![]() Oral terbinafine is effective in the treatment of relatively resistant superficial dermatophyte infections including tinea unguium (onychomycosis), tinea pedis and tinea corporis or tinea cruris, achieving mycological cure in over 80% of adult patients ( 43). Loss of the sense of taste has been reported, but resolves after therapy has ended. Terbinafine is well tolerated, with gastrointestinal and skin reactions in only 2% to 7% of patients. Because it is not metabolized through cytochrome P-450, many of the drug interactions seen with the azoles do not occur. It diffuses to keratinocytes from the blood stream to reach the stratum corneum and hair follicles ( 42). Terbinafine is a lipophilic and keratinophilic fungicidal agent, active in vitro against dermatophytes and some moulds. Although some experts never use steroids with antifungal agents, others advocate them in CDD. The place for low concentrations of steroids (eg, 1% hydrocortisone) is unclear. Potent anti-inflamatory preparations, such as those with high concentrations of steroids, may impair the response to antifungal agents and should be avoided. There are no well-designed trials to assess the efficacy of adding a topical anti-inflammatory agent in treatment of CDD. In another study ( 18), relapses were decreased (although not significantly) when an oral supplement of nonabsorbable nystatin was added to the topical ointment of nystatin (16% versus 33%). In two studies ( 18, 19), no difference in the initial clinical responses was found. It is still not clear whether concomitant oral and topical antifungals should be recommended. ![]() Ointments, creams and powders of nystatin, miconazole and clotrimazole are available ( Table 1). In one randomized, double-blind, controlled trial ( 17) comparing miconazole ointment with zinc oxide petroleum base, miconazole was safe and more effective, particularly in moderate to severe cases. Topical antifungal therapy is also necessary. Treatment should include decreasing maceration of the skin by eliminating impervious diaper covers, changing diapers frequently and leaving diapers off for long periods of time. Candida albicans is present in the feces of 90% of such infants ( 13, 16). Although these drugs are effective, they are not recommended as first-line management of thrush in normal children because of limited paediatric data, potentially significant adverse effects and high costs.ĬDD is common during the second to fourth months of life in healthy infants ( 7, 8). ![]() Second-generation imidazoles, such as fluconazole and itraconazole or other new oral antifungals, may be considered if conventional topical treatments fail, particularly among immunocompromised patients. Because these therapeutic approaches have not been evaluated in controlled trials, they are not recommended as first-line therapies. There is also anecdotal experience that clotrimazole suppositories in a pacifier or clotrimazole vaginal cream applied to the oral mucosa after feedings are effective against thrush ( 14, 15). Chronic oral candidiasis can respond to clotrimazole troches ( 13). However, miconazole gel and oral preparation of clotrimazole are not licensed in Canada. It should be administered after feeds.įirst-generation imidazoles, such as miconazole and clotrimazole, are more effective than nystatin ( 12). The usual dosage of 200,000 units four times daily is highly effective, curing 50% of newborns after one week and 80% of newborns after two weeks of treatment ( 11). It is well tolerated and remains the most frequently prescribed agent for thrush. Nystatin suspension has been used since the 1950s ( 10). Gentian violet stains tissue and clothing and, thus, is not well accepted by parents it also interferes with clinical assessment. Topical gentian violet, the oldest therapeutic agent, is moderately effective against thrush but prolonged use can cause irritation and even ulceration ( 9). Use of an infant soother increases the incidence of thrush and may make treatment less effective, unless the soother is carefully washed after use ( 8). Response to antifungal agents is usually good in neonates with no major underlying condition, but a prolonged course may be required and recurrences are common. Oropharyngeal candidiasis (thrush) may start as early as seven days after birth, with an incidence in infants of 5% to 10% depending on the population studied ( 6– 7).
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