Antimicrobial therapies for skin, soft tissue and mucosal infections

[Pages:22]Antimicrobial therapies for skin, soft tissue and mucosal infections

Caroline Chen

Antimicrobial Pharmacist National Centre for Antimicrobial Stewardship

Outline

? Skin

? Topical antifungals

? Combination antifungal-corticosteroid products

? Topical antibacterials

? Anti-staphylococcal antibiotic creams ? Metronidazole cream ? Scabies treatment

? Eye

? Bacterial conjunctivitis and role of ocular antibiotics

? Mouth

? Topical treatments for oral thrush

? Useful resources

Topical antifungals for the skin

General considerations

? Reduce moisture as much as possible

? Wear loose fitting clothing with natural fibres (e.g cotton) ? Infected areas should be completely dried before covering with clothing ? Avoid occlusive dressing over the area

? Be mindful of patients with poorly controlled diabetes ? Generally, topical therapy is safe, effective and very well tolerated

? No robust evidence to suggest development of resistance from topical antifungal therapy

? Oral therapy may be required for extensive or persistent disease

Azole antifungals

? Clotrimazole, bifonazole, econazole, ketoconazole, miconazole ? Used superficial skin fungal infections e.g. tinea, dandruff ? Apply to the affected skin and surrounding area ? pay particular

attention to skin folds ? Must be used regularly (3-4 times per day) and continue

treatment for 2 weeks after the symptoms have resolved

? Not to be used "PRN"

? Clotrimazole (Canesten?) and micronazole (Daktarin?, Resolve?) are available as liquids, but contains alcohol

? Also available as a foaming liquid, powder and shampoo

Combination antifungal + cortisone

? Hydrozole? (clotrimazole and hydrocortisone), Resolve Plus? (Miconazole and hydrocortisone)

? Cortisone provides symptomatic relief of early inflammation BUT ? Dosing intervals are different for the two components ? Prolonged use of the steroid can lead to real problems

? thinning of the skin ? Tinea incognita: physical appearance of tinea is altered by the cortisone

original infection slowly spreads and is misdiagnosed as dermatitis vicious cycle ? May encourage growth of resistant fungi

? Use until the inflammation subsides, then continue with clotrimazole alone

Other skin antifungals

? Nystatin (Mycostatin?), terbinafine (Lamisil?), amorolfine (Loceryl?), ciclopirox (Rejuvenail?), tolnaftate (Tinaderm?)

? Terbinafine (Lamisil?)

? Apply 1-2 times per day ? Available as cream and gel ? Gel contains alcohol so not good for broken skin ? Also available in a "once" only application gel (contains

alcohol) ? Some available as powders ? may help to promote dryness, but

powder may clump together and be further irritating on the skin

Is there a difference between various topical antifungal?

? No real difference in terms of cure at the end of treatment ? Terbinafine (Lamisil) seems to be better in terms of sustained cure ? Most common reasons for failure are poor adherence to treatment,

misdiagnosis, reinfection, drug resistance and infection with an uncommon species

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