Fungal Skin Infection ( Ringworm ) - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  --
Last review: 15/03/2016  
Next review: 05/12/2020  
Clinical Guideline
CURRENT 
ID: 2261 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Fungal Skin Infection (Ringworm)

Illness

Comments

Preferred option

Alternative

Fungal Skin Infection(Ringworm)
CKS -body/groin
CKS -foot
CKS -scalp

Terbinafine electronic Medicines Compendium information on Terbinafine is fungicial 1, so treatment time shorter than with fungistatic imidazoles.
If Candida possible, use imidazole 1
If intractable: send skin scrapings 2C
If infection confirmed, use oral Terbinafine electronic Medicines Compendium information on Terbinafine/Itraconazole electronic Medicines Compendium information on Itraconazole3B+ 
Scalp: discuss with specialist

Terbinafine electronic Medicines Compendium information on Terbinafine 
Topical BD
1-2 weeks 4A+

One of the Imidazole creams
Topical BD 4A+
OR (athlete’s foot only)
Undecanoate cream (Mycota) 4B+BDTopical BD
1-2 wks after healing (i.e. 4-6wks) 4A+

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if intractable.  
  5. Limit prescribing over the telephone to exceptional cases.
  6. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Please refer to BNF for further information.

Provenance

Record: 2261
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Fungal Skin Infection (Ringworm)

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.


Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.


Study design

Recommendation
grade

Good recent systematic review of studies

A+

One or more rigorous studies, not combined

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Formal combination of expert opinion

C

Informal opinion, other information

D

Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

Dermatophyte infection – skin

  1. ABPI Medicines Compendium. Lamisil AT 1% cream. 2009. Datapharm Communications Ltd. http://www.medicines.org.uk/EMC/searchresults.aspx?term=Lamisil&searchtype=QuickSearch Accessed 23.09.14. RATIONALE: Terbinafine cream is not licensed for the treatment of Candida infection.
  2. Public Health England Fungal skin and nail infections: diagnosis & laboratory investigation. Quick reference guide for primary care for consultation and local adaptation. 2009 https://www.gov.uk/government/publications/fungal-skin-and-nail-infections-diagnosis-and-laboratory-investigation Accessed 22.09.14. RATIONALE: The recommendation to send skin scrapings to confirm the diagnosis before starting oral treatment is based on expert opinion and clinical experience.
  3. Bell-Syer SEM, Hart R, Crawford F, Torgerson DJ, Tyrrell W, Russel I. Oral treatments for fungal infection of the foot. Cochrane Database of Systematic Reviews. 2002. Issue 2 www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003584/frame.html Accessed 23.09.14. RATIONALE:Terbinafine: one RCT (n=41) found that oral terbinafine, 250mg a day for 6 weeks, was more effective than placebo for treating athlete’s foot. At 8 weeks, 65% of the terbinafine group were cured, compared with none of the placebo group (relative risk [RR] of cure with terbinafine 25, 95% CI 2 to 384). Itraconazole: one RCT (n=77) found that oral itraconazole, 400mg a day for 1 week, was more effective than placebo. At 9 weeks, 55% of the itraconazole group were cured compared with 8% of the placebo group (RR of cure with itraconazole 7, 95% CI 2 to 20). Terbinafine vs itraconazole: Pooled data from three RCTs (n=222) found no difference in cure rates between oral terbinafine 250mg a day for 2 weeks (76% cured), and itraconazole 100mg a day for 4 weeks (71% cured); risk difference 5%, 95% CI –6 to +27
  4. Crawford F and Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database of Systematic Reviews 2007. Issue 3. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001434/frame.html Accessed 23.09.14. RATIONALE: Terbinafine and imidazoles: pooled data (8 RCTs; n=962) found little difference between allylamines (e.g. terbinafine for 1-2 weeks) and imidazoles (for 4-6 weeks) at 2 weeks after baseline. But at 6 weeks after baseline, there was a relative reduction in treatment failure with allylamines compared with imidazoles (RR 0.63, 95% CI 0.42 to 0.94). Treatment with an imidazole for 4-6weeks reduced the risk of treatment failure by 60% compared with placebo at 6-weeks (Risk Ratio 0.40, 95% CI 0.35 to 0.46; n=1235). Treatment with an allylamine for 1-4 weeks reduced the risk of treatment failure by 67% compared with placebo at 6 weeks (Risk Ratio 0.33, 95% CI 0.24 to 0.44; n=1116) Undecanoates: this systematic review identified two RCTs of undecanoates compared with placebo (n=283). There was a 71% relative reduction in the risk of treatment failure at 6 weeks with 4 weeks treatment with undecanoates compared with placebo (Risk Ratio 0.29, 95% CI 0.12 to 0.70).
  5. Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia. 2008 Nov-Dec;166(5-6):353-67. RATIONALE: Topical medications applied once or twice daily are the primary treatment indicated for tinea corporis/cruris, and tinea pedis/manuum. Use of oral antifungals may be practical where the tinea involvement is extensive or chronic, or where application of a topical is not feasible. For tinea unguium (onychomycosis) and tinea capitis, oral therapies are the primary treatments recommended. Topical amorolfine and ciclopirox formulations have been approved for use in milder onychomycosis cases, and their role in the treatment of the different clinical forms of onychomycosis is currently being defined. Relapse of infection remains a problem, particularly with tinea pedis/unguium. Appropriate follow-up duration and education of patients on proper foot hygiene are also important components in providing effective therapy.

Document history

LHP version 1.0

Related information

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