When to Treat with Systemic vs Local Antifungal Agents

When to Treat with Systemic vs Local Antifungal Agents

Systemic Therapy

Tinea capitis

Oral therapy is required to adequately treat tinea capitis, as they are able to penetrate the infected hair shaft where topical therapies cannot.

Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form.

Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks.

In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans. However, in children with microsporum infection, new evidence suggests that the effect of griseofulvin is better than that of terbinafine.

Tinea unguium

Though griseofulvin is approved for tinea infection of the nails, its affinity for keratin is low and long-term therapy is required. The oral therapy regimens for tinea unguium (onychomycosis)are as follows:

terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails only) itraconazole 200 mg twice daily as pulse therapy one pulse: 1 week of itraconazole followed by 3 weeks without itraconazole two pulses: fingernails three pulses: toenails Local Therapy

Tinea pedis, tinea manuum, tinea corporis, and tinea cruris can be treated with topical antifungal medications.

A wide variety of topical agents are available, in cream, gel, lotion, and shampoo formulations. A majority of the agents are of the ‘azole’ antifungal family (clotrimazole, miconazole, econazole, coiconazole, ticonazole, etc.). Terbinafine and naftifine represent the ‘allylamine’ family of agents. Both families of drugs are known for their high efficacy against the dermatophytes.

Cure rates of tinea corporis/tinea cruris/tinea pedis are high, with infections resolving with two to four weeks of topical therapy.

Skin Biopsy

Type of biopsy


Tool & specimen size

Incisional /

punch biopsy

Incisional biopsy means taking out a part of the skin lesion

Punch biopsy is a specific incisional biopsy using a cylindrical dermal biopsy tool.

Disposable punches are very convenient and available from two to eight millimeters in size.

A full thickness of skin can easily be obtained with a punch biopsy.

If a lesion is less than three millimeters in size, it does not need stitches after biopsy.

Excisional biopsy

Excisional biopsy involves removing the whole lesion with a two to three millimeter margin, depending on the nature of the lesion.

Larger-sized punches may be useful for excisional punch biopsies.

Diagnostic method of choice if there is a strong suspicion of malignant melanoma.

Shave biopsy

Shave biopsy is feasible when the lesion is elevated above the surface.

Some experts occasionally elevate the lesion with lidocaine and shave in certain circumstances in order to avoid stitches.

Skin Lesion Therapy


Conditions treated

More details

Surgical excision

Most widely used treatment for cutaneous squamous-cell carcinomas (SCCs), particularly high risk lesions.

Well defined, small (< 2 centimeters) SCC lacking any high-risk features requires a four millimeter margin of normal tissue around the visible tumor to result in 95% histologic cure rate.

Patients with any nonmelanoma skin cancer greater than two centimeters,

The surgeon can immediately review the pathology to confirm complete excision during a staged excision. Since this allows removal of the least


microscopic surgery

lesions with indistinct margins, recurrent lesions, and those close to important structures, including the eyes, nose, and mouth, should be considered for referral for complete excision via Mohs micrographic surgery, with possible plastic repair.

necessary amount of tissue, this procedure is indicated in cosmetically sensitive areas. This ability to immediately confirm pathology is also useful in lesions with indistinct margins where more tissue than clinically apparent may require removal. If a difficult repair is anticipated or a poor cosmetic result is expected, referral is appropriate. To learn more about Mohs surgery, read an article from the American Academy of Family Physicians.

Topical 5fluorouracil


Approved by the United States Food and Drug Administration (FDA) for the treatment of actinic keratoses.

Although topical 5 -FU is not approved for the treatment of Bowen’s disease (squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in these diseases when other treatment modalities are impractical and for patients who refuse surgical treatment.


Useful for small, well defined, low risk invasive SCCs and Bowen’s disease.

Destroys malignant cells by freezing and thawing. Cryotherapy does not permit histologic confirmation of the adequacy of treatment margins; thus, a substantial amount of training and experience is required to achieve consistently high cure rates.

Radiation therapy

An option for the initial management of small, well-defined, primary SCCs, especially older patients and those who are not surgical candidates.

However radiation therapy is contraindicated on tumors located on trunk and extremities. These areas are subjected to greater trauma and tension than skin on the head and neck, and they are more prone to break down and ulcerate as a result of the atrophy and poor vascularity of irradiated tissue.

Management of Symptomatic Benign Prostatic Hyperplasia (BPH)

Behavior modifications to decrease lower urinary tract symptoms:

avoiding fluids prior to bedtime or before going out

reducing consumption of mild diuretics such as caffeine and alcohol limiting the use of salt and spices maintaining voiding schedules

Alpha-adrenergic antagonists decrease urinary symptoms in most males with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin and doxazosin. The American Urology Association (AUA) Guidelines Committee believes that all four medications are equally effective.

5-alpha-reductase inhibitors are more effective in males with larger prostates. Their effect on preventing acute urinary retention and reduction in need of surgery require long term treatment for more than a year. There are two 5-alpha-reductase inhibitors approved in the United States: finasteride and dutasteride.

In males with severe symptoms, those with a large prostate (>40 g), and in those who do not get an adequate response to maximal dose monotherapy with an alpha-adrenergic antagonist, combination treatment with an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor may be desirable.

In general, if bladder outlet obstruction is creating a risk for upper urinary tract injury such as hydronephrosis, renal insufficiency, or lower urinary tract injury such as urinary retention, recurrent urinary tract infection, or bladder decompensation; surgical intervention is needed. Surgery also should be considered if combination treatment fails to improve symptoms of BPH.

Benign Prostatic Hyperplasia (BPH) Treatment

BPH treatment focuses on relieving symptoms.

Instruct patients to:

Give yourself time to urinate completely.

Do not drink alcohol, drinks with caffeine in them (coffee, tea, colas), or other fluids in the evening. Do not take decongestants like Sudafed.

Do not take antihistamines like Benadryl.

For moderate to severe symptoms (AUA score of 8 or more), prescribe alpha blockers to cause the muscles of the urethra to relax. Side effects of alpha blockers: feeling tired or sleepy.


Clinical manifestation

Lower urinary tract symptoms (LUTS)

hesitancy urgency weak urinary stream

These symptoms typically appear slowly and progressively over a period of years.

Other conditions with similar symptoms

urinary tract and prostatic infections medication side effects, overactive bladder prostate cancer

Complications of untreated BPH

urinary tract infections acute urinary retention obstructive nephropathy

When evaluating for BPH, perform:

Digital rectal exam should be done to assess prostate size and consistency and to detect nodules, indurations, and asymmetry — all of which raise suspicion for malignancy. Rectal sphincter tone should also be determined.

Urinalysis should be done to detect urinary tract infection and blood, which could indicate bladder cancer or stones. Serum prostate specific antigen (PSA) level determination is recommended for males with a life expectancy of 10 years or longer and for those whose PSA level may influence BPH treatment. This includes most patients who are considering treatment with a 5-alpha reductase inhibitor. This practice should be distinguished from recommendations about utilizing the PSA as a screening test. In this case, the patient actually has symptoms that could represent prostate cancer; screening is only for asymptomatic individuals.

Clinical Reasoning

Differential of Oval-Shaped, Erythematous 18 x 16 mm Patch

Most Likely Diagnoses


Eczema can appear erythematous and is often pruritic.

Typically occurs behind the ears and on flexural areas.

Squamous cell


Squamous cell carcinomas are scaly and erythematous but, unlike actinic keratoses, tend have a raised base.

Lesions may take the form of a patch, plaque, or nodule, sometimes with scaling and/or an ulcerated center.

Borders are often irregular and bleed easily.

Unlike basal cell carcinomas, the heaped-up edges of a squamous cell carcinoma are fleshy rather than clear in appearance.

Squamous cell carcinoma comprises 20 percent of all cases of skin cancer.

History of significant sun exposure is a risk factor for squamous cell carcinoma and it typically occurs on areas of the skin that have been exposed to sunlight for many years, such as the extremities or face.

Actinic keratoses

Actinic keratoses are scaly keratotic patches that are often more easily felt than seen.

A history of significant sun exposure is a risk factor for actinic keratosis.

Basal cell carcinomas

Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and/or telangiectasia.

Usually there is no associated itching or change in skin color.

Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere.

Comprising 60 percent of primary skin cancers, basal cell carcinomas are typically slow-growing lesions that invade local tissues but rarely metastasize.

A long history of sun exposure is a risk factor for basal cell carcinoma.

In the United States, the median age at diagnosis of melanoma is 53, with about one in four new cases


occurring in those younger than 40 years.

Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern for melanoma.

Although it comprises only 1 percent of all skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths.

The lesions of superficial spreading melanoma are dark brown or black.

Slowly spreading irregular outline in the initial phase. Some areas may be a lighter shade.

Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds with minor trauma.

More than half of melanoma in females occurs on the legs.

Sun exposure is a risk factor for melanoma; studies have shown that the prevalence of melanoma increases with proximity to the equator.

Persons with skin types that burns easily and tans with difficulty, and with red or blond hair, and freckles are at higher risk.

Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk.

Fungal infection

Can have acute, erythematous appearance.

Less Likely Diagnoses


Psoriasis is usually bilateral and involves extensor surfaces of elbows and knees.

Although psoriasis can present with involvement in patches, it usually plaque-like, with scaly, elevated lesions.

Lichen planus

Lichen planus typically presents as 2-10 mm flat-topped papules with an irregular, angulated border (polygonal papules) that are commonly located on the flexor surface of wrists and and on the legs immediately above the ankles.

Most of the times, the lesions are multiple.

Lichen planus is common in middle age.

Seborrheic keratoses

Elevated hyperpigmented lesions with a well-circumscribed border, stuck-on appearance, and variable tanbrown-black color and are most commonly located on the face and trunk.


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