SKIN INFECTIONS

PRICING INFO



Infection Treatment Other
Acne

Mild acne (mainly small red spots and/or comedones)


Moderate acne (red inflamed lesions, back acne)


Severe acne (nodular, scarring)

  • Acne is caused by follicular hyperkeratinization, colonization with Propionibacterium acnes, sebum production, and complex inflammatory mechanisms
  • There are few comparative studies in the treatment of acne, therefore most recommendations are not evidence-based. The treatment algorithm presented here is derived from the AAP 2013 recommendations and the AAD 2016 guidelines.
  • Acne regimens typically require 6 - 8 weeks to achieve their full effect
  • If beneficial response to oral antibiotics is seen then continue for 3 - 4 months. Antibiotic use should be limited to prevent bacterial resistance.
  • Oral antibiotics should be prescribed with a retinoid +/- benzoyl peroxide. Oral antibiotic monotherapy is discouraged.
  • Upon stopping oral antibiotics, a 2.5% benzoyl peroxide cream washout for 2 weeks to eradicate resistant Propionibacterium acnes may be beneficial. Topical antibiotics may then be tried. If acne worsens, then repeat course of oral antibiotics. [1,2,27]

Infection Treatment Other
Bites
(animal and human)

Infected ANIMAL bites (IDSA 2014)


Infected HUMAN bites (IDSA 2014)


Cat and dog bite prophylactic therapy (IDSA 2014)

  • Prophylactic therapy is recommended in the following patients:
    • Immunocompromised
    • Asplenic
    • Advanced liver disease
    • Preexisting or resultant edema of the affected area
    • Moderate to severe injuries, especially to the hand or face
    • Injuries that may have penetrated the periosteum or joint capsule
  • Therapy should be for 3 - 5 days
  • Rabies prophylaxis should be considered in appropriate cases
  • About 16% of dog bite wounds become infected
  • Purulent bite wounds are often polymicrobial (mixed aerobes and anaerobes). Nonpurulent wounds commonly yield staphylococci and streptococci.
  • Tetanus vaccine should be given to patients who have not had one within 10 years [3]

Infection Treatment Other
Boils and
abscesses
Boils and abscesses (IDSA 2014)
  • Simple (no systemic signs of infection, no cellulitis)
    • Incision and drainage only
  • Moderate (systemic signs of infection, cellulitis)

Recurrent boils and abscesses (IDSA 2014)
  • Five day decolonization regimen that includes the following:
    • Intranasal mupirocin two times a day for 5 days each month
    • Daily chlorhexidine or dilute bleach (1/4 - 1/2 cup per full bath) washes
    • Daily washing of towels, sheets, clothes, combs, and razors
Other
  • Systemic signs of infection include fever, tachycardia, tachypnea, and elevated white count
  • Evidence for the effectiveness of decolonization regimens is weak
  • Children with recurrent abscesses should be evaluated for neutrophil disorders [3]

Studies
  • Clindamycin vs Bactrim vs Placebo for 10 days after I&D in patients with small abscesses, NEJM (2017) - Randomized, controlled trial (N=786) in patients with small skin abscesses (≤ 5 cm). Results: Clindamycin - 83%, Bactrim - 82%, Placebo - 69% (p<0.001) [PMID 28657870]
  • Bactrim vs Placebo for 7 days after I&D in patients with abscesses, NEJM (2016) - Randomized, controlled trial (N=630) in patients with skin abscesses. Results: Bactrim - 81%, Placebo - 74% (p=0.005) [PMID 26962903]

Infection Treatment Other
Cat scratch disease

Cat scratch disease (IDSA 2014)

  • Azithromycin
    • Patients > 45 kg - 500 mg on day 1 followed by 250 mg for 4 additional days ($)
    • Patients < 45 kg - 10 mg/kg on day 1 and 5 mg/kg for 4 more days ($)
  • Bartonella henselae causes most cat scratch disease
  • A papule or pustule develops from 3 - 30 days following a scratch or bite
  • Lymph nodes surrounding the inoculation enlarge about 3 weeks after the scratch
  • The benefit of antibiotics in cat scratch disease is questionable and mostly unproven
  • In most people, the disease resolves without treatment
  • Cutaneous bacillary angiomatosis may develop in immunocompromised patients [3,4]

Infection Treatment Other
Cellulitis

(skin infection)
Non-MRSA (IDSA 2014)
    Pediatric
    • Cephalexin - 25 - 50 mg/kg/day (max 2000 mg/day) given in 4 divided doses for 5 - 10 days ($)
    • Dicloxacillin - 25 - 50 mg/kg/day (max 2000 mg/day) given in 4 divided doses for 5 - 10 days ($)
    Adults
    • Cephalexin - 500 mg four times a day for 5 - 10 days ($)
    • Dicloxacillin - 500 mg four times a day for 5 - 10 days ($)
    • Penicillin VK - 250 - 500 mg four times a day for 5 - 10 days (streptococcal infections only) ($)

MRSA coverage (IDSA 2014)
    Pediatric
    • Clindamycin - 30 - 40 mg/kg/day (max 1800 mg/day) given in 3 divided doses for 5 - 10 days ($$-$$$)
    • Linezolid - 10 mg/kg/dose given twice a day for 5 - 10 days ($$-$$$)
    • Sulfamethoxazole-trimethoprim - 8 – 12 mg/kg/day (based on trimethoprim component) given in 2 divided doses for 5 - 10 days ($)
Other
  • Recommended duration of treatment is 5 days, but it should be extended if the infection has not improved in this time period
  • Patients with systemic signs of infection (e.g. fever, tachycardia, tachypnea, elevated white count) should receive intravenous antibiotics
  • Immunocompromised patients should receive intravenous antibiotics [3]

Studies
  • Cephalexin + Bactrim (CB) vs Cephalexin alone (C) for 7 days, JAMA (2017) - Randomized, controlled trial (N=496) in patients diagnosed with cellulitis in the ER. Results: No significant difference (CB - 84%, C - 86%, p=0.50) [PMID 28535235]
  • Clindamycin vs Bactrim for 10 days, NEJM (2015) - Randomized, controlled trial (N=524) in patients with cellulitis, abscesses > 5 cm in diameter, or both. Results: No significant difference (Clindamycin - 80%, Bactrim - 78%, p=0.52). MRSA status did not affect cure rates. [PMID 25785967]

Infection Treatment Other
Diabetic foot ulcer

Diabetic foot ulcer, empiric treatment for mild infections (IDSA 2014)

  • NOTE: IDSA makes no specific dosing recommendations. Dosing presented here based on PI and/or IDSA cellulitis recs.

Diabetic foot ulcer, empiric treatment for moderate infections (IDSA 2014)

  • NOTE: IDSA makes no specific dosing recommendations. Dosing presented here based on PI and/or IDSA cellulitis recs
    • Non-MRSA
    • MRSA coverage
      • Linezolid - 400 - 600 mg twice daily for 7 - 14 days ($$-$$$)
  • *Clindamycin was not listed under MRSA coverage, but it was noted to be "Usually active against community-associated MRSA"
  • Only infected wounds should be cultured. Cultures should be from deep tissue after debridement and not from swab specimens.
  • Uninfected wounds should not be treated with antibiotics
  • All patients should have foot X-ray. MRI may be necessary in patients where abscess or osteomyelitis is suspected.
  • Wounds should be debrided, and pressure should be off-loaded from the wound
  • Skin equivalents, growth factors, granulocyte colony-stimulating factors, hyperbaric oxygen therapy, and negative pressure wound therapy have not been proven to improve wound healing [5]

Infection Treatment Other
Herpes zoster

Varicella zoster
shingles
Herpes zoster (IDSA 2007)
  • Antivirals - most patients
    • Acyclovir 800 mg five times a day for 7 - 10 days ($)
    • Famciclovir 500 mg three times a day for 7 days ($-$$)
    • Valacyclovir 1000 mg three times a day for 7 days ($)
  • Corticosteroids - select patients
    • Prednisone 60 mg a day for 7 days, then 30 mg a day for 7 days, then 15 mg a day for 7 days, then discontinue (IDSA regimen, others may suffice) ($)
  • Pain control
  • Herpes zoster is caused by varicella zoster virus (VZV). VZV infection typically occurs in childhood (chickenpox), and it's estimated that 95% of the world's population has been infected.
  • For patients infected with varicella, the lifetime risk of shingles is 10 - 20%. For patients who live to be 85 years, the lifetime risk is 50%.
  • Postherpetic neuralgia (PHN) is defined as pain persisting for ≥ 90 days after onset of rash. PHN develops in 10 - 50% of patients with herpes zoster (risk increase with age)
  • Antivirals decrease pain and speed resolution of rash, but have not been proven to decrease risk of PHN
  • Steroids may benefit acute pain. They have not been proven to reduce the risk of PHN.
  • Most zoster trials have excluded patients with symptoms > 72 hours, but this does not mean treatments do not benefit patients with symptoms > 72 hours
  • Patients with visual symptoms should be referred to ophthalmology
  • There are two shingles vaccines - Shingrix and Zostavax. Shingrix cuts the risk of shingles by roughly 90% for at least 4 years. Zostavax cuts the risk by about 50%. The vaccines also reduce the risk of PHN should shingles occur.
  • The lifetime risk of recurrent shingles in immunocompetent individuals is 5% [13,14,28]

Infection Treatment Other
Hidradenitis suppurativa
  • Hidradenitis suppurativa (HS) is marked by recurrent painful, pruritic nodules in the apocrine-gland regions that progress to chronic purulent discharge, scarring, and sinus formation
  • The pathology of HS involves perifollicular lymphocyte infiltration of the hair follicles followed by sebaceous gland lost. As HS progresses, local increases in interleukin (IL)-1, tumor necrosis factor (TNF), IL-17, S100A8, S100A9, caspase-1, and IL-10 lead to the migration of neutrophils, monocytes, and mast cells into affected tissue. Chronic inflammation causes tissue destruction and scarring.
  • The axillary (armpits) and inguinal (groin) areas are most commonly affected.
  • Risk factors include female sex, smoking, family history, and obesity
  • No consensus guidelines for HS treatment have been published [16,17,29]

Infection Treatment Other
Impetigo

Impetigo (IDSA 2014)

    Pediatric
    • Amoxicillin-clavulanate - 25 mg/kg/day (max 1750 mg/day) of the amoxicillin component given in 2 divided doses for 7 days ($)
    • Cephalexin - 25 – 50 mg/kg/day (max 1000 mg/day) given in 3–4 divided doses for 7 days ($)
    • Clindamycin - 20 mg/kg/day (max 1600 mg/day) given in 3 divided doses for 7 days ($-$$)
    • Erythromycin - 40 mg/kg/day (max 1000 mg/day) given in 3–4 divided doses for 7 days ($$$$)
    • Mupirocin - apply ointment twice a day for 5 days ($)
    • Retapamulin - apply ointment twice a day for 5 days ($$$-$$$$)
    Adults

Impetigo (other)

    Pediatric
    • Benzathine penicillin G (Bicillin L-A®)
      • ≤ 6kg - 225 mg (300,000 units) IM given as a one time dose
      • 6.1 - 10 kg - 337.5 mg (450,000 units) IM given as a one time dose
      • 10.1 - 15 kg - 450 mg (600,000 units) IM given as a one time dose
      • 15.1 - 20 kg - 675 mg (900,000 units) IM given as a one time dose
      • > 20 kg - 900 mg (1,200,000 units) IM given as a one time dose ($$-$$$)
    • Sulfamethoxazole-trimethoprim
      • Once daily - 8 mg/kg/day (trimethoprim component) (max 320 mg/day) given once daily for 5 days
      • Twice daily - 8 mg/kg/day (trimethoprim component) (max 320 mg/day) given in two divided doses for 3 days ($)
  • Caused by both Staphylococcus aureus and/or β-hemolytic Streptococcus (Strep pyogenes)
  • Oral therapy recommended for patients with numerous lesions
  • Impetigo can be bullous or nonbullous
  • If MRSA is suspected, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) is recommended (see Cellulitis)

Infection Treatment Other
Lice

(head and body)
(pediculosis)

Topical

    Over-the-counter (OTC)
    • Permethrin 1% lotion (Nix®) - Apply to damp hair and scalp. Leave on for 10 minutes then rinse with water. Repeat in 7 days if necessary. Approved for patients ≥ 2 months. ($)
    • Pyrethrins 0.3% / piperonyl butoxide 4% shampoo (Rid®) - Apply to dry hair and scalp. Leave on for 10 minutes then wash with water and shampoo. Repeat in 7 - 10 days. Approved for patients ≥ 2 years. ($)
    Prescription
    • Benzyl alcohol 5% lotion (Ulesfia®) - apply to dry hair to completely saturate the scalp and hair; leave on for 10 minutes, then thoroughly rinse off with water. Repeat application after 7 days. The Ulesfia® PI gives recommendations for number of bottles needed depending on hair length - Ulesfia® PI. Approved for children ≥ 6 months. ($$-$$$$)
    • Malathion 0.5% lotion (Ovide®) - Apply lotion on dry hair in amount just sufficient to thoroughly wet the hair and scalp. Allow hair to dry naturally. After 8 - 12 hours, shampoo hair. Rinse and use fine tooth comb. Repeat in 7 - 9 days if necessary. Not approved for infants. ($$-$$$)
    • Spinosad 0.9% (Natroba®) - Apply to dry scalp and hair. Leave on for 10 minutes then rinse with warm water. May repeat in 7 days. Approved for patients ≥ 4 years. ($$$-$$$$)
    • Ivermectin lotion (Sklice®) - Apply to dry hair and scalp. Leave on for 10 minutes then rinse with water. Approved for patients ≥ 6 months. ($$$$)

Systemic (oral) therapy

  • Ivermectin (Stromectol®) - Ivermectin 400 mcg/kg/dose with one dose given on Day 1 and Day 8. Treatment based on one study [PMID 20220184]. Patients ≥ 2 years and weigh at least 15kg. ($)
  • Most common symptom is itching. Itching may not develop for 4 - 6 weeks after first infestation.
  • Adult louse is about the size of a sesame seed and is usually tan to grayish-white in color
  • Diagnosis is made by observation of louse or eggs. Lice are commonly found behind the ears and on the back of the neck. Eggs are found 1 cm from the scalp and are pigmented to match the color of the hair. Empty egg casings called "nits" are white and can be found throughout the hair. Nits may remain in the hair for months after successful treatment.
  • Lice are typically passed through direct contact. Passage through contaminated fomites is uncommon.
  • Presence of nits (empty louse eggs) does not indicate active infection. Nits are often confused with dandruff and other debris. Nits and eggs are firmly affixed to the hair shaft where dandruff is not.
  • Children with head lice should not be kept out of school, because lice do not pass easily within classrooms
  • Family members of infested patients should be examined and treated if live lice are found
  • Lice typically survive for less than a day away from the scalp. Only items that have been in contact with the head of the infected person in the 24 - 48 hours before treatment should be considered for cleaning. Washing or drying items at ≥ 130° F should be sufficient. Furniture and carpeting can be vacuumed.
  • Treatment of pubic lice is similar to head lice [12, 21]

Infection Treatment Other
Onychomycosis

(fungal nail infection)

Systemic (oral) therapy

  • Toenails
    • Terbinafine (Lamisil®) - 250 mg once daily for 12 weeks ($)
    • Itraconazole (Sporanox®) - 200 mg once daily for 12 weeks; OR 200 mg twice daily for 1 week a month for 3 consecutive months ($$$$)
    • Griseofulvin
      • Griseofulvin microsize - 500 mg once daily for 6 months ($$$$)
      • Griseofulvin ultramicrosize - 375 mg twice daily for 6 months ($$$$)
  • Fingernails
    • Terbinafine (Lamisil®) - 250 mg once daily for 6 weeks ($)
    • Itraconazole (Sporanox®) - 200 mg twice daily for 1 week a month for 2 consecutive months ($$$$)
    • Griseofulvin
      • Griseofulvin microsize - 500 mg once daily for 4 months ($$$$)
      • Griseofulvin ultramicrosize - 375 mg twice daily for 4 months ($$$$)

Topical

  • Ciclopirox 8% (Penlac®) - Apply once daily at bedtime to affected nail(s) for 48 weeks. Cover entire nail and under the tip. FDA-approved for toenails and fingernails. ($, one 6.6 ml bottle)
  • Efinaconazole 10% (Jublia®) - Apply once daily to affected nail(s) for 48 weeks. When applying, ensure that the toenail, the toenail folds, toenail bed, hyponychium, and the undersurface of the toenail plate, are completely covered. FDA-approved for toenails only. ($$$$)
  • Tavaborole 5% (Kerydin®) - Apply once daily to affected nail(s) for 48 weeks. Cover entire nail and under the tip. FDA-approved for toenails only. ($$$$)
Other
  • Nail findings include subungual hyperkeratosis (excessive proliferation and scaling of the skin under the nail), onycholysis (detachment of nail plate from its bed), nail thickening and crumbling, and yellow and/or white discoloration. Tinea pedis is also present in up to a third of patients.
  • Onychomycosis is the most common cause of nail dystrophies, but other etiologies are present in 50% of patients; therefore, the diagnosis should be confirmed before treatment. [26]

    • Diagnostic testing includes:
      • PAS staining - sensitivity 82%
      • KOH stain of nail scraping - sensitivity 48%
      • Fungal culture - sensitivity 53% [25]

  • Typically caused by Trichophyton species
  • Topical treatments should be reserved for cases where < 50% of the nail is involved, ≤ 4 nails affected, and nail thickness < 3 mm [26]
  • Full effect of treatment not seen for > 12 months [26]
  • Relapse occurs in about 25 - 30% of patients [9]

Treatment success


  • Mycological cure - negative culture and negative KOH
  • Normal nail - mycological cure and completely normal-appearing nail
  • Reference - Manufacturer PI
Treatment Mycological cure Normal nail
Terbinafine 70% 38%
Itraconazole 54% 14%
Ciclopirox 36% 9%
Efinaconazole 55% 18%
Tavaborole 31% 7%

Infection Treatment Other
Pseudofolliculitis barbae

Treatments (mostly unvalidated in clinical trials)

  • Pseudofolliculitis barbae (PB) develops after shaving when cut hairs curl inwards back into the skin. The ingrown hair produces an inflammatory reaction that may lead to infection, scarring, hyperpigmentation, and keloids.
  • Predominantly seen in patients of African descent
  • The face, axilla, and pubic areas are most commonly affected
  • Acne keloidalis nuchae is a related condition that occurs on the occipital scalp (back of the head)
  • No consensus treatment recommendations have been published [19]
  • Randomized trials of PB treatments are almost nonexistent

Infection Treatment Other
Scabies

First-line

  • Permethrin 5% cream (Elimite®) - thoroughly massage cream into the skin from the head to the soles of the feet. Leave on for 8 - 14 hours (preferably overnight), then wash. Infants should be treated on the scalp, temple, and forehead. May repeat in 8 - 15 days if necessary. ($-$$)

Other

  • Ivermectin (Stromectol®) - 200 mcg/kg/dose given one time and then repeated in 8 - 15 days (NOTE: 1000mcg = 1 mg). Take with food. ($)

NOTE: Ivermectin is approved for patients ≥ 5 years but has been used in trials in patients ≥ 2 years who weigh at least 15kg (see Lice)
Body weight
(kg)
Number of 3 mg tablets
of ivermectin
15 - 24 1
25 - 35 2
36 - 50 3
51 - 65 4
66 - 79 5
≥ 80 200mcg/kg
  • Scabies is caused by the mite, Sarcoptes scabiei variety hominis
  • Typically passed through direct skin-to-skin contact. Passage through fomites (linens, clothing) is uncommon.
  • Symptoms include generalized itching that is worse at night. Red papules develop at sites of infection. Wavy lines may be seen where the mite burrows.
  • Lesions are typically found on the interdigital finger webs and flexor surfaces of the wrists. Elbows, armpits, buttocks, and genitalia are also involved, as are the breast areola in women.
  • Bed linen and clothing should be washed in hot water. Shoes and other nonwashable items should be sealed in an airtight plastic bag for 3 days.
  • Skin scrapings have very low diagnostic sensitivity
  • In the first few days after initiating therapy, itching may worsen and/or persist. This is not a sign of treatment failure.
  • One treatment is generally sufficient. Need for repeat treatment is rare.
  • Close contacts of infected individuals may need to be treated [10,11]
  • CDC website with info on scabies

Infection Treatment Other
Tinea capitis

Pediatric (Infants)


Pediatric (≥ 1 year)

  • Terbinafine tablets
  • NOTE: Tablet dosing based on one small study [PMID 12195561]
    • Weight 10 - 20 kg - 62.5 mg daily for 4 weeks
    • Weight 20 - 40 kg - 125 mg daily for 4 weeks
    • Weight > 40 kg - 250 mg daily for 4 weeks ($)
  • Terbinafine granules
  • NOTE: Terbinafine granules are FDA-approved for children ≥ 4 years old
    • Weight < 25 kg - 125 mg daily for 6 weeks
    • Weight 25 - 35 kg - 187.5 mg daily for 6 weeks
    • Weight > 35 kg - 250 mg daily for 6 weeks
  • Griseofulvin microsize
    • 20 - 25 mg/kg once daily for 6 - 8 weeks ($-$$$)
  • Griseofulvin ultramicrosize
    • 10 - 15 mg/kg once daily for 6 - 8 weeks ($$-$$$$)
  • Itraconazole
    • 5 mg/kg once daily for 2 - 4 weeks ($$$$)
    • Alternative:
      • Weight < 20 kg - 50 mg once daily for 4 weeks
      • Weight > 20 kg - 100 mg once daily for 4 weeks
      • [Based on PMID 11069511]
  • Fluconazole
    • 6 mg/kg once daily for 2 - 3 weeks ($-$$)
    • [Based on PMID 10468805]
    • Alternative:
      • 8 mg/kg once weekly for 8 - 12 weeks ($-$$)
      • [Based on PMID 10809856]

Adult

  • Topical treatments are not effective against tinea capitis
  • Symptoms of tinea capitis include flaking, broken-off hairs, alopecia, occipital lymphadenopathy, pustules and kerions, and circular grey patches
  • In U.S., 90 percent of cases are caused by Trichophyton tonsurans, and fewer than 5 percent are caused by Microsporum species
  • Terbinafine is not effective against Microsporum species
  • Griseofulvin and azoles are effective against Microsporum species
  • Combs and brushes should be sterilized
  • Lab monitoring (CBC, ALT, AST) during griseofulvin treatment does not appear to be necessary in healthy patients
  • Lab monitoring during terbinafine therapy (CBC, AST, ALT) of < 6 weeks duration is likely unnecessary in healthy patients [6,7,22]

Infection Treatment Other
Tinea corporis

(ringworm)

Pediatric

  • First-line
    • Terbinafine (Lamisil®) topical - topical terbinafine 1% applied once or twice daily ($)
    • Topical azoles (e.g. clotrimazole, miconazole) - apply twice daily ($)
  • Extensive and/or resistant cases
    • Terbinafine tablets
    • NOTE: Dosing based on study in children ≥ 2 years with tinea capitis [PMID 12195561]
      • Weight 10 - 20 kg - 62.5 mg daily for 2 - 4 weeks
      • Weight 20 - 40 kg - 125 mg daily for 2 - 4 weeks
      • Weight > 40 kg - 250 mg daily for 2 - 4 weeks ($)
    • Fluconazole (Diflucan®) - 6 mg/kg (max 150 mg) once weekly for 2 - 4 weeks ($)
    • Griseofulvin
      • Griseofulvin microsize - 10 mg/kg once daily (max 500 mg/day) for 2 - 4 weeks ($-$$)
      • Griseofulvin ultramicrosize - 7.25 mg/kg once daily (max 375 mg/day) for 2 - 4 weeks ($$$-$$$$)

Adult

  • Rash is pruritic and erythematous with a scaly, raised edge that may contain pustules or vesicles. Rash spreads centrifugally and results in annular patches of varying sizes.
  • Commonly caused by Trichophyton species
  • Topical medications are preferred [7,8]

Infection Treatment Other
Tinea cruris
(jock itch)

Tinea pedis
(athlete's foot)

Tinea manuum
(hand infection)

Pediatric

  • First-line
    • Terbinafine (Lamisil®) topical - topical terbinafine 1% applied once or twice daily ($)
    • Topical azole (e.g. clotrimazole, miconazole) - apply twice daily ($)
  • Extensive and/or resistant cases
    • Terbinafine tablets
    • NOTE: Dosing based on study in children ≥ 2 years with tinea capitis [PMID 12195561]
      • Weight 10 - 20 kg - 62.5 mg daily for 2 - 4 weeks
      • Weight 20 - 40 kg - 125 mg daily for 2 - 4 weeks
      • Weight > 40 kg - 250 mg daily for 2 - 4 weeks ($)
    • Fluconazole (Diflucan®) - 6 mg/kg (max 150 mg) once weekly for 2 - 4 weeks ($)
    • Griseofulvin
      • Griseofulvin microsize - 10 mg/kg once daily (max 500 mg/day) for 2 - 8 weeks ($-$$)
      • Griseofulvin ultramicrosize - 7.25 mg/kg once daily (max 375 mg/day) for 2 - 8 weeks ($$$-$$$$)

Adult

  • Tinea cruris and pedis
    • Rash is pruritic and erythematous with a scaly, raised edge that may contain pustules or vesicles. Rash spreads centrifugally and results in annular patches of varying sizes.
    • Commonly caused by Trichophyton species
    • Tinea cruris and tinea pedis often occur together. Both should be treated or recurrence is likely.
    • Talc powders (e.g. Gold Bond®) absorb moisture and may help prevent recurrences
    • Patients should be instructed to avoid tight-fitting clothes and to keep feet dry [7,8]
  • Tinea manuum
    • Tinea manuum typically causes dry, scaly palms. Typically unilateral, but may be bilateral.
    • Commonly caused by Trichophyton species [7]

Infection Treatment Other
Tinea versicolor

(pityriasis versicolor)

Topical

  • Selenium sulfide 2.5% lotion - apply to affected area and lather with a small amount of water. Leave on skin for 10 minutes then rinse off. Perform once daily for 7 days, then on the first and third day of the month for 6 months (2.5% strength is prescription-only) ($)
  • Ketoconazole 2% shampoo (Nizoral®) - Apply the shampoo to the damp skin of the affected area and a wide margin surrounding this area. Lather, leave in place for 5 minutes, and then rinse off with water. Perform once daily for up to 3 days. (2% strength is prescription-only) ($)
  • Zinc pyrithione shampoo (Head and Shoulders®, etc.) - Apply to affected area and leave in place for 5 minutes. Perform daily for 2 weeks. ($)
  • Terbinafine (Lamisil®) - topical terbinafine applied twice daily for one week ($) NOTE: Oral terbinafine is not effective [23]

Systemic (oral) therapy

  • Infection is marked by irregularly shaped, scaly patches of hypo- or hyperpigmented skin
  • Affected areas: back (most common), chest, neck, and face
  • Recurrence after treatment is common - up to 80% after 2 years
  • Caused by Malassezia yeast species [8]
  • Topical terbinafine (Lamisil®) is effective, but oral terbinafine is not [23]