PEDIATRICS Vol. 111 No. 1 January 2003, pp. 201-203
Persistent and Recurrent Tinea Corporis in Children Treated With Combination Antifungal/ Corticosteroid Agents
Sharonda J. Alston, MD*,
Bernard A. Cohen, MD*,
and
Marisa Braun, MD
* Johns Hopkins University School of Medicine
Division of Pediatric Dermatology, Baltimore, MD 21287
University of Maryland School of Medicine Baltimore, MD 21201
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ABSTRACT
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Background. Combination antifungal/corticosteroid preparations are widely used by nondermatologists in the treatment of superficial fungal infections in patients of all ages. Over half of the prescriptions written for the most commonly used combination agent clotrimazole 1%/betamethasone diproprionate 0.05% cream (Lotrisone, Schering, Kenilworth, NJ) were prescribed for children younger than 4 years old. Our pediatric dermatology division has recently encountered a series of children with recurrent or persistent tinea corporis, especially tinea faciei, treated initially with combination antifungal/corticosteroid cream.
Methods. All children evaluated for tinea corporis in a university hospital pediatric dermatology clinic from January through June 2001 were identified from the clinic registry for a retrospective chart review. Response to therapy was confirmed by telephone survey and/or follow-up visits at least 1 month after clearing of infection.
Results. Six children ranging in age from 4 to 11 years were evaluated for tinea corporis in a pediatric dermatology clinic at our institution during the 6-month period. All 6 children were diagnosed clinically by their pediatrician with tinea corporis and initially treated with clotrimazole 1%/betamethasone diproprionate 0.05% cream for 2 to 12 months. In our pediatric dermatology clinic, patients had their diagnosis confirmed with a positive potassium hydroxide preparation and were treated with one of several oral or topical antifungal agents with clearing of all tinea infections.
Conclusion. The use of combination clotrimazole 1% cream/betamethasone diproprionate 0.05% cream (Lotrisone) for the treatment of tinea corporis may be associated with persistent/recurrent infection.
Key Words: tinea corporis • persistent • recurrent • combination antifungal • corticosteroid cream • therapy
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INTRODUCTION
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Combination antifungal/corticosteroid preparations are widely used by nondermatologists in the treatment of superficial fungal infections in patients of all ages.1,2 These preparations typically consist of an imidazole antifungal agent and a moderate- to high-potency topical corticosteroid. In theory, such combinations have the advantage of providing immediate symptomatic relief because of the antiinflammatory effect of the corticosteroid. Others have proposed a synergistic effect between the corticosteroid and the antifungal agent.3 Given these assumptions, it is understandable that combination antifungal/corticosteroid preparations are frequently prescribed.
We report a series of 6 pediatric patients with tinea corporis, primarily tinea faciei, whose treatment with clotrimazole 1% cream/betamethasone diproprionate 0.05% cream prolonged the course of therapy by months and put patients at risk for long-term complications of moderate- to high-potency topical corticosteroids.
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METHODS
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All children evaluated for tinea corporis in a university hospital pediatric dermatology clinic from January through June 2001 were identified from the clinic registry for a retrospective chart review. The diagnosis of tinea corporis was established by clinical findings and a positive potassium hydroxide preparation. Children with tinea corporis who did not have a confirmatory potassium hydroxide preparation or fungal culture were excluded from the chart review. Treatment response was determined by reevaluation of patients by phone survey and/or follow-up visit at least 1 month after completion of therapy. Cure was defined as clearing of inflammation, scale, and symptoms for at least 1 month after discontinuation of treatment.
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RESULTS
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All 6 patients presented to their pediatricians with pruritic, annular, and scaly red plaques located on either the face or arm. A clinical diagnosis of tinea corporis was made, and a combination agent, clotrimazole 1%/betamethasone diproprionate 0.05% cream (Schering, Kenilworth, NJ), was prescribed (Table 1). All patients were instructed to use the medication until the rash had cleared. In 1 patient lesions had not improved after 6 months of treatment, and in 1 patient there was partial resolution after 2 months of treatment. The rash resolved within several days to several weeks of treatment in 4 patients. However, recurrent lesions in the sites of the original infection developed within 2 weeks in all patients after discontinuation of therapy. Patients were treated with multiple courses of clotrimazole 1%/betamethasone diproprionate 0.05% cream over the next 2 to 8 months, only to have the lesions recur after each treatment.
Patients were subsequently referred to our pediatric dermatology clinic, where potassium hydroxide preparations showed multiple branching septate hyphae in all 6 cases. Treatment was changed to one of the following oral and/or topical antifungal medications: oxiconazole 1% cream (GlaxoSmithKline, Research Triangle Park, NC) or econazole 2% cream (Ortho Dermatological, Skillman, NJ) topically twice daily until 10 days after clearing of the lesions; griseofulvin (Ortho Dermatological, Skillman, NJ), 11 mg/kg orally each day for 1 month; or itraconazole (Janssen Pharmaceuticals, Titusville, NJ), 100 mg orally each day for 2 weeks. Topical treatment was maintained for 
1 month in the patients who used oxiconazole or econazole cream.
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DISCUSSION
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Recent studies show that combination antifungal/corticosteroid preparations are widely used by nondermatologists in the treatment of superficial fungal infections in patients of all ages.1,2
Previous studies comparing the efficacy of single-agent topical agents and combination antifungal/corticosteroid preparations have produced conflicting results. Two investigators concluded that a single antifungal agent, naftifine cream (Allergan, Inc, Irvine, CA), was superior to combination preparations in treating dermatophyte infections. Smith et al4 found a 45% failure rate and a 36% relapse rate for a clotrimazole/betamethasone combination, compared with naftifine, which had an 8% failure rate and a 7% relapse rate. Similarly, Nada et al5 found that a miconazole/hydrocortisone preparation had a 44% cure rate as compared with a 95% cure with naftifine.
Three other studies report no significant difference in treatment efficacy between combination agents and single antifungal medications when treating tinea cruris and tinea corporis.3,6,7 Wortzel3 and Katz et al7 concluded that clotrimazole/betamethasone was "clinically superior" to clotrimazole alone, based on immediate relief of symptoms, but cure rates were similar for both groups based on mycologic studies. Elewski and colleagues8 found no difference in symptom alleviation and cure rates with the use of a hydrocortisone 1%/clotrimazole combination when compared with naftifine alone.
The American Academy of Dermatology treatment guidelines for superficial mycoses recommend that topical imidazole antifungals be considered for initial therapy.9 Although combination antifungal/corticosteroid agents are listed as treatment options, caution regarding frequency and length of application is recommended especially when fluorinated topical steroids are used.9
Clotrimazole/betamethasone diproprionate cream is a commonly prescribed combination agent. The manufacturer recommends that it be used for superficial fungal infections in patients over 12 years of age for no longer than 2 weeks without occlusion. Fleischer and Feldman1 found that 56% of prescriptions for this agent were written for children younger than 4 years of age for diagnoses of inflammatory dermatitis, diaper rash, candidiasis, and tinea. Although high-potency corticosteroids comprise only 5% of all topical steroid prescriptions written by pediatricians, high-potency steroids in combination agents are much more frequently prescribed.1
The most likely explanation is that pediatricians are unaware of the potency of these corticosteroids and the potential for cutaneous and systemic toxicity. Although systemic adverse events have not yet been reported, there are multiple case reports of local effects including striae, recurrence or exacerbation of the fungal infection, atrophy, and telangiectasia.10–12 The risk of these side effects increases with prolonged use particularly when applied to the face or when occluded in the diaper area or other intertriginous sites.
Our finding that clotrimazole/betamethasone diproprionate cream may be associated with persistent and recurrent infection is not surprising. The suppression of inflammation with the use of this agent produces a rapid decrease in inflammation and symptoms while infection persists. This can result in premature discontinuation of treatment and a rebound of symptoms and clinical findings. Moreover, most topical antifungal agents are static and probably require intact local immunity for eradication of dermatophytes.
Our experience shows that treatment of tinea corporis with a combination topical antifungal/corticosteroid cream can prolong the course of therapy for months. We recommend that clinicians prescribe single-agent topical antifungal preparations for primary treatment of tinea corporis and consider the use of low-potency topical corticosteroids for less than a week, not more than twice a day, only when symptoms are severe.
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FOOTNOTES
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Received for publication May 7, 2002; Accepted Aug 14, 2001.
Address correspondence to Bernard Cohen, MD, Division of Pediatric Dermatology, Brady 208, Johns Hopkins Hospital, 601 N Wolfe St, Baltimore, MD 21287
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REFERENCES
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- Fleischer AB, Feldman SR. Prescription of high-potency corticosteroid agents and clotrimazole-betamethasone diproprionate by pediatricians.
Clin Ther.1999; 21
:1725
–1731[CrossRef][ISI][Medline]
- Smith EB, Fleischer AB, Feldman SR. Non-dermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: analysis of office visits for cutaneous fungal infections, 1990–1994.
J Am Acad Dermatol.1998; 39
:43
–47[CrossRef][ISI][Medline]
- Wortzel MH. A double-blind study comparing the superiority of a combination antifungal (clotrimazole)/steroid (betamethasone diproprionate) product.
Cutis.1982; 30
:258
–261[Medline]
- Smith EB, Breneman DI, Griffith RF, et al. Double-blind comparison of naftifine cream and clotrimazole/betamethasone diproprionate cream in the treatment of tinea pedis.
J Am Acad Dermatol.1992; 26
:125
–127[Medline]
- Nada M, Hanafi S, Al-Omari H, et al. Naftifine versus miconazole/hydrocortisone in inflammatory dermatophyte infections.
Int J Dermatol.1994; 33
:570
–572[Medline]
- Evans EG, James IGV, Seaman RAJ, Richardson MD. Does naftifine have anti-inflammatory properties? A double blind study with 1% clotrimazole/1% hydrocortisone in clinically diagnosed fungal infection of the skin.
J Am Acad Dermatol.1993; 129
:437
–442
- Katz HI, Bard JB, Cole GW, et al. SCH 370 (clotrimazole-betamethasone diproprionate cream) in patients with tinea curis or tinea corporis.
Cutis.1984; 34
:183
–187[Medline]
- Elewski BE, Jones T, Zaias N. Comparison of an antifungal used alone with an antifungal used with a topical steroid in inflammatory tinea pedis.
Cutis.1996; 58
:305
–307[Medline]
- Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: tinea corporis, tinea curis, tinea faciei, tinea manuum, and tinea pedis.
J Am Acad Dermatol.1996; 34
:282
–286[CrossRef][ISI][Medline]
- Barkey WF. Striae and persistent tinea corporis related to prolonged use of betamethasone diproprionate 0.005% cream/clotrimazole 1% cream (Lotrisone cream).
J Am Acad Dermatol.1987; 17
:518
–519[Medline]
- Rosen T, Elewski BE. Failure of clotrimazole-betamethasone diproprionate cream in the treatment of Microsporum canis infections.
J Am Acad Dermatol.1995; 32
:1050
–1052[Medline]
- Reynolds RD, Boiko S, Lucky AW. Exacerbation of tinea corporis during treatment with 1% clotrimazole/betamethasone diproprionate (Lotrisone) [letter].
Am J Dis Child.1991; 145
:1224
–1225[Medline]
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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TOP
ABSTRACT
INTRODUCTION
