Antifungals
Place in Therapy
Place in Therapy: Antifungals
Antifungal agents, such as miconazole, clotrimazole or nystatin, are indicated when an obvious Candida infection is present. Although this can be confirmed by a fungal culture, clinical presentation is commonly used to diagnose Candida diaper dermatitis. It is considered a fungal infection when beefy red plaques are present with maceration, papules and satellite pustules and when it affects creases of the skin.1 When diaper dermatitis is present for at least <3> days, it is likely that a secondary infection with Candida is present and consequently antifungal agents would be beneficial.<2> It has been shown that miconazole, in combination with a barrier cream, is more effective for moderate to severe diaper rashes and for Candida-positive rashes when compared to barrier cream alone. Despite the lack of fungal cultures to confirm fungal diaper dermatitis, many of the rashes classified as moderate to severe in studies showed symptoms of papulopustules, erosions or ulcerations, which suggest that they were complicated by Candida.<3>
Most of the studies looked at miconazole for the treatment of Candida diaper dermatitis. Although the concentration of miconazole was lower in the studies than what is available in Canada, the efficacy of antifungal agents still exists, and they are fairly safe.<3> This is the same for clotrimazole, as it is assumed to be a class effect. There is one minor study that indicated that clotrimazole was superior to nystatin <4>, but there is no strong conclusive evidence. Since imidazoles have been more extensively studied, their use should be taken into consideration first for the treatment of Candida diaper dermatitis.
References
1. Sibbald, D. Diaper Dermatitis. In: McLeod PJ, Allen M, Conly J, eds. Patient Self-Care - Helping Your Patients Make Therapeutic Choices. 2nd ed. Ottawa, ON: Canadian Pharmacists Association; 2010: 534-545.
2. Horii, KA, Prossick, TA. Overview of diaper dermatitis in infants and children. In: Corona, R (Ed), UpToDate, Waltham, MA, 2013.
3. Concannon P, et al. Diaper dermatitis: a therapeutic dilemma. Results of a double-blind placebo controlled trial of miconazole nitrate 0.25%. Pediatr Dermatol. 2001 Mar-Apr;18(2):149-55.
4. Hoeger PH, Stark S, Jost G. Efficacy and safety of two different antifungal pastes in infants with diaper dermatitis: a randomized, controlled study. J Eur Acad Dermatol Venereol. 2010 Sep;24(9):1094-8.
5. Eichenfield LF, Bogen ML. Absorption and efficacy of miconazole nitrate 0.25% ointment in infants with diaper dermatitis. J Drugs Dermatol. 2007 May;6(5):522-6.
Antifungal agents, such as miconazole, clotrimazole or nystatin, are indicated when an obvious Candida infection is present. Although this can be confirmed by a fungal culture, clinical presentation is commonly used to diagnose Candida diaper dermatitis. It is considered a fungal infection when beefy red plaques are present with maceration, papules and satellite pustules and when it affects creases of the skin.1 When diaper dermatitis is present for at least <3> days, it is likely that a secondary infection with Candida is present and consequently antifungal agents would be beneficial.<2> It has been shown that miconazole, in combination with a barrier cream, is more effective for moderate to severe diaper rashes and for Candida-positive rashes when compared to barrier cream alone. Despite the lack of fungal cultures to confirm fungal diaper dermatitis, many of the rashes classified as moderate to severe in studies showed symptoms of papulopustules, erosions or ulcerations, which suggest that they were complicated by Candida.<3>
Most of the studies looked at miconazole for the treatment of Candida diaper dermatitis. Although the concentration of miconazole was lower in the studies than what is available in Canada, the efficacy of antifungal agents still exists, and they are fairly safe.<3> This is the same for clotrimazole, as it is assumed to be a class effect. There is one minor study that indicated that clotrimazole was superior to nystatin <4>, but there is no strong conclusive evidence. Since imidazoles have been more extensively studied, their use should be taken into consideration first for the treatment of Candida diaper dermatitis.
References
1. Sibbald, D. Diaper Dermatitis. In: McLeod PJ, Allen M, Conly J, eds. Patient Self-Care - Helping Your Patients Make Therapeutic Choices. 2nd ed. Ottawa, ON: Canadian Pharmacists Association; 2010: 534-545.
2. Horii, KA, Prossick, TA. Overview of diaper dermatitis in infants and children. In: Corona, R (Ed), UpToDate, Waltham, MA, 2013.
3. Concannon P, et al. Diaper dermatitis: a therapeutic dilemma. Results of a double-blind placebo controlled trial of miconazole nitrate 0.25%. Pediatr Dermatol. 2001 Mar-Apr;18(2):149-55.
4. Hoeger PH, Stark S, Jost G. Efficacy and safety of two different antifungal pastes in infants with diaper dermatitis: a randomized, controlled study. J Eur Acad Dermatol Venereol. 2010 Sep;24(9):1094-8.
5. Eichenfield LF, Bogen ML. Absorption and efficacy of miconazole nitrate 0.25% ointment in infants with diaper dermatitis. J Drugs Dermatol. 2007 May;6(5):522-6.