Azole antifungals Azole antifungals are generally divided into two groups,
imidazoles and
triazoles. Common examples of imidazoles include
clotrimazole,
econazole,
miconazole,
ketoconazole, while
fluconazole,
itraconazole,
posaconazole and
voriconazole fall under the triazole group. Both groups cause substantial damage in fungal
membrane integrity by lowering
ergosterol levels, along with the loss of
cytoplasmic components, thus bringing similar effects to the
polyene antifungals.
Mechanism of action Azole antifungal drugs exert their effects by inhibiting the synthesis of the
sterol components of the fungal
membrane.
Azoles are predominantly
fungistatic, which inhibit the growth of the fungus instead of killing it. These drugs target the ergosterol biosynthetic pathway by inhibiting the C-14 α-demethylase, a
cytochrome P450 enzyme, thus preventing the
demethylation of
lanosterol to ergosterol which is an essential component of the fungal cell membrane. The impaired synthesis of ergosterol leads to a cascade of
membrane defects. Hence, fungal cell growth is inhibited due to the disrupted structure and function of the membrane.
Clinical use Most topically used
azole antifungals belong to the
imidazole group; listed below are some of the most common azole antifungals according to the
British National Formulary. • Clotrimazole • :
Clotrimazole is widely used to treat fungal infections on different parts of the body, including infections in the
otitis externa (ear), the skin, regions of the vagina, and vulva. It is available in the form of
pessaries, liquid, creams, and spray. Common side effects of clotrimazole are skin irritations,
itchiness or redness in areas where the drug is applied. • Econazole • :
Econazole in the form of creams and nail lacquers is often used to treat fungal skin and nail infections respectively. It can also be used to treat vaginal and vulval
candidiasis by administering creams or pessaries vaginally. Some patients may experience skin reactions such as itchiness and redness after application. • Miconazole • :
Miconazole is a widely used topical antifungal medication for the treatment of many fungal infections, namely skin infections, nail infections and vaginal
candidiasis. The drug is usually formulated in creams, powders and sprays. However, it is suggested that patients developing acute
porphyrias should avoid using this drug. Miconazole can also be used for both prevention and treatment of
oral candidiasis which the drug is formulated as oromucosal gel. It is suggested that the usage of miconazole for oral lesions in infants with swallowing reflexes should be avoided. • Ketoconazole • :
Ketoconazole is majorly used topically to treat fungal skin infections such as
tinea pedis (Athlete's foot),
seborrhoeic dermatitis,
dandruff, and
pityriasis versicolor. It can also be used to prevent the recurrence of fungal infections. The drug comes in the form of creams, shampoos, and tablets. Other than treating the infection, ketoconazole may cause skin reactions at the site of application, including skin rash and itching. Ketoconazole is contraindicated in patients with acute porphyrias, where patients may present with
shortness of breath and
seizures. If not treated promptly, acute porphyrias can be life-threatening. • : In July 2013, the European Medicines Agency's Committee on Medicinal Products for Human Use (CHMP) advised that oral medicines containing ketoconazole should be suspended due to the high risk of
hepatotoxicity outweighing its benefits. The advice does not affect topical ketoconazole products, and the oral use of the drug for
Cushing's syndrome.
Cautions Avoid contact with eyes and
mucous membranes using topically. Avoid
intravaginal preparations (particularly those that require the use of an applicator) in young girls who are not sexually active, unless there is no alternative (in children).
Polyene antifungals Polyene antifungals do not work well orally, so they are mostly seen as a solution or given topically or
intravenously as a systemic antifungal. They are not suitable for dermatophyte fungal infections.
Mechanism of action Polyene antifungals have high affinity for ergosterol in fungal cell membranes. Upon binding to the fungal cell membrane and forming pores,
membrane permeability and transport in fungus are altered. As a result, fungal cell death occurs. Nystatin is the only polyene antifungal that is available for topical administration. The drug is derived from
Streptomyces noursei and has activity against Candida but not dermatophytes.
Clinical use Nystatin is used topically for the treatment of Candida infections of the skin and
mucous membranes. •
Oral candidiasis (oral thrush) • : Nystatin is commonly used in treatment of
lesions of the mouth caused by oral candidiasis. The drug can be formulated in
pastilles or
suspensions and is directly applied to the affected area. After application, patients should avoid taking food or drink for an hour to allow sufficient time for the drug to exert its effect locally. Oral irritation or
sensitisation may occur in some patients after applying the drug to the oral
mucous membrane. •
Fungal skin infections • : Nystatin in the forms of creams,
ointments or powders can also be used to treat fungal infections of the skin. The medication is directly applied to the affected area at around the same times on a daily basis. Some patients may experience itchiness, pain or burning sensations in the area where the drug is applied, while some may develop
rashes or
hives. On rare occasions, patients may have
difficulty breathing or
swallowing after topical use of Nystatin. •
Vaginal infections • : Nystatin is also used to treat fungal infections in the vaginal area. It is commonly formulated into
pessaries or vaginal
cream for application.
Ointments, gels, creams or
dusting powder may be used when patients develop cutaneous lesions. Skin irritations may occur in some patients after applying the medication vaginally. Patients who are concurrently using latex
contraceptives should be reminded that some intravaginal preparations of nystatin may damage the contraceptive. Additional contraceptive measures may be needed during the treatment duration.
Allylamine antifungals Mechanism of action Allylamines are a new type of antifungal drug that is highly selective for the fungal enzyme but has a minimal effect on humans. They work in a similar way as azoles but have their effects earlier on in the ergosterol synthesis pathway. Allylamines allow the active ingredients in the medication to accumulate well within the
stratum corneum of the skin and nails to exert their actions. They inhibit the enzyme
squalene epoxidase which converts
squalene into ergosterol. This inhibition results in decreased amounts of sterols, causing cell death and the disruption of the fungal cell wall synthesis. They are known to be quite effective against dermatophytes, yeast, and molds.
Clinical use Common
allylamine antifungals are
naftifine and
terbinafine. They are usually used topically for the treatment of skin infections. •
Naftifine • :
Naftifine is used topically for the treatment of
dermatophytosis, including
tinea cruris (jock itch),
tinea corporis (ringworm of the body),
tinea pedis (athlete's foot) and
tinea manuum (ringworm of the hand). It is available in creams or gels.
Occlusive dressings should be avoided after applying the topical preparations. Clinical improvement usually occurs within the first week of treatment with Naftifine. Topical preparations containing Naftifine are contraindicated in patients
hypersensitive to the drug or any ingredient in the formulation. The major adverse effects of Naftifine are local irritation,
skin dryness and rash. • Terbinafine • :
Terbinafine is used to treat skin infections caused by a fungus (yeast), including
tinea corporis (ringworm of the body),
tinea cruris (jock itch),
onychomycosis, Pityriasis Versicolor and
tinea pedis (athlete's foot). It is available in gel, spray and cream. These topical preparations should not be administered intravaginally and applied in or near the mouth or eyes. In addition, they should not be used on nails or
scalp directly. Topical preparations containing terbinafine are contraindicated in patients hypersensitive to the drug or any ingredient in the formulation. The major adverse effects of Terbinafine are transient burning and stinging, local irritation and rash.
Benzoxaborole antifungals Mechanism of action Benzoxaborole antifungals are a newer class of antifungal medication. They work by blocking the ability of the fungus to produce proteins in a highly specific way, hence disrupting the action of yeast cytoplasmic enzymes involved in the
translation process. A common example of this class of antifungal is
Tavaborole.
Clinical use • Onychomycosis • : Benzoxaborole antifungal is for the treatment of
onychomycosis of toenails. It is applied to the affected toenail once daily for 48 weeks. The major adverse effects associated with its use is the ingrowing of toenails and application site reactions including
exfoliation,
erythema, and
dermatitis.
Ciclopirox olamine Mechanism of action Ciclopirox and
ciclopirox olamine are synthetic antifungal agents. The exact mechanism of action of Ciclopirox olamine antifungals is not well understood. It appears that the medication works by causing depletion of important substrates such as
amino acids and/or
ions within fungal cells, resulting in the inhibition of transport of these substances across fungal cell membranes. Finally, it disrupts the synthesis of
DNA,
RNA and
proteins in fungal cells and leads to cell death. Ciclopirox may also exert its
antimycotic effects by altering fungal
cell permeability. However, the leakage of cellular constituents resulting from the decreased cell permeability is only apparent at high drug concentrations. •
Fungal skin infections • : Ciclopirox olamine cream or lotion is used to treat certain
dermatophytosis such as
tinea pedis,
tinea cruris, and
tinea corporis. They can also be used for the treatment of
cutaneous candidiasis and
pityriasis versicolor. The medication is sometimes formulated into
gels when treating tinea corporis and interdigital tinea pedis. •
Scalp infections • : Ciclopirox olamine gels and shampoos are used topically to treat
seborrheic dermatitis of the scalp. •
Nail infections • : Nail lacquers are formulated from ciclopirox olamine solutions to treat mild to moderate
onychomycosis of fingernails and toenails without the involvement of the lunula (the white area at the base of a nail).
Adverse effects In general, ciclopirox and ciclopirox olamine preparations are well tolerated by patients when used topically for treatment of fungal infections. Pain, itchiness and burning sensations may occur following topical application of the medication. For patients using ciclopirox nail lacquers, redness of the skin around the nail and the proximal nail fold may occur, while a few of them develop nail disorders such as ingrown nails, changes in shape, and discoloration. The above adverse reactions are usually mild and self-terminating. They are rarely severe enough to require discontinuation of the drug.
Thiocarbamate antifungals Mechanism of action Thiocarbamate antifungals have a similar mechanism of action as
allylamine antifungals. They both inhibit the enzyme squalene-epoxidase, which converts squalene to lanosterol, the raw material for producing ergosterol in fungal cells. By blocking the sterol synthesis in fungal cells and cell extracts, the integrity of fungal cell membranes will be interrupted, thus leading to impeded fungal growth.
Clinical use Tolnaftate is one example of
thiocarbamate antifungals. •
Tolnaftate • : Tolnaftate is a topically used antifungal for treating or preventing superficial
dermatophyte infections, also known as skin infections,
ringworm or tinea, and
pityriasis versicolor. It is available in gel, solution, powder, ointment, or cream. Repeated treatment may be required if conditions do not improve within two to six weeks. It is important to note that tolnaftate is effective in inhibiting the growth of dermatophytes such as
Epidermphyton and
Microsporum, but the drug has no use against
candida or bacteria infections. Contraindications include nail or scalp infections, and
sulfa allergy or hypersensitivity to tolnaftate itself. Tolnaftate is usually useful for patients desiring self-medication of mild tinea infections.
Adverse effects Side effects are rare with tolnaftate and may include irritation, burning, pruritus (itchiness), and
contact dermatitis.
Undecylenic alkanolamide antifungals Mechanism of action Undecyclenic alkanolamide antifungals, also referred to as
undecylenic acid and
undecenoic acid, is a type of
unsaturated fatty acid that inhibits fungal growth on the skin.
Clinical use Although undecylenic acids possess antifungal properties, the drug itself is seldom used on its own for antifungal purposes. Salts of undecylenic acid such as zinc undecenoate and calcium undecenoate are commonly formulated into antifungal creams, ointments, solutions or powders. Undecenoic acid and its salt forms are applied topically to treat superficial
dermatophytosis, in particular
tinea corporis (ringworm),
tinea pedis (athlete's foot), and
tinea cruris (jock itch). Undecenoic acid is also formulated into several other salts and derivatives such as
methyl,
phenyl and
propyl undecenoate, which are also used to treat fungal infections on the skin. There has been limited evidence showing the effectiveness of undecylenic acid in treating nail and scalp fungal infections.
Adverse effects Irritation may occur in some patients after topical application of undecylenic acid or its salts and derivatives. == References ==