Management Overview

The choice of antifungal across the 3 fungal skin infections is similar but not the same, therefore this concise summary is made:

• Scalp
  • 1st line: oral antifungal (terbinafine or griseofulvin)

 

• Body + groin + foot (Athlete’s foot) are the same
  • 1st line: topical antifungal (terbinafine or imidazole)
  • Oral antifungal (1st line: terbinafine) reserved for severe / extensive disease

NB that this summary does not replace the below sections.

Scalp Infection

Management

Referral Criteria

• Suspected kerion – urgent referral
• Unsuccessful treatment in primary care
• Severe / extensive / recurrent infection
• Immunocompromised

General Management / Self-Care Advice

Self management:

• Soften any surface crusts (e.g. moistened dressings), then gently tease away

Measures to prevent spread and transmission:

• Discard / disinfect objects that can transmit fungal spores (e.g. hats, scarves, hairbrushes, combs, pillows, blankets, scissors)
• Do not share towels, and wash frequently
• If household pet is the suspected source, assess and treat by a vet

Antifungal Treatment

Indications to Treat

Offer oral antifungal if any of the following:

• +ve microscopy or culture of the skin and hair
• -ve mycology but suggestive clinical features (but arrange repeat skin and hair sampling)
• Strong clinical suspicion before mycology results are back

Choice of Antifungal

1st line: oral terbinafine or griseofulvin +/- topical antifungal (e.g. ketoconazole shampoo, imidazole cream)

• Blind treatment (before culture results available)
  • If person lives in urban area → terbinafine for 4 weeks
  • If person lives in rural area → griseofulvin for 4-8 weeks

 

• Cultured guided treatment (adjust treatment accordingly)
  • If Trichophyton tonsurans → terbinafine
  • If Microsporum species → griseofulvin

2nd line antifungal: oral itraconazole

Follow Up

Review the patient 4-8 weeks after completing oral antifungal therapy.

If signs of persistent / recurrent infection, or hair regrowth do not occur → repeat skin and hair sampling for fungal microscopy and culture.

Body and Groin Infection

Management

General Management / Self-Care Advice

Self management:

• Wear loose-fitting clothes made of cotton or material designed to keep moisture away from the skin
• Wash affected skin daily + dry the skin after washing (esp. in the skin folds)
• Avoid scratching affected skin (as this may spread the infection to other sites)

Measures to prevent spread and transmission:

• Do not share towels, and wash frequently
• Wash clothes and bed linen frequently

If a child is affected, it is NOT necessary to exclude them from school or nursery

Antifungal Treatment

Mild Non-Extensive Disease

1st line: topical antifungal cream

• Terbinafine cream (only if >12 y/o), or
• Imidazole (e.g. clotrimazole, miconazole, econazole) (for all ages)

Consider a mildly potent topical corticosteroid (e.g. hydrocortisone 1%) if there is associated marked inflammation.

Severe / Extensive Disease

Consider oral antifungal

• 1st line: terbinafine
• 2nd line: itraconazole / griseofulvin

Foot Infection (Athlete’s Foot)

Management

General Management / Self-Care Advice

Self management:

• Foot hygiene
  • Wear well-fitting, non-occlusive footwear that keeps the feet cool and dry
  • Wear different pair of shoes every 2-3 days
  • Wear cotton, absorbent socks
  • Dry the skin after washing the feet (esp. between the toes)
• Avoid scratching affected skin (as this may spread the infection to other sites)

Measures to prevent spread and transmission:

• Replace old footwear which could be contaminated with fungal spores
• Do not share towels, and wash frequently
• Wear protective footwear when using communal bathing places, locker rooms, gyms

If a child is affected, it is NOT necessary to exclude them from school or nursery

Antifungal Treatment

Mild Non-Extensive Disease

1st line: topical antifungal cream

• Terbinafine cream (only if >12 y/o), or
• Imidazole (e.g. clotrimazole, miconazole, econazole) (for all ages)

Consider a mildly potent topical corticosteroid (e.g. hydrocortisone 1%) if there is associated marked inflammation.

2nd line options

• OTC undecenoic acid cream, or
• Topical preparations containing tolnaftate

Severe / Extensive Disease

Consider oral antifungal

• 1st line: terbinafine
• 2nd line: itraconazole / griseofulvin

References