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Topical Antifungals

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Topical Antifungals

Topical antifungals are used for treating a variety of conditions affecting the skin, nails, mouth, ears, and more. As fungal infections of these areas are common, topical antifungals are some of the most frequently prescribed compounded medications. There are several antifungals that have been available commercially for many years. Nystatin, for example, was first discovered in the 1950s. However the dosage strengths and methods of administration can often be limited. A compounding pharmacy is able to take these well-proven antifungals and make them into new formulations for modern treatment protocols.

Topical vs. Systemic Antifungals

Antifungal medications may be given orally or intravenously to systemically treat a fungal infection. If a condition can be treated topically, however, this is usually the first course of action. Topical medications produce fewer side effects than systemic medications in most cases. There are a wide range of antifungals available in topical formulations such as creams, mouthwashes, nasal sprays (for topical sinus therapy), and more. Many of these are effective at treating common fungal infections. Only when topical treatment fails or the infection is more invasive are systemic antifungals recommended.

Topical Antifungals

Here is a list of antifungals that have been used to topically treat infections:

Amorolfine Griseofulvin
Amphotericin B Itraconazole
Benzylamine Ketoconazole
Butenafine Miconazole
Butoconazole Naftifine
Carbolfuchsin Nystatin
Ciclopirox Oxiconazole
Clioquinol Sulconazole
Clotrimazole Terbinafine
Econazole Terconazole
Fluconazole Tioconazole
Fluconazole Tolnaftate
Gentian violet

In our compounding pharmacy we focus on formulations for topical antifungals. For systemic antifungals we generally recommend finding a commercially available product as opposed to a compounded formulation.

Superficial Fungal Infections

There are a few categories of dermatological conditions that are commonly treated with topical antifungals. These categories are based on the type of fungus and the area of infection. Fungal infections of the skin, hair, nails, and mucous membranes may be caused by dermatophytes or yeast.

Dermatophytes: A broad term to describe a large group of fungal species that can cause infections. Most of these infections have the word tinea (“worm”) in their name, however this is based on the appearance of some infections and not because there actually are worms involved. These infections tend to be less invasive than yeast infections, and rarely spread beyond the surface of the skin and nails. Dermatophyte infections are not painful but can be uncomfortable and unsightly. Some examples of dermatophyte infections include jock itch, ringworm, and athlete’s foot.

Microscopic view of Candida species.

Yeast: This type of fungal infection can infect the skin and nails as well as the genitals and mucous membranes of the mouth. The infection can become more invasive than dermatophytoses.  The most common type of yeast infection is from yeast in the genus Candida. The risk of systemic infection with Candida is higher than with dermatophytes. The risk of a systemic infection is more significant in individuals with weakened immune systems such as those suffering from HIV/AIDS. Candida yeasts are actually prevalent in the body, even on healthy individuals. It is usually something that throws off the balance of bacteria and fungi in the body that allows it to grow and become an infection. That is why Candida infections often occur after a treatment course with antibiotics.

Infections and Treatment Selection

Candidiasis of the mouth (oral thrush): The most frequently prescribed oral treatment is nystatin suspension. Nystatin suspension is swished around in the mouth then can be swallowed. An antifungal may also be made into a troche that dissolves in the mouth.

Vulvovaginal candidiasis: Miconazole, butoconazole, terconazole, and tioconazole are examples of antifungals used for treating vulvovaginal candidiasis. For all types of candidiasis, antifungals that are in the class called imidazoles are generally most effective.

Dermatophytoses: Numerous antifungals may be used for treating dermatophytoses. These include terbinafine, clotrimazole, ketoconazole, miconazole, clioquinol, tolnaftate, and more. Mild dermatophytoses infections may be treated with undecylenic acid, which is available over-the-counter in strengths up to 25%.

Certain drugs like terbinafine are effective for treating dermatophytoses but not for Candida infections. Choosing the appropriate class of antifungal based on the type of infection is important. However within classes of antifungals there is not always consensus as to which is the most effective. The medication that works well for one individual may not work for every patient the same way.  

Compounding Topical Antifungal Treatments

Many of the antifungals listed above have been available for many years and the original patents have long since expired. There are numerous manufactured, commercially available versions of these drugs available. However there is not much activity in the research and development of new formulations. There are also formulations that have been used by doctors for a long time that are no longer manufactured. A compounding pharmacy is able to provide topical antifungal formulations that are not commercially available.

Another situation where a compounding pharmacy can help is when manufacturers experience delays that result in drug shortages. Recently this happened with nystatin oral suspension. Until the manufacturers begin shipping nystatin oral suspension again, our compounding pharmacy is able to make a similar formulation in our pharmacy. Compounding pharmacies obtain bulk active pharmaceutical ingredients (APIs) that can be made into customized formulations. Unlike a manufactured product, each prescription is made-to-order in the pharmacy.

Topical Sinus Therapy

In recent years there has been increased interest in topical treatment of fungal infections of the nasal passages and sinuses as it pertains to environmentally acquired illnesses. Naturopaths and integrative physicians are treating patients with conditions related to mold exposure. Mold is a type of fungus that is common in water-damaged buildings. Exposure to airborne mold spores can cause health problems for susceptible individuals.

Sometimes referred to as biotoxin illness or Chronic Inflammatory Response Syndrome (CIRS), mold-related conditions are often treated using a step-by-step protocol. The Shoemaker protocol is by far the most popular and involves the use of nasal sprays, chelating agents, and supplements. The Brewer protocol is another protocol for treating mold-related illness and calls for intranasal administration of a topical antifungal like Amphotericin B.

There are no commercially available preparations that include these types of antifungal and chelating ingredients in a nasal spray. That is why compounding pharmacies have become an essential resource for patients with these conditions. Antifungals that are often compounded for topical sinus therapy include amphotericin b, itraconazole, and nystatin.

Other Topical Treatments for Fungal Infections

Topical treatment of a fungal infection can involve other types of medication or treatment besides antifungal drugs. There are treatments available over the counter and by prescription for treating dry skin, itching, redness, and other symptoms of a skin infection. Proper hygiene is an essential part of treating many types of superficial fungal infections. Compounding pharmacies can provide a full range of customized formulations for managing fungal infections and related skin problems.

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