13.10.2 Antifungal preparations

ChoiceDrugDosage
1st choiceClotrimazole 1% cream

Dose:
Apply 2-3 times daily

or
Miconazole 2% creamDose:
Apply twice daily continuing for 10 days after the lesions have healed.
Nail infections: apply 1-2 times daily
or
Terbinafine 1% creamDose:
Apply 1-2 times daily

Prescribing Notes

  • Topical clotrimazole, miconazole, terbinafine and amorolfine can be purchased over the counter and self care should be encouraged.
  • Topical antifungal therapy offers very little benefit for the management of fungal nail infections. It should only be considered if the infection is mild and superficial or where systemic therapy is contra-indicated or not tolerated e.g. hepatic or liver impairment. Patients can be advised to purchase over the counter (OTC) amorolfine 5% nail lacquer for the treatment of a maximum of 2 nails.
  • Athlete’s foot and dhobie itch can be managed and treated in community pharmacy under the NI Minor Ailments Scheme.
  • Refer to Primary Care Antibiotic Guidelines for management of athlete’s foot, fungal skin infections and fungal nail infections.
  • To prevent relapse, local antifungal treatment should be continued for 1-2 weeks after the disappearance of all signs of infection.
  • Systemic treatment is necessary for nail or scalp infection or if the skin infection is widespread, disseminated, or intractable. Skin scraping should be examined if systemic therapy is being considered or where there is a doubt about the diagnosis. Refer to Primary Care Antibiotic Guidelines.
  • Combination of an imidazole antifungal and a mild corticosteroid may be of value in the treatment of eczematous intertrigo and (in the first few days only) of a severely inflamed patch of ringworm.
  • Combination of a mild corticosteroid with either an imidazole or nystatin may be of use in the treatment of intertrigo associated with candida.
  • Selenium sulphide shampoo can useful for pityriasis versicolor (an unlicensed indication) when used as a lotion and left on the affected area for 10 minutes before rinsing off; it should be applied once daily for 7 days, and the course repeated if necessary.

 

Cautions

  • Topical miconazole can enhance the anticoagulant effect of warfarin—if miconazole and warfarin are used concurrently the anticoagulant effect should be carefully monitored and, if necessary, the dose of warfarin reduced. See MHRA
  • Patients taking warfarin should not use over the counter miconazole oral gel (Daktarin). If you plan to prescribe miconazole oral gel in a patient on warfarin, you should closely monitor them and advise that if they experience any sign of bleeding they should stop miconazole oral gel and seek immediate medical attention. For further information see MHRA