There are a number of topical agents used in treatment of superficial cutaneous mycoses, oropharyngeal candidiasis, and vulvovaginal candidiasis. The superficial cutaneous mycoses that respond to topical therapy include the localized infections of hair, nails, and epidermis due to the dermatophytes and Candida. While some of these topical agents are polyenes, azoles (imidazoles) or allylamines, others are of distinct chemical classes.
In addition to those used for treatment of cutaneous, oropharyngeal, and vulvovaginal fungal infections, an ophthalmic topical antifungal agent, pimaricin (natamycin) is also available. Pimaricin is a polyene used in treatment of keratomycosis. Its commercial formulation is an ophthalmic suspension available in USA (Natacyn™, Alcon Laboratories, Inc., Forthworth, TX). Following ophthalmic installation, pimaricin adheres to the corneal ulcer base very effectively and exerts favorable therapeutic efficacy. Pimaricin suspension is usually applied in concentrations of 2.5 to 5%. It may be used alone or in combination with topical or systemic azole preparations or amphotericin B, depending on the severity of the infection [462, 1139, 1866, 1963, 2223].
Pimaricin is effective mostly against moulds. While it is usually effective in vitro and in vivo against particularly Fusarium spp., clinical failure or in vitro resistance of this fungus against pimaricin has also been reported [861, 1899, 1973]. Similarly, its in vitro or in vivo activity in keratomycosis due to Pseudallescheria boydii may also vary [777, 1541, 1973].
Topical azoles are usually preferred in treatment of keratomycosis due to yeasts. Nevertheless, there are reports on favorable activity of pimaricin in cases due to yeasts as well. Concommittant therapy with pimaricin ointment and local amphotericin B injection to anterior chamber has been effective in keratomycosis due to Candida tropicalis .
Pimaricin is effective also against Exserohilum rostratum, Acremonium spp., and Cunninghamella spp.[73, 1973]. On the other hand, Aspergillus spp. , and dermatophytes are frequently resistant to pimaricin [1399, 1866].
The major characteristics of the currently available topical antifungal agents that are in general effective in treatment of superficial cutaneous mycoses and/or candidiasis are shown below [85, 899, 1274, 1744, 1886, 2057, 2092].
Agents which have limited applications and/or unclear efficacy are not included in the list. For more detailed information about clinical use of these agents, refer to the page on related infection. For detailed information on systemic use of polyenes, azoles, and allylamines, refer to the related pages.
|Chemical Class Generic Name||Trade names||Manufacturers||Formulations||Indications|
|Amphotericin B||C, L, O||CC|
|Nystatin||C, O, OS, P, VT, T||CC, OC, VC|
|Clotrimazole||C, L, S, T, VT||D, CC, OC, VC|
|Ketoconazole||C, S||D, CC|
|Miconazole||C, L, S, P, VS||D, CC, VC|
|Oxiconazole||C, L||D, CC|
|Sulconazole||C, S||D, CC|
|Terazole 3||Ortho McNeil|
|Terazole 7||Ortho McNeil|
|Allylamines and other non-azole ergosterol synthesis inhibitors|
|Naftifine||C, O, P||D|
|Ciclopirox olamine||Loprox||Hoechst Marion Roussel||C, L||D, CC|
|Tolnaftate||C, S, P||D|
|Undecylenate||C, P, O, S||D|
C: cream L: lotion
NL: nail lacquer O: ointment
OS: oral suspension P: powder
S: solution/spray VO: vaginal ointment
VS: vaginal suppository T: troche VT: vaginal tablet
D: dermatophytosis CC: cutaneous candidiasis
OC: oropharyngeal candidiasis VC: vulvovaginal candidiasis