Topical Antifungal Agents
Introduction to Pediatric Topical Antifungal Agents
Key Principles
- Topical antifungal medications are first-line treatments for superficial fungal infections in children
- Selection depends on: causative organism, anatomical site, extent of infection, and patient age
- Treatment duration typically ranges from 2-6 weeks depending on infection site and severity
Common Indications
- Tinea corporis (ringworm)
- Tinea pedis (athlete's foot)
- Tinea capitis (scalp ringworm) - as adjunct to oral therapy
- Candidal diaper dermatitis
- Pityriasis versicolor
Azole Antifungals
Mechanism of Action
Inhibits ergosterol synthesis by blocking 14α-demethylase, disrupting fungal cell membrane integrity
Common Agents
- Clotrimazole (1%)
- Age: ≥2 years
- Application: 2-3 times daily
- Duration: 2-4 weeks
- Excellent safety profile
- Miconazole (2%)
- Age: All ages
- Application: 2 times daily
- Particularly effective for candidal infections
- Available OTC
- Ketoconazole (2%)
- Age: ≥2 years
- Application: Once daily
- Excellent for seborrheic dermatitis
- Good penetration into hair follicles
Allylamines
Mechanism of Action
Inhibits squalene epoxidase, blocking ergosterol synthesis at an earlier step than azoles
Primary Agent: Terbinafine
- Formulations
- Cream 1%
- Solution 1%
- Gel 1%
- Clinical Use
- Age: ≥12 years
- Application: 1-2 times daily
- Duration: 1-2 weeks for most infections
- Particularly effective against dermatophytes
- Advantages
- Shorter treatment duration than azoles
- Fungicidal (versus fungistatic)
- High cure rates for tinea pedis/corporis
Other Antifungal Agents
Ciclopirox
- Properties
- Broad-spectrum activity
- Anti-inflammatory properties
- Available as cream, gel, suspension
- Clinical Use
- Age: ≥10 years
- Application: Twice daily
- Excellent for seborrheic dermatitis
Nystatin
- Properties
- Specific for Candida species
- Limited systemic absorption
- Clinical Use
- Age: Any age
- Primary indication: Candidal diaper dermatitis
- Application: 3-4 times daily with diaper changes
Clinical Applications
Treatment Selection Guidelines
- Tinea Corporis/Cruris
- First-line: Azoles or allylamines
- Duration: 2-4 weeks
- Continue 1 week after clinical clearance
- Candidal Diaper Dermatitis
- First-line: Nystatin or miconazole
- Add low-potency steroid if inflammation severe
- Duration: 7-10 days
- Tinea Capitis
- Requires systemic therapy
- Topical therapy as adjunct only
- Selenium sulfide or ketoconazole shampoo to reduce spores
Monitoring and Follow-up
- Assess response at 1-2 weeks
- Consider culture if no improvement
- Monitor for secondary bacterial infection
- Document extent of infection and response
