Ensure Patients Properly Use Topical Antifungal Agents

Dermatophytoses, commonly known as fungal infections, can affect the skin, nails, and hair.¹ Pharmacists are likely to encounter patients seeking advice on the various topical nonprescription antifungal medications indicated for managing some mild to moderate fungal skin infections when no contraindications are present. Pharmacists can also direct patients to seek further medical evaluation when warranted to obtain proper treatment and prevent complications, especially in patients with other medical conditions, those taking certain medications, and those with severe infections or who are experiencing worsening symptoms despite self-care measures.

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Fungal infections are generally superficial, and common fungal skin infections include tinea pedis (commonly called athlete’s foot) and onychomycosis, or tinea unguium, which affects the nails and may occur concurrently with tinea pedis.¹ Examples of other commonly occurring fungal skin infections include tinea corporis (ringworm of the body), tinea capitis (ringworm of the scalp), and tinea cruris (commonly referred to as jock itch).¹ Tinea infections are commonly caused by genera Trichophyton, Microsporum, and Epidermophyton.^1,2 Most fungal skin infections result from a barrier breakdown in the skin or nails; if left untreated, these types of infections can cause secondary bacterial infections.^1,2

Patients may present with varying degrees of symptoms, including skin irritation, erythematous appearance to the skin, scaly skin, itching, burning sensation, pain, swelling, and blisters, depending on the severity of the infection. Treatment should be tailored to address the patient’s individual needs. In general, therapy aims to relieve symptoms, eradicate infections, and implement measures to prevent future infections.^1,2

Although fungal skin infections can occur in anyone, research has established that certain risk factors may augment an individual’s risk for these types of infections. Examples of risk factors include uncontrolled diabetes, obesity, history of autoimmune diseases, use of immunosuppressive drugs, impaired circulation, poor hygiene, and poor nutrition.^1-4

OTC Antifungals

In general, topical antifungal therapy is the most preferred route of administration for most patients with fungal skin infections. Nonprescription topical antifungal agents include butenafine hydrochloride 1%, clotrimazole 1%, miconazole nitrate 2%, terbinafine hydrochloride 1%, tolnaftate 1%, and undecylenic acid 25%, which are all safe and effective for the treatment of fungal skin infections.^1,2

Depending on the agent, these treatments are available in various dose forms, including aerosol sprays, lotions, creams, ointments, and powders.¹ The use of powder formulations should be reserved only for extremely mild infections or as an adjunctive therapy, according to the Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care.¹ In general, factors considered when selecting therapy may include type and location of infection, degree of severity, cost of treatment, dose delivery, frequency of administration, and patient preferences.

News and Recent Data

According to a recent CDC report, incorrect use of antifungal creams and combinations of antifungal treatments with corticosteroids are possible causes contributing to the augmented incidence and transmission of severe skin, scalp, and nail fungal infections. “Severe antimicrobial-resistant superficial fungal infections have recently been detected in the United States; evaluating topical antifungal use is an initial step in developing strategies to prevent the global emergence and spread of these infections,” the authors wrote.⁵ The authors also noted that clinicians should expand patient education initiatives about the recommended use of these agents.⁵

Counseling Tips

Prior to recommending any product, the pharmacist should ascertain whether self-treatment is appropriate, screen for contraindications, and refer patients to primary health care providers when warranted.

Pharmacists can be instrumental in guiding patients in product selection, educating patients about the proper use of topical antifungals, assisting patients in identifying possible causes when feasible, and making recommendations for nonpharmacological measures that may reduce or prevent infections. Key measures include the following^1,2:

• Educate patients about the proper use of selected topical agents, including applying them as directed to clean and dry skin that is affected by the infection. Treatment should be applied for the recommended duration of therapy, and the goals of therapy and treatment expectations should be clearly communicated. Hands should be washed after applying topical therapy.
• Patients should be advised about the importance of treatment adherence in order to improve clinical outcomes. Additionally, counsel patients regarding the duration of therapy to avoid under- or overuse.
• Discontinue use if experiencing any adverse effects or if there is no resolution of symptoms or worsening of symptoms. Patients should be advised to immediately call a primary health care provider for additional treatment if this occurs.
• Advise patients to seek medical care if they are exhibiting signs of a secondary bacterial infection, if the infection is recurring, or if the cause is unknown.
• To prevent tinea pedis, advise patients to wear protective footwear in public showers, always wash feet daily, and dry them completely. Wear socks with moisture-wicking material to keep feet dry and avoid occlusive footwear.

Conclusion

Generally, topical therapies can effectively treat and manage fungal skin infections, especially with early diagnosis, appropriate clinical intervention, and adherence to the selected therapy. Due to their frequent interactions with patients, pharmacists are well positioned to identify patients who experience recurring infections and to encourage these patients to seek further evaluation from their primary health care provider, as frequent fungal skin infections may be a sign of undiagnosed diabetes, an immune disorder, or another medical issue.¹

References

1. Smith MG. Fungal skin infections. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; 2021.

2. Goldstein AO, Goldstein BG. Dermatophyte (tinea) infections. UpToDate. Updated November 7, 2023. Accessed April 25, 2024. https://www.uptodate.com/contents/dermatophytetinea-infections

3. Diabetes and skin complications. American Diabetes Association. Accessed April 25, 2024. https://diabetes.org/about-diabetes/complications/skin-complications

4. Who gets fungal infections? CDC. Reviewed August 26, 2021. Accessed April 25, 2024. https://www.cdc.gov/fungal/infections/index.html

5. Benedict K, Smith DJ, Chiller T, Lipner SR, Gold JAW. Topical antifungal prescribing for Medicare Part D beneficiaries– United States, 2021. MMWR Morb Mortal Wkly Rep.2024;73(1):1-5. doi:10.15585/mmwr.mm7301a1