Superficial fungal infections, including dermatophytosis (often called ringworm, tinea, jock itch, or athlete's foot), are common outpatient ailments.[1]Typically, superficial fungal infections are minor conditions that clear with topical antifungals, which are often available for purchase over the counter.[2,3]
Recently, however, some superficial fungal infections that are resistant to first-line over-the-counter and prescription treatments have emerged as a public health concern globally and in the United States.[4,5,6] These infections cause extensive pruritic plaques requiring prolonged courses of oral prescription antifungal therapies previously reserved for more invasive fungal infections.[5,7]
The misuse and overuse of topical antifungal medications, particularly combination antifungal-corticosteroid products, are considered a likely driver of antimicrobial-resistant superficial fungal infections.[8,9] Therefore, a renewed emphasis is needed on the judicious use of topical antifungals and combination topical antifungal-corticosteroid products.[10,11,12]
Here are five things to know when prescribing or recommending topical antifungals.
1. Visual diagnosis of superficial fungal infections is often incorrect.
Superficial fungal infections frequently resemble nonfungal skin conditions such as eczema, rosacea, psoriasis, and impetigo.[2,13] Even specialists may incorrectly diagnose possible superficial fungal infections based on appearance if diagnostic testing is not used.[14]
In the United States, patient self-diagnosis and over-the-counter treatment for suspected superficial fungal infections are common,[15] and most clinicians do not perform diagnostic testing before prescribing or recommending antifungal therapy.[16,17]
2. Diagnostic testing or referral to a dermatologist can help ensure that patients get the right treatment for their skin conditions.
Diagnostic testing can help determine whether a skin condition is due to fungal infection and should be performed whenever feasible.[2,3] For example, clinicians can use potassium hydroxide preparation of skin scrapings to confirm superficial fungal infections. Fungal cultures can help identify causative organisms and guide antifungal selection, although frequent false-negative results and long turnaround times can limit the utility of these tests. Polymerase chain reaction testing is increasingly used for diagnosing superficial fungal infections. Whenever possible, clinicians should use diagnostic testing to confirm superficial fungal infections. If a patient has a negative test result despite clinical suspicion for a superficial fungal infection, the test can be repeated. Referral to a dermatologist or other specialist may be beneficial when diagnosis is uncertain.[18]
3. Avoid using combination topical antifungal-corticosteroid products.
Sometimes, when the cause of a skin condition is uncertain, clinicians prescribe topical antifungal-corticosteroid products as an attempt to empirically treat for both fungal infections and nonfungal inflammatory conditions.[19,20] Prescribing topical antifungal-corticosteroid combination products is discouraged, however.[21] Topical antifungal-corticosteroid combination products may be less effective and more expensive than antifungal monotherapy and are potential drivers of antimicrobial resistance.[8,9,19,21]
Furthermore, clinicians may be unaware that the most commonly prescribed topical antifungal-corticosteroid, clotrimazole–betamethasone dipropionate (Lotrisone), contains a high-potency corticosteroid.[19,20] Use of this product can cause serious adverse effects, including skin atrophy, ulcerations, and systemic side effects including hypothalamic‐ pituitary ‐ adrenal axis suppression.[3,19,20] Recent studies have suggested that prescribing of topical antifungal-corticosteroid products is very common in the United States,[3] including in instances that are inappropriate, such as to young children and people without a diagnosed fungal infection.[21]
4. For suspected fungal skin infections, consider topical antifungal monotherapy products instead of topical antifungal-corticosteroid products.
Instead of combination antifungal-corticosteroid products, clinicians can prescribe or recommend using topical antifungal monotherapies for patients with confirmed or highly suspected fungal skin infections.[22] These products can help decrease inflammation and alleviate itching while sparing patients the potential side effects of high-potency steroids like betamethasone dipropionate. If no improvement occurs with topical antifungal monotherapy, diagnostic testing should be ordered if it was not already performed.
5. Be a good steward of topical antifungal products.
By performing diagnostic testing for superficial skin infections whenever possible and avoiding the overuse of topical antifungal and combination antifungal-corticosteroid products, healthcare professionals can help ensure that patients receive optimal treatment while aiming to preserve the effectiveness of antifungal drugs. Prescribers, pharmacists, and the public can work together to stop the drivers of emergence and spread of antimicrobial-resistant dermatophytes in outpatient settings.
For visual guides on therapeutic drug monitoring, download the infographics here.
Disclaimer: The conclusions, findings, and opinions expressed by the authors do not necessarily reflect the official position of the US Department of Health and Human Services, the Public Health Service, or the Centers for Disease Control and Prevention. Use of trade names and commercial sources is for identification only and does not imply endorsement by the US Department of Health and Human Services or the US Centers for Disease Control and Prevention.
COMMENTARY
5 Things to Know When Prescribing or Recommending Topical Antifungals and Combination Antifungal-Corticosteroids
Jennifer H. Pham, PharmD, MPH; Shari R. Lipner, MD, PhD; Kaitlin Benedict, MPH; Dallas J. Smith, PharmD, MAS; Avrom S. Caplan, MD; Jeremy A. W. Gold, MD, MS
DISCLOSURES
| July 02, 2024Editorial Collaboration
&
Superficial fungal infections, including dermatophytosis (often called ringworm, tinea, jock itch, or athlete's foot), are common outpatient ailments.[1]Typically, superficial fungal infections are minor conditions that clear with topical antifungals, which are often available for purchase over the counter.[2,3]
Recently, however, some superficial fungal infections that are resistant to first-line over-the-counter and prescription treatments have emerged as a public health concern globally and in the United States.[4,5,6] These infections cause extensive pruritic plaques requiring prolonged courses of oral prescription antifungal therapies previously reserved for more invasive fungal infections.[5,7]
The misuse and overuse of topical antifungal medications, particularly combination antifungal-corticosteroid products, are considered a likely driver of antimicrobial-resistant superficial fungal infections.[8,9] Therefore, a renewed emphasis is needed on the judicious use of topical antifungals and combination topical antifungal-corticosteroid products.[10,11,12]
Here are five things to know when prescribing or recommending topical antifungals.
1. Visual diagnosis of superficial fungal infections is often incorrect.
Superficial fungal infections frequently resemble nonfungal skin conditions such as eczema, rosacea, psoriasis, and impetigo.[2,13] Even specialists may incorrectly diagnose possible superficial fungal infections based on appearance if diagnostic testing is not used.[14]
In the United States, patient self-diagnosis and over-the-counter treatment for suspected superficial fungal infections are common,[15] and most clinicians do not perform diagnostic testing before prescribing or recommending antifungal therapy.[16,17]
2. Diagnostic testing or referral to a dermatologist can help ensure that patients get the right treatment for their skin conditions.
Diagnostic testing can help determine whether a skin condition is due to fungal infection and should be performed whenever feasible.[2,3] For example, clinicians can use potassium hydroxide preparation of skin scrapings to confirm superficial fungal infections. Fungal cultures can help identify causative organisms and guide antifungal selection, although frequent false-negative results and long turnaround times can limit the utility of these tests. Polymerase chain reaction testing is increasingly used for diagnosing superficial fungal infections. Whenever possible, clinicians should use diagnostic testing to confirm superficial fungal infections. If a patient has a negative test result despite clinical suspicion for a superficial fungal infection, the test can be repeated. Referral to a dermatologist or other specialist may be beneficial when diagnosis is uncertain.[18]
3. Avoid using combination topical antifungal-corticosteroid products.
Sometimes, when the cause of a skin condition is uncertain, clinicians prescribe topical antifungal-corticosteroid products as an attempt to empirically treat for both fungal infections and nonfungal inflammatory conditions.[19,20] Prescribing topical antifungal-corticosteroid combination products is discouraged, however.[21] Topical antifungal-corticosteroid combination products may be less effective and more expensive than antifungal monotherapy and are potential drivers of antimicrobial resistance.[8,9,19,21]
Furthermore, clinicians may be unaware that the most commonly prescribed topical antifungal-corticosteroid, clotrimazole–betamethasone dipropionate (Lotrisone), contains a high-potency corticosteroid.[19,20] Use of this product can cause serious adverse effects, including skin atrophy, ulcerations, and systemic side effects including hypothalamic‐ pituitary ‐ adrenal axis suppression.[3,19,20] Recent studies have suggested that prescribing of topical antifungal-corticosteroid products is very common in the United States,[3] including in instances that are inappropriate, such as to young children and people without a diagnosed fungal infection.[21]
4. For suspected fungal skin infections, consider topical antifungal monotherapy products instead of topical antifungal-corticosteroid products.
Instead of combination antifungal-corticosteroid products, clinicians can prescribe or recommend using topical antifungal monotherapies for patients with confirmed or highly suspected fungal skin infections.[22] These products can help decrease inflammation and alleviate itching while sparing patients the potential side effects of high-potency steroids like betamethasone dipropionate. If no improvement occurs with topical antifungal monotherapy, diagnostic testing should be ordered if it was not already performed.
5. Be a good steward of topical antifungal products.
By performing diagnostic testing for superficial skin infections whenever possible and avoiding the overuse of topical antifungal and combination antifungal-corticosteroid products, healthcare professionals can help ensure that patients receive optimal treatment while aiming to preserve the effectiveness of antifungal drugs. Prescribers, pharmacists, and the public can work together to stop the drivers of emergence and spread of antimicrobial-resistant dermatophytes in outpatient settings.
For visual guides on therapeutic drug monitoring, download the infographics here.
Disclaimer: The conclusions, findings, and opinions expressed by the authors do not necessarily reflect the official position of the US Department of Health and Human Services, the Public Health Service, or the Centers for Disease Control and Prevention. Use of trade names and commercial sources is for identification only and does not imply endorsement by the US Department of Health and Human Services or the US Centers for Disease Control and Prevention.
Public Information from the CDC and Medscape
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