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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

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.

Available treatments

Topical imidazoles commonly used in the treatment of vulvovaginal candidiasis:

  • Clotrimazole
  • Econazole
  • Miconazole

Triazole drug group and are taken orally:

  • Fluconazole
  • Itraconazole

Polyene antifungals. These are not absorbed orally:

  • Amphotericin
  • Nystatin
  • Griseofulvin
  • Flucytosine
  • Terbinafine
Indications for use
  • 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.
    • Topical nystatin is more effective against certain resistant strains of yeast such as Candida glabrata.
  • Oral candida:
    • First-line therapy is with topical treatment which may be amphotericin, miconazole, or nystatin.
    • 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.4 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. Nystatin and the imidazoles (clotrimazole, econazole, ketoconazole, miconazole, and sulconazole) are all effective.
    • 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.5
  • 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.
Cautions and contraindications

  • Amphotericin has a risk of toxicity when given parenterally. It should only be used parenterally in hospitalised patients, or those under close clinical observation.
    • If serum creatinine exceeds 260 micromol/l the drug should be discontinued or the dosage markedly reduced until renal function is improved.
    • Weekly blood counts and serum potassium levels are also advisable.
    • Low serum magnesium levels have also been noted.
    • Therapy should be discontinued if liver function test results (elevated alkaline phosphatase and bilirubin) are abnormal.
    A test dose is required. After this the patient is observed closely for 30 minutes. Rapid infusion carries a risk of arrhythmias.
  • Fluconazole carries a risk of hepatic impairment. Use with caution in pregnancy, breast feeding and impaired liver function.
  • Oral ketoconazole is not usually indicated in the treatment of vulvovaginal candidiasis. It can rarely cause fulminant hepatitis and is therefore reserved for recurrent vulvovaginal candidiasis unresponsive to other therapies.6
  • Griseofulvin may impair the ability to perform skilled tasks e.g. driving. The toxic effects of alcohol are increased. It is CONTRAINDICATED in severe liver disease and systemic lupus erythematosus.
  • Ketoconazole is CONTRAINDICATED in hepatic disease, pregnancy and breast feeding.
  • Miconazole is CONTRAINDICATED in liver disease.
  • Terbinafine should be used with caution in liver or kidney disease, pregnancy or breast feeding.
  • Topical nystatin is not normally recommended for uncomplicated vulvovaginal candidiasis, as it is taken as a 14-day intravaginal regimen and may stain clothes yellow, but it may be useful in treatment failure.7

Adverse effects

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

Document references
  1. Spence D.; Clinical Evidence. Candidiasis (vulvovaginal).; Registration required to access.
  2. Marrazzo J; Vulvovaginal candidiasis.; BMJ. 2002 Sep 14;325(7364):586.
  3. Sobel JD; Management of patients with recurrent vulvovaginal candidiasis.; Drugs. 2003;63(11):1059-66. [abstract]
  4. Crawford F, Ferrari J.; Clinical Evidence.; Registration required for access.
  5. Trullas JC, Cervera C, Benito N, et al; Invasive pulmonary aspergillosis in solid organ and bone marrow transplant recipients.; Transplant Proc. 2005 Nov;37(9):4091-3. [abstract]
  6. Spence D; Candidiasis (vulvovaginal).; Clin Evid. 2003 Dec;(10):2044-57.
  7. Hainsworth T; Diagnosis and management of candidiasis vaginitis.; Nurs Times. 2002 Dec 3-9;98(49):30-2. [abstract]
  8. MeReC (2004). An Update on Vulvovaginal Candidiasis (thrush). MeReC Bulletin. 14(4),13-16.
  9. Doty RL, Haxel BR; Objective assessment of terbinafine-induced taste loss.; Laryngoscope. 2005 Nov;115(11):2035-7. [abstract]
Internet and further reading AcknowledgementsEMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 259
Document Version: 1
DocRef: bgp25151
Last Updated: 23 Nov 2007
Review Date: 22 Nov 2008




















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PS - Health and Poverty

Perhaps the biggest cause of ill health in the world is poverty. Help to Make Poverty History. For example, why not lend some of your money to disadvantaged communities to enable them to trade their way out of poverty through schemes such as Shared Interest.

See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

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