OTHER




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)
IDSA 2014 recommendations for infected animal bites
IDSA 2014 recommendations for infected human bites
IDSA 2014 recommendations for prophylactic antibiotic therapy in dog and cat bites
  • 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
IDSA 2014 recommendations boils and abscesses
  • Simple (no systemic signs of infection, no cellulitis)
    • Incision and drainage only
  • Moderate (systemic signs of infection, cellulitis)

IDSA 2014 recommendations for recurrent boils and abscesses
  • 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
  • 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
  • Bactrim vs placebo after I&D of abscess, NEJM 2016
    630 patients with skin abscess were randomized to bactrim 320/1600 twice a day for 7 days or placebo after abscess I&D.
    PRIMARY OUTCOME: Clinical cure at 7 - 14 days after treatment ended
    RESULTS: Clinical cure was seen in 80.5% of the bactrim group and 73.6% of the placebo group (p=0.005) [PubMed abstract]

Infection Treatment Other
Cat scratch disease IDSA 2014 recommendations cat scratch disease
  • Azithromycin
    • Patients > 45kg - 500 mg on day 1 followed by 250 mg for 4 additional days ($)
    • Patients < 45kg - 10 mg/kg on day 1 and 5 mg/kg for 4 more days ($)
  • 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)
IDSA 2014 recommendations for outpatient cellulitis treatment (non-MRSA)
    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) ($)

IDSA 2014 recommendations for outpatient cellulitis treatment (MRSA coverage)
    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 ($)
  • 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
  • Clinda vs bactrim - a study in the NEJM (2015) randomized 524 patients with cellulitis to treatment with clindamycin (300 mg three times a day X 10 days) or sulfamethoxazole-trimethoprim DS (twice a day for 10 days). MRSA was cultured in 32% of the patients. RESULTS: There was no significant difference in the cure rates between the two treatments (Clindamycin - 80%, SMX-TMP - 78%). MRSA status did not affect cure rates. [PubMed abstract]

Infection Treatment Other
Diabetic foot ulcer IDSA 2014 suggested empiric treatment for mild infections
  • NOTE: IDSA makes no specific dosing recommendations. Dosing presented here based on PI and/or IDSA cellulitis recs.

IDSA 2014 suggested empiric treatment for moderate infections
  • 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)
IDSA 2007 recommendations
  • Antivirals - most patients
    • Acyclovir 800 mg five times a day for 7 - 10 days ($)
    • Famciclovir 500 mg three times a day for 7 days ($-$$)
    • Valacyclovir 1000 mg three times a day for 7 days ($)
  • Corticosteroids - select patients
    • Prednisone 60 mg a day for 7 days, then 30 mg a day for 7 days, then 15 mg a day for 7 days, then discontinue (IDSA regimen, others may suffice) ($)
  • Pain control
    • Gabapentin (Neurontin®) - Starting - 300 mg on day 1, then 300 mg twice a day on day 2, then 300 mg three times a day on day 3; Maintenance - 900 - 1800 mg a day ($)
    • Pregabalin (Lyrica®) - Starting - 150 mg a day given in two or three divided doses; Maintenance - 150 - 300 mg a day ($$$$)
    • Nortriptyline (Pamelor®) - Starting - 25 mg at bedtime; increase by 25 mg daily every 2 - 3 days; max - 150 mg/day ($)
    • Opioids and tramadol
  • Lifetime risk of herpes zoster for patients who live to 85 years is 50%
  • Zoster vaccine cuts risk of shingles by roughly 50%. Vaccine also reduces the risk of PHN.
  • 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 [13,14]

Infection Treatment Other
Hidradenitis suppurativa Treatments
  • Hidradenitis suppurativa (HS) is marked by recurrent painful nodules that progress to chronic purulent discharge, scarring, and sinus formation
  • The axillary (armpits) and inguinal (groin) areas are commonly affected.
  • Risk factors include female sex, smoking, family history, and obesity
  • Randomized trials evaluating HS treatment are limited to nonexistent
  • No consensus guidelines for HS treatment have been published [16,17]

Infection Treatment Other
Impetigo IDSA 2014 recommendations for impetigo
    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 ($-$$)
    • Erythromycin - 40 mg/kg/day (max 1000 mg/day) given in 3–4 divided doses for 7 days ($$$$)
    • Mupirocin - apply ointment twice a day for 5 days ($)
    • Retapamulin - apply ointment twice a day for 5 days ($$$-$$$$)
Other
    Pediatric
    • Benzathine penicillin G (Bicillin L-A®)
      • ≤ 6kg - 225 mg (300,000 units) IM given as a one time dose
      • 6.1 - 10kg - 337.5 mg (450,000 units) IM given as a one time dose
      • 10.1 - 15kg - 450 mg (600,000 units) IM given as a one time dose
      • 15.1 - 20kg - 675 mg (900,000 units) IM given as a one time dose
      • > 20kg - 900 mg (1,200,000 units) IM given as a one time dose ($$-$$$)
    • 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
  • 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. ($$$$)
  • Tavaborole 5% (Kerydin®) - Apply once daily to affected nail(s) for 48 weeks. Cover entire nail and under the tip. FDA-approved for toenails only. ($$$$)
  • 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 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
Postexposure
prophylaxis for HIV,
Hepatitis B, and Hepatitis C
Occupational exposure
  • The University of California at San Francisco provides free, rapid expert consultation and advice on management of occupational HIV, Hepatitis C, and Hepatitis B exposure. They can be contacted by phone or email - UCSF website.

Nonoccupational exposure to HIV (IV drug abuse, sex, etc.)
  • CDC recommendations from 2005
    • If ≤ 72 hours since exposure, treat for 28 days with one of the following:
      • NNRTI-based regimen:
        Efavirenz 600 mg daily at bedtime; +
        Lamivudine (150 mg twice daily or 300 mg once daily) OR emtricitabine (200 mg once daily); +
        Zidovudine (200 mg three times daily or 300 mg twice daily) OR tenofovir (300 mg once daily)

      • Protease inhibitor-based regimen
        Lopinavir/ritonavir (Kaletra®) 3 tablets twice daily; +
        Lamivudine (150 mg twice daily or 300 mg once daily) OR emtricitabine (200 mg once daily); +
        Zidovudine (200 mg three times daily or 300 mg twice daily)

    • Complete CDC recs are available here - CDC website

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®) - 200mcg/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 following study - PubMed abstract
    • Weight 10 - 20kg - 62.5 mg daily for 4 weeks
    • Weight 20 - 40kg - 125 mg daily for 4 weeks
    • Weight > 40kg - 250 mg daily for 4 weeks ($)
  • Terbinafine granules
  • NOTE: Terbinafine granules are FDA-approved for children ≥ 4 years old
    • Weight < 25kg - 125 mg daily for 6 weeks
    • Weight 25 - 35kg - 187.5 mg daily for 6 weeks
    • Weight > 35kg - 250 mg daily for 6 weeks
  • Griseofulvin microsize
    • 20 - 25 mg/kg once daily for 6 - 8 weeks ($-$$$)
  • Griseofulvin ultramicrosize
    • 10 - 15 mg/kg once daily for 6 - 8 weeks ($$-$$$$)
  • Itraconazole
    • 5 mg/kg once daily for 2 - 4 weeks ($$$$)
    • Alternative:
      • Weight < 20 kg - 50 mg once daily for 4 weeks
      • Weight > 20 kg - 100 mg once daily for 4 weeks
      • Based on PubMed 11069511
  • Fluconazole
    • Alternative:

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 (see PubMed abstract)
      • Weight 10 - 20kg - 62.5 mg daily for 2 - 4 weeks
      • Weight 20 - 40kg - 125 mg daily for 2 - 4 weeks
      • Weight > 40kg - 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 (see PubMed abstract)
      • Weight 10 - 20kg - 62.5 mg daily for 2 - 4 weeks
      • Weight 20 - 40kg - 125 mg daily for 2 - 4 weeks
      • Weight > 40kg - 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 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]