In this article as part of the exclusive series on dermatophytosis, Dr. DG Saple explains new antifungal treatments and highlights the need for a holistic approach to manage tinea cruris and corporis that involves patient counselling so as to prevent treatment failure and recurrence.

Tinea cruris and corporis were generally responsive to simple topical antifungal creams in the past. However, in the past decade, there has been a surge in the incidence of dermatophyte infections wherein only topical measures are not adequate. A combination of topical creams and systemic antifungal medication is the need of the hour in nearly all of the cases.

Topical medications are known to have a better pharmacokinetic profile than systemic antifungals. Therefore, combination is expected to have better mycological clearance than systemic and topical alone.

However, a holistic approach is what is necessary in today's times for proper management of dermatophytic infections. Treatment of the infection as well as counseling of the patient to prevent clinical failure, recurrence of the infection, as well as spread of the infection to other family members should be the basis of management.

---

Medical management

Whitfields ointment and castellani’s paint which were used in the past, have negligible role in the present day scenario of dermatophytic infections.

Topical creams continue to be the first-line treatment in naïve tinea infections involving limited body surface area. The list of currently used antifungal creams is summarised in Table 1. Topical azole creams are now favoured for local management of tinea cruris and corporis. Amorolfine-based creams may be used where azole-based creams have not proved beneficial.

Table 1

Imidazole
Clotrimazole 1% Econazole 1 % Miconazole 1% Oxiconazole 2% Sertaconazole 2% Luliconazole 1% Eberconazole 1%	Cream Cream Cream, lotion Cream, lotion Cream Cream, lotion Cream
Allylamines
Terbinafine Naftifine 1% Butenafine 1%	Cream, powder Cream Cream
Others
Amolorfine 0.25 % Amphotericin B (1mg) 0.1%	Cream Lipid based gel

Treatment naïve patients with limited lesions of tinea cruris or corporis may be prescribed only topical creams. Luliconazole 1% cream has shown to have clinical and mycological cure rates.

A paper by Moriarty et al. (cited by Sahoo AK and Mahajan R) has emphasised upon the use of topical therapy in treating tinea corporis, cruris, and pedis. According to them, the common reasons of failure of therapy include poor adherence to treatment, reinfection from close contact, drug resistance, misdiagnosis, and infection with uncommon species. Hence, special importance should be given to patient counseling so that they adhere to the treatment. Addition of steroid (mild) has been shown to improve the bioavailability and reduce inflammation. However, in a country like India where steroids are easily available as an OTC product, this practice should be avoided. Antifungals with potent anti-inflammatory action such as sertaconazole and luliconazole should instead be preferred.

---

Current regimen

The current regimen for oral antifungal treatment in listed in the Table 2. However, as the infection has evolved, our treatment guidelines need to be revisited and in this current tinea epidemic scenario the treatment duration should be extended to atleast 6 to 8 weeks. Even if the patient reports improvements within the first couple of weeks, continuing the regimen for a minimum period of 6 weeks has shown to reduce the incidence of relapses and recurrences.

According to literature, itraconazole (100 mg twice daily) is quite effective in treating naïve cases especially cases of recalcitrant tinea. Albeit, itraconazole is one of the most favoured oral antifungal, it has a lot of known drug interactions as well as cost limitations.

Fluconazole, in a dose of 100 mg/day daily for 6 weeks has shown excellent results. It ensures good drug compliance as well as a favourable cost-benefit ratio.

Table 2

Drug	Dose
Terbinafine	250 mg once daily, 3-6 mg/kg/day for 2-3 weeks
Itraconazole	100 mg BD, 2 weeks
Fluconazole	150-300 mg once per week for 3-4 weeks
Griseofulvin (microsized)	500mg/day (10-20 mg/kg/day) for 2-4 weeks
Griseofulvin (ultramicrosized)	300-375 mg/day (5-10 mg/kg/day)

Patients who do not show adequate response even after 4 weeks of antifungal therapy, i.e. patients with chronic dermatophytosis, need to undergo anti-fungal drug sensitivity testing.

---

General treatment measures

1. Patients should be properly counselled regarding the importance of drug compliance and adherence. Most of the patients discontinue the treatment once they achieve clinical cure and this is the major factor for clinical failure and relapse.
2. Duration of treatment should be individiualised depending upon the severity and disease extent. On an average 6 weeks of treatment should be administered to ensure complete clinical and mycological cure.
3. Patient should be strongly discouraged from using any over-the-counter steroid creams and self-medication.
4. It is important to inform the patients regarding hygiene measures- wearing dry clothes as far as possible and changing clothes at the end of the day before sleeping.
5. Patients should be advised to wash clothes everyday, including undergarments which should be washed in hot boiling water and ironed inside out before wearing.
6. Patient should be advised to not share clothes/towels with other individuals of the family.
7. All the immediate family members should be questioned/examined for similar complaints and treated simultaneously.

---

---

This article is part of an exclusive series on Dermatophytosis by Dr. DG Saple. Click on the following links to read other articles in the series.

Emerging recalcitrant dermatophytosis in India

Exclusive series: Diagnosis of Dermatophytosis- Dr. DG Saple

Exclusive series: Resistance in Dermatophytosis- Dr. DG Saple

---

References :

[1] Sahoo AK, Mahajan R. Management of tinea corporis, tinea cruris, and tinea pedis: a comprehensive review. Indian Dermatol Online J. 2016;7(2):77–86.

[2] Rajagopalan, M., Inamadar, A., Mittal, A. et al. Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). BMC Dermatol 18, 6 (2018)

[3] Rengasamy M, Chellam J, Ganapati S. Systemic therapy of dermatophytosis: Practical and systematic approach. Clin Dermatol Rev 2017;1, Suppl S1:19-23

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. DG Saple is a Senior Consultant and Director of Dermatology at a Mumbai-based clinic.