Antifungal Medications (not Eye Preps)

Systemic or disseminated fungal infections usually require specialist treatment. Immunocompromised patients are at particular risk from fungal infections and may require prophylactic treatment.

Topical imidazole group:

• Clotrimazole
• Econazole
• Miconazole

Triazole drug group and are taken orally:

• Fluconazole
• Itraconazole

Polyene antifungals:

• Amphotericin
• Nystatin
• Griseofulvin
• Flucytosine
• Terbinafine

N.B. Griseofulvin tablets are still available but have been largely superseded by other antifungal agents. It is however still the drug of choice in trichophyton infections in children.

• Candidal vulvovaginitis:
  • Topical imidazoles are commonly used in the treatment of vulvovaginal candidiasis. No particular topical imidazole has been found to be superior to any other.¹ The efficacy of topical imidazoles does not depend on the length of the course of treatment, but is related to the total dose of drug received. A single high dose is as effective as a lower divided dose over several days.^2,3 To be effective, intravaginal application is required. However, women should apply cream to the vulva as well as inserting a pessary or intravaginal cream where possible, as this area is also commonly affected.
  • Oral fluconazole and itraconazole are as effective, but not better than topical imidazoles.
• Oral candida:
  • First-line therapy is with topical treatment which may be amphotericin or miconazole.⁴
  • Second-line therapy is with systemic anticandidal treatment.
  • Fluconazole and itraconazole are used in immunocompetent patients.
  • Children should only receive topical anticandidal treatment.
• Nail infections:
  • Oral terbinafine has been found to be superior to placebo, griseofulvin and itraconazole.⁵ Other treatments have not been compared. It is only effective against dermatophyte nail infections. It has fungistatic activity against Candida albicans.
    
    
    
  • Fluconazole is not licensed for nail disease, but is used for severe infection in immunosuppressed people.
  • Griseofulvin is not effective against Candida spp.
• Skin infections:
  • Topical antifungals should be prescribed in most cases. The imidazoles (clotrimazole, econazole, ketoconazole, miconazole, and sulconazole) are all effective.⁶
  • Systemic treatment is only indicated in severe, extensive skin infection, or if there is associated systemic infection e.g. in immunosuppressed people, or in the rare person unresponsive to topical treatment.
• Aspergillosis - most commonly in the respiratory tract of severely immunocompromised patients, is treated with amphotericin. Recent work suggests there may be a reduction in mortality rate from using combination therapy, or liposomal amphotericin B, rather than amphotericin monotherapy.⁷
• Cryptococcosis - this is uncommon, except in immunocompromised patients e.g. AIDS. Cryptococcal meningitis is the most common form of fungal meningitis. Treatment is with amphotericin, with or without flucytosine. Fluconazole can be given alone to AIDS patients with no disturbance of consciousness. It is also used as prophylaxis against relapse.
• Histoplasmosis - is very rare in this country. It can be life threatening, particularly in HIV infected patients. Itraconazole or ketoconazole orally can be given in less severe infection. Intravenous amphotericin is used in more severe infections.

Many antifungals have similar adverse effects. They all may cause GI upset, rashes, headaches etc. In addition:

• Amphotericin may cause muscle and joint pain, hypokalaemia/ hypomagnesaemia, hearing loss, diplopia, convulsions or peripheral neuropathy.
• Fluconazole may cause liver function test abnormalities, rash - toxic epidermal necrolysis and Stevens-Johnson syndrome have been reported.
• Griseofulvin may aggravate or precipitate systemic lupus erythematosus.
• Application of topical imidazoles can be painful in some instances where there is particularly bad inflammation.⁸
• Terbinafine is associated with loss of taste (all four areas), particularly in underweight or elderly patients.⁹