BNF for Children 2011-2012

588 13.10.2 Antifungal preparations BNFC 2011–201213 SkinRosiced c (Fabre) ACream, metronidazole 0.75%, net price 30 g = £7.50Excipients include propylene glycolDoseInflammatory papules and pustules of rosaceaChild 1–18 years apply twice daily for 6 weeks (longer ifnecessary)Rozex c (Galderma) ACream, metronidazole 0.75%, net price 40 g = £6.86Excipients include benzyl alcohol, isopropyl palmitateGel, metronidazole 0.75%, net price 40 g = £6.86Excipients include disodium edetate, hydroxybenzoates (parabens),propylene glycolDoseInflammatory papules, pustules and erythema ofrosaceaChild 1–18 years apply twice dailyZyomet c (Goldshield) AGel, metronidazole 0.75%, net price 30 g = £12.00Excipients include benzyl alcohol, disodium edetate, propylene glycolDoseAcute inflammatory exacerbations of rosaceaChild 1–18 years apply thinly twice daily13.10.2 Antifungal preparationsMost localised fungal infections are treated with topicalpreparations. To prevent relapse, local antifungal treatmentshould be continued for 1–2 weeks after thedisappearance of all signs of infection. Systemic therapy(section 5.2) is necessary for nail or scalp infection or ifthe skin infection is widespread, disseminated or intractable.Specimens of scale, nail or hair should be sent formycological examination before starting treatment,unless the diagnosis is certain.Dermatophytoses Ringworm infection can affect thescalp (tinea capitis), body (tinea corporis), groin (tineacruris), hand (tinea manuum), foot (tinea pedis, athlete’sfoot), or nail (tinea unguium, onychomycosis). Tineacapitis is a common childhood infection that requiressystemic treatment with an oral antifungal (section 5.2);additional application of a topical antifungal, during theearly stages of treatment, may reduce the risk of transmission.A topical antifungal can also be used to treatasymptomatic carriers of scalp ringworm.Tinea corporis and tinea pedis infections in childrenrespond to treatment with a topical imidazole (clotrimazole,econazole, ketoconazole, or miconazole) or terbinafinecream. Nystatin is less effective against tinea.Compound benzoic acid ointment (Whitfield’s ointment)has been used for ringworm infections but it iscosmetically less acceptable than proprietary preparations.Antifungal dusting powders are of little therapeuticvalue in the treatment of fungal skin infections andmay cause skin irritation; they may have some role inpreventing re-infection.Antifungal treatment may not be necessary in asymptomaticchildren with tinea infection of the nails. If treatmentis necessary, a systemic antifungal (section 5.2) ismore effective than topical therapy. However, topicalapplication of tioconazole may be useful for treatingearly onychomycosis when involvement is limited tomild distal disease in up to 2 nails, or for superficialwhite onychomycosis, or where there are contra-indicationsto systemic therapy. Chronic paronychia on thefingers (usually due to a candidal infection) should betreated with topical clotrimazole or nystatin, but thesepreparations should be used with caution in childrenwho suck their fingers. Chronic paronychia of the toes(usually due to dermatophyte infection) can be treatedwith topical terbinafine.Pityriasis versicolor Pityriasis (tinea) versicolor canbe treated with ketoconazole shampoo or seleniumsulphide shampoo (section 13.9). Topical imidazoleantifungals such as clotrimazole, econazole, ketoconazole,and miconazole, or topical terbinafine are alternatives,but large quantities may be required.If topical therapy fails, or if the infection is widespread,pityriasis versicolor is treated systemically with an azoleantifungal (section 5.2). Relapse is common, especiallyin the immunocompromised.Candidiasis Candidal skin infections can be treatedwith topical imidazole antifungals clotrimazole, econazole,ketoconazole, or miconazole; topical terbinafineis an alternative. Topical application of nystatin isalso effective for candidiasis but it is ineffective againstdermatophytosis. Refractory candidiasis requires systemictreatment (section 5.2.1) generally with a triazolesuch as fluconazole; systemic treatment with griseofulvinor terbinafine is not appropriate for refractorycandidiasis. For the treatment of oral candiasis seesection 12.3.2 and for the management of nappy rashsee section 13.2.2.Angular cheilitis Miconazole cream is used in thefissures of angular cheilitis when associated with Candida.For further information on angular cheilitis, seep. 545.Cautions Contact with eyes and mucous membranesshould be avoided.Side-effects Occasional local irritation and hypersensitivityreactions include mild burning sensation,erythema, and itching. Treatment should be discontinuedif symptoms are severe.Compound topical preparations Combination of animidazole and a mild corticosteroid (such as hydrocortisone1%) (section 13.4) may be of value in the treatmentof eczematous intertrigo and, in the first few days only,of a severely inflamed patch of ringworm. Combinationof a mild corticosteroid with either an imidazole ornystatin may be of use in the treatment of intertriginouseczema associated with candida.AMOROLFINECautions see notes above; also avoid contact withears; use with caution in child likely to suck affecteddigitsPregnancy systemic absorption very low, but manufactureradvises avoid—no information availableBreast-feeding manufacturer advises avoid—noinformation availableSide-effects see notes aboveLicensed use not licensed for use in children under12 years