar way as azoles but have their effects earlier on in the ergosterol synthesis pathway. Allylamines allow the active ingredients in the medication to accumulate well within the stratum corneum of the skin and nails to exert their actions. They inhibit the enzymesqualene epoxidase which converts squalene into ergosterol. This inhibition results in decreased amounts of sterols, causing cell death and the disruption of the fungal cell wall synthesis. They are known to be quite effective against dermatophytes, yeast, and molds.
Naftifine is used topically for the treatment of dermatophytosis, including tinea cruris (jock itch), tinea corporis (ringworm of the body), tinea pedis (athlete's foot) and tinea manuum (ringworm of the hand). It is available in creams or gels. Occlusive dressings should be avoided after applying the topical preparations. Clinical improvement usually occurs within the first week of treatment with Naftifine. Topical preparations containing Naftifine are contraindicated in patients hypersensitive to the drug or any ingredient in the formulation. The major adverse effect of Naftifine is local irritation, skin dryness and rash.
Terbinafine is used to treat skin infections caused by a fungus (yeast), including tinea corporis (ringworm of the body), tinea cruris (jock itch), onychomycosis, Pityriasis Versicolor and tinea pedis (athlete's foot). It is available in gel, spray and cream. These topical preparations should not be administered intravaginally and applied in or near the mouth or eyes. In addition, they should not be used on nails or scalp directly. Topical preparations containing terbinafine are contraindicated in patients hypersensitive to the drug or any ingredient in the formulation. The major adverse effect of Terbinafine is transient burning and stinging, local irritation and rash.
Benzoxaborole antifungals are a newer class of antifungal medication. They work by blocking the ability of the fungus to produce proteins in a highly specific way. Hence, disrupting the action of yeastcytoplasmic enzymes involved in the translation process. A common example of this class of antifungal is Tavaborole.
Benzoxaborole antifungal is for the treatment of onychomycosis of toenails. It is applied to the affected toenail once daily for 48 weeks. The major adverse effects associated with its use is the ingrowing of toenails and application site reactions including exfoliation, erythema, and dermatitis.
Ciclopirox and ciclopirox olamine are synthetic antifungal agents. The exact mechanism of action of Ciclopirox olamine antifungals is not well understood. It appears that the medication works by causing depletion of important substrates such as amino acids and/or ions within fungal cells, resulting in the inhibition of transport of these substances across fungal cell membranes. Finally, it disrupts the synthesis of DNA, RNA and proteins in fungal cells and leads to cell death. Ciclopirox may also exert its antimycotic effects by altering fungal cell permeability. However, the leakage of cellular constituents resulting from the decreased cell permeability is only apparent at high drug concentrations.
Nail lacquers are formulated from ciclopirox olamine solutions to treat mild to moderate onychomycosis of fingernails and toenails without the involvement of the lunula (the white area at the base of a nail).
In general, ciclopirox and ciclopirox olamine preparations are well tolerated by patients when used topically for treatment of fungal infections. Pain, itchiness and burning sensations may occur following topical application of the medication. For patients using ciclopirox nail lacquers, redness of the skin around the nail and the proximal nail fold may occur, while a few of them develop nail disorders such as ingrown nails, changes in shape, and discoloration.
The above adverse reactions are usually mild and self-terminating. They are rarely severe enough to require discontinuation of the drug.
Tolnaftate is a topically used antifungal for treating or preventing superficial dermatophyte infections, also known as skin infections, ringworm or tinea, and pityriasis versicolor. It is available in gel, solution, powder, ointment, or cream. Repeated treatment may be required if conditions do not improve within two to six weeks. It is important to note that tolnaftate is effective in inhibiting the growth of dermatophytes such as Epidermphyton and Microsporum, but the drug has no use against candida or bacteria infections. Contraindications include nail or scalp infections, and sulfa allergy or hypersensitivity to tolnaftate itself. Tolnaftate is usually useful for patients desiring self-medication of mild tinea infections.
Although undecylenic acids possess antifungal properties, the drug itself is seldom used on its own for antifungal purposes. Salts of undecylenic acid such as zinc undecenoate and calcium undecenoate are commonly formulated into antifungal creams, ointments, solutions or powders. Undecenoic acid and its salt forms are applied topically to treat superficial dermatophytosis, in particular tinea corporis (ringworm), tinea pedis (athlete’s foot), and tinea cruris (jock itch). Undecenoic acid is also formulated into several other salts and derivatives such as methyl, phenyl and propylundecenoate, which are also used to treat fungal infections on the skin. There has been limited evidence showing the effectiveness of undecylenic acid in treating nail and scalp fungal infections.
Adverse effects
Irritation may occur in some patients after topical application of undecylenic acid or its salts and derivatives.
