Cutaneous Fungal Infections: Ringworm, Athlete's Foot, Jock Itch, Cutaneous Candidiasis, Onychomycosis Flashcards
What are the 2 common types of Cutaneous Fungal Infection? Give brief pathophys.
Dermatophytes (referred to as Tinea)
* Tinea corporis –ringworm of the body
* Tinea cruris –“jock itch”
* Tinea pedis –athlete’s foot
Yeast
* Cutaneous Candidiasis - Occurs in intertriginous areas-groin, axillae, interdigital
spaces, under the breast
* Pityriasis versicolor (previously classified as a “tinea”)
Tinea corporis -
ringworm of the body
Tinea cruris –
“jock itch”
Tinea pedis -
athlete’s foot
What are the Goals of Therapy for CFI’s?
- Eradicate existing infection –inhibit fungal growth (CURE the infection)
- Provide symptomatic relief (e.g. itching, burning and other discomforts)
- Stop infection from spreading
- Stop complications (such as secondary bacterial infection)
- Avoid recurrences
What are the non-rx tx’s?
- Clotrimazole 1% OR Miconazole 2%
- Tolnaftate 1%
- Undecylenic Acid
- Nystatin 100 000 units/g
What is the classification, mech of action & adverse effects, & avail. as of Clotrimazole 1% OR Miconazole 2%?
- Classification: azoles
- Mechanism of Action:
- FungiSTATIC, concentration may lead to fungicidal effects
- Blocks production of ergosterol, triglycerides and phospholipids by fungi
- Effective in treatment of dermatophyte and yeast infections
- Adverse Effects: local skin irritation (erythema, pruritus, rash, stinging) and rarely hypersensitivity (gen. well tolerated)
- Nonprescription preparations currently available in Canada:
- Clotrimazole 1% (Canesten®+ generics) CREAM
- Miconazole nitrate 2% (Micatin® + generics) CREAM, SPRAY & POWDER
What is the classification, mech of action & adverse effects, & avail. as of Tolnaftate 1%?
- Classification: thiocarbamate
- Narrow spectrum antifungal:
- Effective in treatment of dermatophyte infections
- Ineffective in treatment of cutaneous candidiasis
(GOOD FOR PREVENTION, RATHER THAN Tx) - Adverse Effects: Local skin irritation
- Available as cream, aerosol, topical powder
What is the classification, mech of action & adverse effects, & avail. as of Undecylenic Acid?
- Effective in treatment of dermatophyte infections
- INeffective in treatment of cutaneous candidiasis
(LOWEST EFFICACY - LOW CURE RATE)
- Adverse Effects: Itching, burning, stinging
- Available as gel, liquid, cream, ointment, powder or spray
What is the classification, mech of action & adverse effects, & avail. as of Nystatin 100 000 units/g?
- Classification: Polyene
- Fungistatic or fungicidal, binds to sterols in cell membrane
- Effective for candidal infections
- INeffective in treatment of dermatophyte infections
- Available as cream or ointment
- Adverse Effects: Rarely irritation
What are the rx products?
- Topical Ciclopirox
- Terbinafine
- Ketoconazole
What is the classification, mech of action & adverse effects, & avail. as of Topical Ciclopirox rx?
- Classification: hydroxypyridone
- Broad spectrum agent: effective against dermatophytes and yeast
- Fungicidal in vitro, exact mechanism of action unknown
- Adverse Effects: pruritus, burning, stinging, skin sensitivity, contact dermatitis
- Available: Loprox® 1% cream or lotion, Stieprox®–1.5% shampoo
(MORE EFFECTIVE THAN CLOTRIMAZOLE/MICONAZOLE)
What is the classification, mech of action & adverse effects, & avail. as of Terbinafine rx?
- Classification: allylamine
- Broad Spectrum FungiCIDAL Agent (WILL DECREASE Tx DURATION)
- Topical: fungicidal to dermatophytes but only fungistatic to Candida
- Adverse Effects:
- For topical treatment: redness, irritation/burning, contact dermatitis
- After terbinafine is topically applied, has a half-life of 14 to 35 hours and < 5% is absorbed 15
- Available formulations:
- Oral tablet, cream or spray
What is the classification, mech of action & adverse effects, & avail. as of Ketoconazole rx?
- Classification: azole
- Broad-spectrum: Effective in treatment of dermatophyte and yeast infections
- Prescription products include cream, oral tablets
** Note: shampoo is available without a prescription (unsched)
What is imp. to note about Ketoconazole rx?
Oral dosage – risk of potentially fatal liver toxicity and therefore should only be used for serious or life threatening systemic fungal infections
What is Dermatophytes?
generally refers to the various Tinea infections
*long, thin hyphae –> apply 1-2 cm beyond due to the hyphae
What do Dermatophytes require, affect & gen. spread by?
Requires dead keratin for growth/proliferation
* Keratin is found in the cornified human epidermis-stratum corneum;
* No mucosal involvement due to lack of keratin
* Do not infect living tissue
- “Affect top layer of the EPIDERMIS, HAIR, NAILS & SKIN”
Generally spread by:
* Direct contact through: person to person contact or person to fomite
* May also be spread by: soil to human or animal to human
What are the most common dermatophytes PATHOGENs in skin infections?
- Trichophyton
- Microsporum
- Epidermophyton
What are the signs/sx’s of Tinea Corporis - Ringworm of the body (type of Dermatophyte condition)?
caused by a dermatophyte - NOT a worm
Affected areas
* Often occurs on skin of the trunk, face, and extremities. (in summer)
* Annular (ring-like), circular, erythematous, flat, scaly patches
* Reddened, raised edges with vesicles and with MARGINS that CLEARly transition from abnormal to normal skin; inner area -clear
(INFLAMMED AREA OF SKIN W/ CLEAR CENTRE)
* Itching is variable depending on patient
What are the differential diagnosis’ of Tinea Corporis (Ringworm)?
- Psoriasis (TC is fine scale, Pso. is thicker & silver)
- Contact dermatitis
- Seborrheic dermatitis
- Nummular eczema
- Lyme disease
- Pityriasis roscea
When would you refer a Tinea Corporis pt?
- Experiencing tinea capitis, tinea barbae or tinea manuum …
- Infection with unclear etiology
- Immunocompromised
- Responding poorly or are intolerant to topical therapy
- Extensive, disabling, multifocal or inflammatory disease
What are the non-pharm suggestions for Tinea Corporis (Ringworm)?
- Skin hygiene (clean) and dry
- Avoid excessive irritation by towels
- Loose fitting cotton clothes (breathable)
- Wash clothes and linens separately from non-infected individuals laundry
What are the TOPICAL antifungal non-rx options for Tinea Corporis (Ringworm)?
- CLOTRIMAZOLE or MICONAZOLE are among the 1st line of treatment
- Apply to affected area BID for 4 WEEKS (morning & night) - 1-2 cm beyond as well
- TOLNAFTATE is less effective than azole options
- UNDECYLENIC ACID lacks comparative evidence of efficacy compared to other options, may be helpful
What are the rx topical options for Tinea Corporis (Ringworm)?
ketoconazole, terbinafine, ciclopirox
- Note: treatment duration less with terbinafine (once daily for 1 WEEK)
What are the affected areas of Tinea Cruris “Jock Itch”?
Affected areas
* Bilateral upper inner thigh
* Groin/pubic
* Gluteal (anal) cleft–less common
* Scrotum and penis are NOT usually affected
- Occurs more commonly in men during summer
- Often CONCURRENT with tinea pedis
What are the signs/sx’s of Tinea Cruris “Jock Itch”?
- Well marginated with defined, raised border
- Erthymatous ring shaped
- Quite pruritic
- Lesions are red-brown, scaly
- Small vesicles may be seen at the margin (little fluid-filled bumps)
What are the risk factors of Tinea Cruris “Jock Itch”?
- Warm & humid condition
- Wearing wet or tight clothes
- Immunocompromised individuals (examples: diabetes, HIV infection,
chemotherapy) - Genetics
What is the differential diagnosis of Tinea Cruris “Jock Itch”?
Pubic Lice
When would you refer a pt for Tinea Crutis ?
?
What are the topical antifungal tx’s for Tinea Cruris “Jock Itch”?
Non-prescription 1st line treatment options are imidazoles:
* Clotrimazole or miconazole
* BID for 2 to 4 WEEKS
* Apply to affected area (for 1 week after)
Prescription topical options: terbinafine, ketoconazole, ciclopirox
* Note: treatment duration less with terbinafine (once daily for 1 WEEK)
Other non-prescription options:
* Tolnaftate less effective than azole options
* Undecylenic acid lacks comparative evidence of efficacy compared to other options, may be helpful
- Treat tinea pedis if also present
What are the non-pharm suggestions for Tinea Cruris “Jock Itch”?
- Loose fitting cotton clothes
- Powder to reduce moisture (not cornstarch)
- baby powder can be used
- Avoid excessive irritation with towels
- Wash clothes and linens separately from non-infected individuals
What is the Prevalence of Tinea Pedis (athlete’s foot)?
- Common, will affect up to 70% of population
- Most common in TEENDAGE and ADULT MALES, NOT common in children (referral if < 16 yoa)
What is the Transmission of Tinea Pedis (athlete’s foot)?
- Direct: contact with infected individual
- Indirect: contact with contaminated surface
- Autoinoculation: spread to other parts of the body (groin or underarms)
What are the risk factors of Tinea Pedis?
- Warmth and dampness creating moist conditions
- Occlusive foot wear
- Diabetes
- Immunosuppression
- Peripheral vascular disease
- Occluded skin
- Poor hygiene
- Obesity
- Trauma
What are the signs/sx’s of Tinea Pedis?
- Dependent of morphologic variant
- Blisters
- Pruritus
- Stinging/burning sensation
- Redness and inflammation
- Macerated skin
- May be odourous
- Severe symptoms: pain, peeling, cracking and/or bleeding
What are 4 subtypes of Tinea Pedis?
- Chronic Interdigital
- Vesicular
- Moccasin-type
- Acute Ulcerative Disease
What is Chronic Interdigital - Tinea Pedis subtype?
** Most common type of infection –fissures, scaling, maceration –generally self-
treatable.
** Occurs between the 4th/5th and/or 3rd/4th toes (b/c overcrowded in shoe most)
* Moist and warmth conditions contribute to worsening
What is Vesicular - Tinea Pedis subtype?
- Small vesicles on the instep of one or both feet
- Some scales between toe webs
- Most prevalent during the summer months
What is Moccasin-type - Tinea Pedis subtype?
- Chronic
- Diffuse scaling with mild inflammation on the soles of the feet –generally found on both feet
- Often involves nails (refer)
What is Acute Ulcerative Disease - Tinea Pedis subtype?
- Macerated, weepy lesions on soles of foot
- Hyperkeratosis and strong odour often present
- May involve 2o infection with gram negative bacteria (refer)
When would you refer for Tinea Pedis (Athlete’s Foot)?
- Pt at risk of delayed wound healing ( ie: has diabetes or cancer or PVD or is immunocompromised or elderly or malnourished)
- Child less than 16 years old
- Lesion: Weeping and severely inflamed or oozing pus or eczematous
or painful - Toenail affected
What are the non-pharm suggestions for Tinea Pedis?
- Emphasize proper footcare/hygiene
- Wash feet with soap and water daily
- Dry between toes and dry feet thoroughly
- Avoid occlusive and tight-fitting footwear
- Change to dry socks 2-3 times daily (if feet sweat) if not: change socks daily. Wear socks made of natural, absorbent materials or synthetic blends (avoid nylon socks)
- Change or alternate shoes. Allow shoes to dry before worn again. (if mandatory, ensure show is dry prior to wearing)
- Avoid being barefoot in public areas
- Do not share personal items (example: towels)
What is the topical antifungal tx of Tinea Pedis?
Non-prescription 1st line treatment options: clotrimazole or miconazole
* BID for up to 4 WEEKS (including 1 to 2 weeks after skin has cleared to prevent recurrences)
* Apply to affected area
- Efficacy of other options tolnaftate and undecylenic acid?
- Tea tree oil (natural product) – no evidence of efficacy
What RELEVANT 2 can Pharmacist’s prescribe for Tinea Pedis ONLY?
- Ciclopirox
- Terbinafine
Ambulatory Ailment Pharmacist Prescribing options:
Treatment of Tinea Pedis ONLY
Prescription options:
* Ciclopirox:
* Apply to affected area twice daily for 4 weeks
- Terbinafine (cream or spray):
- Durationoftherapy:
- 1 week
- Up to 4 weeks (shorter timeframes of treatment (1 to 2 weeks) will have continued improvement for 2 to 4 weeks after treatment ended
- Has a higher cure rate versus other topical antifungals
What is the importance of Tinea Pedis tx?
- Can lead to ulceration
- Complications:
- Secondary bacterial infection
What is Onychomycosis?
- Cause of about 50% of nail issues
- Infection rate for toenails is approximately 6.4% of the Canadian population, *incidence increases with age
- More frequently affects toenails than fingernails
- Quality of life may be affected
What is the pathophys of Onychomycosis?
- Most commonly due to dermatophytes (Trichophyton, Epidermophyton and Microsporum), infrequently due to yeasts, and rarely due to nondermatophyte moulds
- Chronic infection, may progress to additional nails or skin sites
What are 3 subtypes of onychomycosis? What are the signs and symptoms associated with each subtype?
- Distal subungual onychomycosis (DLSO) is the most common (90% of OM cases) and is characterized by nail thickening with yellowish-white discoloration and crumbling yellow debris. Onycholysis, or separation of the nail plate from the nail bed, usually occurs.
- Superficial white onychomycosis (SWO) (up to 7% of OM cases) more commonly affects children than adults and is characterized by chalky, white patches on the top surface of the nail plate, as the dermatophyte invades the nail plate directly from above and does not involve the nail bed (the entire nail plate can be involved where the nail becomes roughened and crumbly).
- Proximal subungual onychomycosis (PSO) (up to 6% of OM cases) is characterized by white discoloration at the proximal nail fold beneath the nail bed; the infecting dermatophyte enters through the proximal nail fold and penetrates the newly formed nail plate, then migrates distally. It is most common in immunosuppressed patients and can be a marker for AIDS.
What are the Risk Factors for dermatophyte onychomycosis?
- Increased Age (> 40 years old)
- Family history and genetics
- Immunodeficiency
- Co-morbid conditions such as: diabetes mellitus, psoriasis, peripheral vascular disease
- Smoking
- Tinea pedis
- Frequent nail trauma
- Sport participation (example: swimming)
What are the differential diagnosis of Fungal Nail Infections?
- Psoriasis
- Eczema
- Onychogryphosis (senile)
- Trauma
- Lichen planus
- Yellow-nail syndrome
- Drugs, e.g. tetracyclines, cancer chemo
- Malignant melanoma affecting the nail matrix or nail bed
- Squamous cell carcinoma
- Bacterial paronychia
What is req’d for Onychomycosis?
- Referral required
- Diagnosis confirmed through microscopy, biopsy or culture. Often combination of culture and microscopy used.
What are appropriate non- pharmacologic suggestions that can be provided for Onychomycosis?
Wearing footwear and socks that minimize humidity
Drying feet and interdigital spaces thoroughly after washing
Using footwear to avoid fungal transmission from shared public spaces (i.e., avoid being barefoot) such as swimming pools and nail salons
Keeping nails clean and cut short
Avoiding sharing nail clippers or footwear
Preventing further trauma to toenails; wearing nonrestrictive footwear or fitted orthotics may be helpful
Discarding old, infected footwear
Wearing rubber gloves to protect fingernails if hands are immersed in water for long periods of time
Applying emollients on cracked skin to reduce further entry points for fungus
Controlling chronic health conditions, such as diabetes mellitus or peripheral vascular disease
What is the Onychomycosis Tx?
- Treatment choice must consider the individual
- Treatment endpoints: mycological cure or clinical cure/efficacy
- Toenails generally need longer duration of treatments compared to fingernails
Pharmacological Treatment Options for Onychomycosis?
Oral versus topical options:
* Oral therapy has higher efficacy (ABLE TO GET IN NAIL BED)
* Note: formulations such as creams, ointments, powders and solutions do not pass through the nail plate
* Topical nail lacquer delivers the medication by evaporating and producing an occlusive film that contains a high concentration of the medication
What is the Onychomycosis Prescription Oral Tx EFFECTIVENESS?
- Terbinafine > itraconazole»_space; fluconazole
- Oral terbinafine:
- Drug of choice for dermatophyte onychomycosis, as is the most effective treatment, tolerable
and less drug interactions versus other oral options - Mycological cure rate: 70%, Clinical cure rate: 38%3
- MOA: Fungicidal (blocks biosynthesis of ergosterol by inhibiting squalene epoxidase)
- Treatment duration:
- Toenails: 12 to 24 weeks
- Fingernails: 6 to 12 weeks
- Risk of severe/fatal liver injury (rare), therefore REQUIRES CLOSE MONITORING including baseline and mid-treatment liver function (aminotransferase level)
- Drug Interactions: Is a CYP2D6 inhibitor
What is the Onychomycosis Prescription Topical Treatment Options?
- Ciclopirox 8% nail lacquer
- Requires daily application for 48 weeks (with debridement)
- 33% mycological cure rate and 7% cure rate
- Adverse effects: local skin irritation, temporary alteration to nail appearance * $49/6g
- Efinaconazole 10% topical solution:
- Drop(s) applied once daily for 48 weeks, no debridement, no removal required
- Mycological cure rate of 54% and clinical cure rate of 17%
- Adverse effects: irritation of skin around application site (vesicles and
dermatitis) - $80/6ml17
What are the Non-prescription options for Onychomycosis?
- Propylene glycol-urea-lactic acid
- Once daily application up to 24 weeks
- Mycological cure rate about 27% (in those with ≤ 50% affected nail)
- Adverse effects: local skin irritation, pain, onycholysis, and frequent whitening and opacity of the nail
- Must wash solution from unaffected skin and hands
- Other options: Vicks VapoRub®, vinegar, tea tree oil
- Not recommended due to lack of evidence
What is the Onychomycosis Monitoring?
- Fungal cure may take months, normal appearance of nail may take up to 18 months (but may never return to normal)
- High recurrence rate, approximately 20% of patients will have infection again within 2 years of treatment
What are other types of tinea infections refer for tx?
- Tinea Capitis– on scalp (affects hair follicles and skin). Common type of lesions appears as a patch of itchy, scaly skin, hair loss occurs: breaks off at scalp and with debris in follicle may look like black dots. Occurs most often in children.
- Tinea Barbae –infection of beard, results in erythematous areas with papules or pustules and hair loss, scaly patches on one side of the face
(REQ. Rx)
What is Pityriasis Versicolor?
- Infection of the stratum corneum by Malassezia
- Upper trunk common area of occurrence (SEBACEOUS GLANDS)
- Highest incidence in warm, humid environments, adolescents and young adults
- REFER IF CAUSATION UNCLEAR, patients may require further assessment
YEAST INFECTION
What are the signs/sx’s of Pityriasis Versicolor?
- Change in cutaneous pigmentation, lesions may hypopigmented or hyperpigmented
- Most common: white to reddish-brown areas
- Lesions occur on back, chest and upper arms (where seb. glands occur)
- Individual lesions are small but can coalesce to form larger patches
- Scratching leads to slight scale forming
- Generally only a COSMETIC ISSUE
- Itching rare
- NOT contagious
- NOT a result of poor hygiene
What are the non-pharm suggestions for Pityriasis Versicolor?
- Reduce moist environments
- Avoid oil on affected skin
What are the non-rx tx options for Pityriasis Versicolor?
Ketoconazole 2% shampoo (used like a lotion)
* Applied to affected area, leave on for 5 minutes then wash off
* one time application or once daily for 3 day
* Efficacy: clinical cure rate of approximately 70%
Topical azole creams (clotrimazole or miconazole): apply bid for 2 weeks
* Similar efficacy to ketoconazole
Selenium sulfide 2.5 % suspension
* Apply to affected area and lather with a little water, leave on skin for 10 minutes, then wash off. Use once daily for 7 to 14 days.
* Prevention: use once or twice a month for prevention (reduces recurrence to 15%)
* Traditionally used, efficacy similar to azole options, may be more cost effective for larger
affected areas
- NOTE: recurrence is common (60 to 80%), are other preventive therapy options such as zinc pyrithione shampoo, etc
What are the rx tx options for Pityriasis Versicolor?
- Topical ciclopirox
- Efficacy similar to topical ketoconazole
- Topical ketoconazole cream formulation
- Topical terbinafine
- Less evidence of efficacy
What is the cause of Cutaneous Candidiasis?
- Most frequently due to Candida albicans leading to an intertrigo infection
- Infections occur when pH of skin is increased, other normal flora (bacteria) is removed due to antibiotics, increased glucose in sweat and/or moist, warm conditions
(ANYWHERE ON BODY WHERE THERE’S A SKIN FOLD)
What are the risk factors for Cutaneous Candidiasis?
- Diabetes mellitus
- Malignancy
- Obesity
- Tropical environment
- Medical conditions: neutropenia, HIV infection, psoriasis, contact dermatitis
- Use of corticosteroid, antibiotic, cytotoxic or immunosuppression medications
- Individuals who have hands in water excessively can experience candida paronychia
What are the signs/sx’s for Cutaneous Candidiasis?
- Affected areas: where moisture can gather, skin folds, examples:
- Groin
- Axillae (armpit)
- Gluteal region
- Under breasts
- Skin folds (i.e. abdominal region)
- Hands (interdigital spaces)
- Presentation
- Bright red (“beefy”)
- Moist skin surface
- Irregular scalloped borders and satellite papules or pustules OUTSIDE of border
- Itching and soreness
When do you refer for Cutaneous Candidiasis?
- Unsuccessful initial treatment (persistent infection) or condition worsens
- Condition extensive or widespread
- Systemic symptoms
- Recurrent infection
- Signs of secondary bacterial infection (presence of purulent discharge)
- Immunocompromised patient
What are the non-pharm therapy for Cutaneous Candidiasis?
- Keeping the area dry (non-medicated powder; avoid cornstarch) * Bathe daily
- Avoid tight clothing
- Cool water compresses (1 minute on, 1 minute off) for 15 to 20 minutes, three times daily. Allow area to air dry (to reduce redness)
What are the topical antifungal non-rx options for Cutaneous Candidiasis?
Topical antifungal non-prescription options:
* Azoles: clotrimazole or miconazole
- Apply BID for 2 to 3 weeks
- Note: using only antifungal powders is less effective than monotherapy antifungal creams/ointments due to lack of penetration of skin
* Nystatin cream/ointment
- Apply BID to TID for 2 to 3 weeks
* NOTE: Tolnaftate and undecylenic acid ineffective
Topical prescription options:
* Ketoconzole, ciclopirox, terbinafine
What is the management for Cutaneous Candidiasis?
In cases with marked inflammation, may use combination therapy:
- low to mid potency topical corticosteroid used once or twice daily for short
period (1 to 2 weeks) with antifungal treatment
- Avoid stronger topical corticosteroids due to occlusive skin which can increase risk of adverse effects
Oral therapy (prescription) may be indicated in cases where it is widespread or in immunosuppressed patients
What is the monitoring for Cutaneous Candidiasis?
- Marked improvement within 1 week of topical therapy
- If topical corticosteroids and antifungals used, must carefully monitor for hidden bacterial infection or adverse effects of corticosteroids (example striae)
- Persistent infections must be referred for further assessment
What is the gen. management of cutaneous fungal infection?
- For tinea infections: apply antifungal to affected are and 2 to 3 cm outside of rash border
- Ensure to be aware of duration of treatment for the various cutaneous fungal infections
What is there to remember about the general management of cutaneous fungal infection?
- Azoles are effective for treatment of dermatophyte and yeast cutaneous
infections - Nystatin effective for yeast but not dermatophyte infections
- Tolnaftate and undecylenic acid ineffective for cutaneous candidiasis
What is there to note?
- In Canada; Lotriderm is a prescription product containing clotrimazole and betamethasone
- In the US, Lotrimin AF is clotrimazole and LotriminUltra is butenafine hydrchloride.
- Fungicure and Fungi Nail product is NOT for nails. Packaging is misleading as it shows a picture of nails Contains undecylenic acid.
- Topical terbinafine in US is OTC, in Canada it is prescription.
What are the Natural Health Product Options?
Not recommended due to lack of evidence:
* Goldenseal, purple coneflower (echineacea), slippery elm bark, St. John’s wort, tea tree oil
What is the use in Pregnancy and Breastfeeding?
- Topical clotrimazole is considered compatible in pregnancy and breastfeeding
- Topical miconazole is considered compatible with pregnancy. There is no human data in regards to breastfeeding and it is considered probably compatible
- Nystatin is considered compatible with pregnancy and breastfeeding
Tinea pedis (Athlete’s foot) OTC tx:
BID X 4wks
Prevention measures
Tinea cruris (Jock itch) OTC tx:
BID X 2wks (may be up to 4 weeks)
Prevention measures
Tinea corporis (Ringworm of the body) OTC tx:
BID X 4wks
Prevention measures
Cutaneous Candidiasis OTC tx:
BID X 2wks ( may be up to 3 weeks)
Prevention measures
