Fungal skin infections

Ringworm

Localised lesion:

Miconazole 2% topically twice daily for 28 days

If unresponsive to treatment:

Terbinafine 1% topically daily for 7 days

If multiple lesions, lesion on palms/soles or intractable lesions:

Terbinafine oral 250mg daily for 28 days

N.B. Idiosyncratic liver reactions can occur with terbinafine. Discuss risks with patient.

Fungal infections of the skin presents with itch and scaly or erythematous macular skin lesions. In athlete’s foot, pustular eruptions may be present.

Treat any positive culture results. Susceptibility testing of dermatophytes is not required, as resistance is unusual and susceptibilities do not predict outcome. For fungal isolates that are not dermatophytes or a candida sp., seek the advice of a microbiologist or dermatologist.

Samples are not needed for uncomplicated athlete’s foot, mild infections of the groin and mild skin ringworm. Take samples if oral treatment is being considered, in severe or treatment refractory infections or when the diagnosis is uncertain.

Dermatophyte infection of the proximal fingernail or toenail

For superficial or early infection:

Amorolfine 5% nail lacquer, apply after filing and cleansing twice a week.

Duration: 6 months for fingers, 9-12 months for toes.

Advanced infection:

Terbinafine oral 250mg daily

Duration: 6-12 weeks for fingers, 3-6 months for toes.

N.B. Idiosyncratic liver reactions can occur with terbinafine. Discuss risks with patient.

For superficial or early infection:

Amorolfine 5% nail lacquer, apply after filing and cleansing twice a week.

Duration: 6 months for fingers, 9-12 months for toes.

For more severe nail disease:

Itraconazole oral 200mg twice daily

Duration: 7 days, repeat the course after 21 day break, 2-3 monthly cycles.

Only 50% of nail dystrophy are fungal. Mycological culture of nail clippings is currently not routinely available and should be discussed with a consultant microbiologist.

Fungal infections of the nail can present with a variety of nail changes, such as nail deformity, brittle or crumbling nails, and white or yellow discolouration.