Uses for ketoconazole cream

Ketoconazole Topical

Prescription ketoconazole comes as a cream and a shampoo to apply to the skin. Over-the-counter ketoconazole comes as a shampoo to apply to the scalp. Ketoconazole cream is usually applied once a day for 2 to 6 weeks. Prescription ketoconazole shampoo is usually applied one time to treat the infection. Over-the-counter ketoconazole shampoo is usually used every 3 to 4 days for up to 8 weeks, and then used as needed to control dandruff. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use ketoconazole exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor.

One treatment with prescription ketoconazole shampoo may successfully treat your tinea versicolor infection. However, it may take several months for your skin color to return to normal, especially if your skin is exposed to sunlight. After your infection is treated, there is a chance that you will develop another tinea versicolor infection.

If you are using over-the-counter ketoconazole shampoo to treat dandruff, your symptoms should improve during the first 2 to 4 weeks of your treatment. Call your doctor if your symptoms do not improve during this time or if your symptoms get worse at any time during your treatment.

If you are using ketoconazole cream, your symptoms should improve at the beginning of your treatment. Continue to use ketoconazole cream even if you are feeling well. If you stop using ketoconazole cream too soon, your infection may not be completely cured and your symptoms may return.

Ketoconazole cream and shampoos are only for use on the skin or scalp. Do not let ketoconazole cream or shampoo get into your eyes or mouth, and do not swallow the medication. If you do get ketoconazole cream or shampoo in your eyes, wash them with plenty of water.

To use the cream, apply enough cream to cover the affected area and all of the skin around it.

To use the prescription shampoo, follow these steps:

  1. Use a small amount of water to wet your skin in the area where you will apply ketoconazole shampoo.
  2. Apply the shampoo to the affected skin and a large area around it.
  3. Use your fingers to rub the shampoo until it forms a lather.
  4. Leave the shampoo on your skin for 5 minutes.
  5. Rinse the shampoo off of your skin with water.

To use the over-the-counter shampoo, follow these steps:

  1. Be sure that your scalp is not broken, cut, or irritated. Do not use ketoconazole shampoo if your scalp is broken or irritated.
  2. Wet your hair thoroughly.
  3. Apply the shampoo to your hair.
  4. Use your fingers to rub the shampoo until it forms a lather.
  5. Rinse all of the shampoo out of your hair with plenty of water.
  6. Repeat steps 2 to 5.

Are you currently using ketoconazole cream?

Use this medication on the skin only. Clean and thoroughly dry the area to be treated. Apply this medication to the affected skin, usually once or twice a day or as directed by your doctor. Dosage and length of treatment depends on the type of infection being treated. Do not apply this more often than prescribed. Your condition will not clear faster, but side effects may be increased.

Apply enough medication to cover the affected skin and some of the surrounding skin. After applying this medication, wash your hands. Do not wrap, cover or bandage the area unless directed to do so by your doctor.

Do not apply this medication in the eyes, nose, mouth, or vagina. If this medication gets in the eyes (for example, when used to treat dandruff), rinse thoroughly with water.

Use this medication regularly in order to get the most benefit from it. Remember to use it at the same time(s) each day.

Continue to use this medication until the full prescribed amount is finished, even if symptoms disappear after starting ketoconazole. Stopping the medication too early may allow the fungus to continue to grow, which may result in a relapse of the infection.

Inform your doctor if your condition persists after the prescribed amount of treatment or worsens at any time.

Our resident pharmacist Rita Ghelani offers her expert advice on using Nizoral cream to treat a fungal infections, including info about how long to use for, how it works and possible side effects.

What is Nizoral cream?

Nizoral cream contains ketoconazole 2%, which is an antifungal medicine. It is only available on prescription in the UK.

Ketoconazole cream can be purchased from pharmacies without a prescription as Daktarin Gold cream or Daktarin Intensiv cream.

What is Nizoral cream used for?

  • Fungal infections of the skin, such as ringworm (tinea corporis), jock itch (tinea cruris) or athlete’s foot (tinea pedis).
  • Inflammatory skin condition with greasy, red and scaly areas (seborrhoeic dermatitis).
  • Fungal skin condition called pityriasis versicolor.
  • Candida infections of the skin.
  • Relieving the external symptoms of vaginal thrush.

How does Nizoral cream work?

Nizoral cream contains the active ingredient ketoconazole, which is a type of medicine called an antifungal.

Ketoconazole kills fungi and yeasts by causing holes to appear in their cell membranes, allowing essential constituents of the cells to leak out. This kills the fungi and yeast cells and helps clear up the infection.

Ketoconazole cream may be prescribed to treat a number of different types of fungal and yeast infections. These include ringworm, athlete’s foot, jock itch, thrush infections of the skin and vagina (candidosis), and skin conditions that are caused by infection with the yeast Pityrosporum (Malassezia), such as seborrheic dermatitis and pityriasis versicolor.

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How to use Nizoral cream

Wash and dry the affected areas of skin thoroughly before applying the cream.

To treat athletes foot, the cream should be gently rubbed into the affected areas twice a day, usually for a week for mild cases. More severe or extensive cases may take longer to clear up. You should keep using the cream twice a day for a few days after all the symptoms have cleared up to make sure the infection is fully treated and prevent it coming back.

To treat other skin infections the cream should be rubbed gently into the affected areas of skin once or twice a day, as directed by your doctor. The length of treatment will depend on the type and severity of the infection. You should keep using the cream for a few days after your symptoms have gone away, to make sure the infection has been fully treated. If there is no improvement in your symptoms after four weeks of treatment you should consult your doctor for advice.

Unless the infected skin is on your hands, wash your hands with soap and water after applying the cream to avoid spreading the infection to other areas of the body, or to other people.

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Key info to know about Nizoral cream

▪️ Nizoral cream is not recommended for children and adolescents under 18 years of age.

▪️ Nizoral cream is for external use on the skin only. It should not be used inside the mouth, nose or eyes.

▪️ It is important to keep using this cream for three or four days after the symptoms of the infection have cleared up. This is to make sure that the infection is fully treated and thus prevent it coming back.

▪️ If the infection has not cleared up after four weeks of treatment you should consult your doctor.

▪️ If you are using another cream, ointment or lotion on the skin infection that contains a steroid it is ok to continue doing this. Use the steroid treatment in the morning and the Nizoral cream in the morning.

▪️ Nizoral cream contains propylene glycol that may cause skin irritation.

▪️ Nizoral cream also contains cetyl alcohol and stearyl alcohol that may cause skin reactions such as contact dermatitis.

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Is it safe to use Nizoral cream if pregnant or breastfeeding?

Ketonazole is not absorbed into the bloodstream when applied to the skin. It can be used if you are pregnant or breastfeeding.

Possible side effects of Nizoral cream

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with Nizoral cream. Just because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect.

A common side effect of using Nizoral cream is getting a burning sensation in the area where the cream is applied to.

Uncommon side effects that affect between 1 and 10 out of every 1000 people using Nizoral cream include:

  • Rash.
  • Allergic inflammation of the skin (contact dermatitis).
  • Skin peeling or blistering.
  • Sticky skin.
  • Reactions such as skin irritation, discomfort, bleeding, tingling or dryness at the application site.

If you want any more information about the possible side effects of Nizoral cream , read the leaflet provided with the medicine or talk to your doctor or pharmacist.

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If you think you have experienced side effects from Nizoral cream you can report them using the yellow card scheme.

Can I use Nizoral cream with other medicines?

Yes – ketoconazole cream is not absorbed through the skin into the bloodstream in significant amounts and so is not expected to affect other medicines.

If you are using any other creams, ointments or lotions (including moisturisers or cosmetics) on the same area of skin, you should preferably not apply these at the same time as ketoconazole 2% cream. This is because they could dilute the medicine and make it less effective at treating the infection. Always leave about 30 minutes between applying different products to the same area of skin, to give them time to be absorbed.

If you are using a steroid cream, then it is best to apply this that a different time of day to the Nizoral cream, for example steroid cream in the morning and the Nizoral cream in the evening.

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Last updated 18.11.2019

Rita Ghelani (BPharm, MRPharmS) Pharmacist A UK registered practising pharmacist with over 20 years’ experience, Rita is a member of the medical journalists’ association (MJA) and has a wealth of experience in community pharmacy. She also has an NHS academy award in healthcare leadership with the Mary Seacole programme. Rita has been the resident pharmacist at for over 10 years.

Ketoconazole Cream


Ketoconazole Cream 2% is not for ophthalmic use.

Ketoconazole Cream 2% contains sodium sulfite anhydrous, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people.



If a reaction suggesting sensitivity or chemical irritation should occur, use of the medication should be discontinued. Hepatitis (1:10,000 reported incidence) and, at high doses, lowered testosterone and ACTH induced corticosteroid serum levels have been seen with orally administered ketoconazole; these effects have not been seen with topical ketoconazole.

Carcinogenesis, Mutagenesis, Impairment Of Fertility

A long-term feeding study in Swiss Albino mice and in Wistar rats showed no evidence of oncogenic activity. The dominant lethal mutation test in male and female mice revealed that single oral doses of ketoconazole as high as 80 mg/kg produced no mutation in any stage of germ cell development. The Ames’Salmonella microsomal activator assay was also negative.

Teratogenic effects : Pregnancy Category C

Ketoconazole has been shown to be teratogenic (syndactylia and oligodactylia) in the rat when given orally in the diet at 80 mg/kg/day, (10 times the maximum recommended human oral dose). However, these effects may be related to maternal toxicity, which was seen at this and higher dose levels.

There are no adequate and well-controlled studies in pregnant women. Ketoconazole should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers

It is not known whether Ketoconazole Cream 2% administered topically could result in sufficient systemic absorption to produce detectable quantities in breast milk. Nevertheless, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

Safety and effectiveness in children have not been established.

Ketoconazole (Topical)


Medically reviewed by Last updated on Jan 19, 2019.

  • Overview
  • Side Effects
  • Dosage
  • Professional
  • Pregnancy
  • More

Commonly used brand name(s)

In the U.S.

  • Extina
  • Ketodan Kit
  • Kuric
  • Nizoral
  • Nizoral A-D
  • Xolegel

In Canada

  • Ketoderm

Available Dosage Forms:

  • Shampoo
  • Cream
  • Foam
  • Gel/Jelly

Therapeutic Class: Antifungal

Chemical Class: Imidazole

Uses for ketoconazole

Ketoconazole is used to treat infections caused by a fungus or yeast. It works by killing the fungus or yeast or preventing its growth.

Ketoconazole cream is used to treat:

Ketoconazole foam or gel is used to treat seborrheic dermatitis (scaly areas on your skin or scalp).

Ketoconazole 1% shampoo is used to treat dandruff.

Ketoconazole 2% shampoo is used to treat “sun fungus” (tinea versicolor; pityriasis versicolor).

Ketoconazole may also be used for other fungus infections of the skin as determined by your doctor.

Most forms of ketoconazole are available only with your doctor’s prescription. Some forms are available without a prescription. However, your doctor may have special instructions on the proper use for your medical condition.

Before using ketoconazole

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For ketoconazole, the following should be considered:


Tell your doctor if you have ever had any unusual or allergic reaction to ketoconazole or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.


Appropriate studies have not been performed on the relationship of age to the effects of ketoconazole topical in children younger than 12 years of age. Safety and efficacy have not been established.


Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of ketoconazole topical in the elderly. However, some elderly patients may be more sensitive to the side effects of ketoconazole.


Pregnancy Category Explanation
All Trimesters C Animal studies have shown an adverse effect and there are no adequate studies in pregnant women OR no animal studies have been conducted and there are no adequate studies in pregnant women.


There are no adequate studies in women for determining infant risk when using this medication during breastfeeding. Weigh the potential benefits against the potential risks before taking this medication while breastfeeding.

Interactions with medicines

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. Tell your healthcare professional if you are taking any other prescription or nonprescription (over-the-counter ) medicine.

Interactions with food/tobacco/alcohol

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Discuss with your healthcare professional the use of your medicine with food, alcohol, or tobacco.

Proper use of ketoconazole

It is very important that you use ketoconazole only as directed by your doctor. Do not use more of it, do not use it more often, and do not use it for a longer time than your doctor ordered. To do so may cause unwanted side effects or skin irritation.

Ketoconazole is for use on the skin only. Do not get it in your eyes, nose, mouth, or vagina. Do not use it on skin areas that have cuts, scrapes, or burns. If it does get on these areas, rinse it off right away with water.

For patients using the cream:

  • Apply enough cream to cover the affected and surrounding skin areas, and rub in gently.
  • To help clear up your infection completely, it is very important that you keep using the cream for the full time of treatment, even if your symptoms begin to clear up after a few days. Since fungus or yeast infections may be very slow to clear up, you may have to continue using ketoconazole every day for up to several weeks. If you stop using ketoconazole too soon, your symptoms may return. Do not miss any doses.

For patients using the foam:

  • Wash your hands before and after using ketoconazole.
  • Do not spray the foam directly on your hand because it will begin to melt as soon as it touches your skin. Instead, spray the foam into the cap of the medicine can or other cool surface. Then dip your fingertips into the foam to pick up small amounts of the medicine, and apply to the affected skin areas. Gently massage the foam into your skin until it disappears.
  • If you are treating skin areas with hair, such as your scalp, move any hair away so the foam can be applied directly to the affected skin.
  • Ketoconazole is flammable. Do not use it near heat, an open flame, or while smoking. Do not puncture, break, or burn the medicine can.

For patients using the gel:

  • Wash your hands before and after using ketoconazole.
  • Apply enough ketoconazole gel to cover the affected and surrounding skin areas, and rub in gently with your fingertips.
  • After applying ketoconazole, do not wash the affected area for at least 3 hours.
  • Cosmetics (makeup or sunscreens) may be used on the treated skin areas no sooner than 20 minutes after ketoconazole is applied.
  • Ketoconazole may be flammable. Do not use it near heat, an open flame, or while smoking.

For patients using the 1% shampoo:

  • Wet your hair and scalp well with water.
  • Apply enough shampoo to work up a good lather and gently massage it over your entire scalp.
  • Rinse your hair and scalp with warm water.
  • Repeat application.
  • Rinse your hair and scalp well with warm water, and dry your hair.

For patients using the 2% shampoo:

  • Wet your hair and scalp well with water.
  • Apply the shampoo to the skin of the affected area and a wide margin surrounding this area.
  • Work up a good lather and leave it in place for 5 minutes.
  • Rinse your hair and scalp well with warm water, and dry your hair.


The dose of ketoconazole will be different for different patients. Follow your doctor’s orders or the directions on the label. The following information includes only the average doses of ketoconazole. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

  • For cream dosage form:
    • For cutaneous candidiasis, tinea corporis, tinea cruris, tinea pedis, or pityriasis versicolor:
      • Adults—Apply to the affected area of the skin and the surrounding area once a day.
      • Children—Use and dose must be determined by your doctor.
    • For seborrheic dermatitis:
      • Adults—Apply to the affected area of the skin and the surrounding area two times per day.
      • Children—Use and dose must be determined by your doctor.
  • For foam dosage form:
    • For seborrheic dermatitis:
      • Adults—Apply to the affected area of the skin and the surrounding area two times per day for 4 weeks.
      • Children—Use and dose must be determined by your doctor.
  • For gel dosage form:
    • For seborrheic dermatitis:
      • Adults, teenagers, and children 12 years of age and older—Apply to the affected area of the skin and the surrounding area once a day for 2 weeks.
      • Children younger than 12 years of age—Use and dose must be determined by your doctor.
  • For 1% shampoo dosage form:
    • For dandruff:
      • Adults—Use every 3 or 4 days for up to 8 weeks. Then use only as needed to keep dandruff under control.
      • Children—Use and dose must be determined by your doctor.
  • For 2% shampoo dosage form:
    • For pityriasis versicolor:
      • Adults—Use once.
      • Children—Use and dose must be determined by your doctor.

Missed dose

If you miss a dose of ketoconazole, apply it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule.


Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Ask your healthcare professional how you should dispose of any medicine you do not use.

Precautions while using ketoconazole

It is very important that your doctor check your progress at regular visits. This will allow your doctor to see if the medicine is working properly and check you for any problems or unwanted effects that may be caused by ketoconazole.

Do not use ketoconazole for a skin problem that has not been checked by your doctor.

If your skin problem does not improve within 2 weeks for cutaneous candidiasis, pityriasis versicolor, tinea corporis, or tinea cruris; or 4 weeks for seborrheic dermatitis; or 4 to 6 weeks for tinea pedis, or if it becomes worse, check with your doctor.

Good health habits are also required for patients using the cream form of ketoconazole to help clear up your infection completely and to help make sure it does not return.

For patients using the cream for athlete’s foot (tinea pedis; ringworm of the foot), the following instructions will help keep the feet cool and dry:

  • Avoid wearing socks made from wool or synthetic materials (e.g., rayon or nylon). Instead, wear clean, cotton socks and change them daily or more often if your feet sweat a lot.
  • Wear sandals or well-ventilated shoes (e.g., shoes with holes).
  • Use a bland, absorbent powder (e.g., talcum powder) or an antifungal powder between the toes, on the feet, and in socks and shoes one or two times a day. It is best to use the powder between the times you use the cream.
  • If you have any questions about these instructions, check with your doctor.

For patients using the cream for ringworm of the groin (tinea cruris; jock itch), the following instructions will help reduce chafing and irritation and will also help keep the groin area cool and dry:

  • Avoid wearing underwear that is tight-fitting or made from synthetic materials (e.g., rayon or nylon). Instead, wear loose-fitting, cotton underwear.
  • Use a bland, absorbent powder (e.g., talcum powder) or an antifungal powder on the skin. It is best to use the powder between the times you use ketoconazole cream.
  • If you have any questions about these instructions, check with your doctor.

The foam form of ketoconazole may make your skin more sensitive to sunlight. Use a sunscreen when you are outdoors. Avoid sunlamps and tanning beds.

Ketoconazole may cause a serious type of allergic reaction called anaphylaxis. Anaphylaxis can be life-threatening and requires immediate medical attention. Call your doctor right away if you have a rash; itching; hoarseness; trouble breathing; trouble swallowing; or any swelling of your hands, face, or mouth while you are using ketoconazole.

Tell your doctor if you have the following symptoms while using the ketoconazole 2% shampoo: hair discoloration, abnormal hair texture, removal of the curl from permanently waved hair, hair loss, itching, burning sensation of the skin, or blistering, peeling, or redness of the skin.

Stop using ketoconazole and check with your doctor right away if you or your child have a skin rash, burning, stinging, swelling, or irritation on the skin.

Ketoconazole side effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

Less common—For cream, shampoo, foam, or gel

  • Itching, stinging, burning, or irritation not present before use of ketoconazole

Rare—For cream, foam, or gel

  • Acne
  • bleeding from sore in the mouth
  • blistering, crusting, irritation, itching, or reddening of the skin
  • burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings
  • cracked, dry, or scaly skin
  • discoloration of the fingernails or toenails
  • dizziness
  • eye dryness, irritation, or swelling
  • red rash with watery, yellow-colored, or pus filled blisters with or without thick yellow to honey-colored crusts
  • skin dryness, pain, rash, redness, or swelling
  • sore in the mouth or on the gums
  • swelling of the face

Rare—For shampoo

  • Hair loss and irritation

Incidence not known—For gel

  • Pain

Incidence not known—For shampoo

  • Blistering, burning, crusting, dryness, or flaking of the skin
  • burning sensation of the skin
  • burning, itching, redness, skin rash, swelling, or soreness at the application site
  • discoloration of the hair
  • dry skin
  • fast heartbeat
  • fever
  • hives
  • hoarseness
  • irritation
  • itching, scaling, severe redness, or soreness of the skin
  • joint pain, stiffness, or swelling
  • rash
  • shortness of breath
  • swelling of the eyelids, face, lips, hands, or feet
  • thinning of the hair
  • tightness in the chest
  • troubled breathing or swallowing
  • wheezing

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

Less common—For shampoo or gel

  • Dryness or oiliness of the hair and scalp
  • headache

Rare—For shampoo

  • Abnormal hair texture
  • mild dryness of the skin
  • scalp pustules

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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US Pharm. 2010;35(8):10-15.

Pharmacists are often asked about treatment of minor medical conditions such as tinea pedis, commonly known as athlete’s foot. At times, patients may need confirmation that they actually have the condition. For this reason, it is important for the pharmacist to be able to recognize tinea pedis and provide appropriate advice in treating it and preventing its recurrence.

Prevalence of Tinea Pedis

The reported prevalence of tinea pedis is dependent on the sampling group chosen, but it is thought to be the most common fungal pathogen.1 In one survey, it was found to affect as many as one-quarter of those visiting a dermatology clinic for reasons unrelated to fungi, and it has been reported to be present in 70% of adults.2,3 Many patients do not know that they suffer from the condition, perhaps attributing their symptoms to other causes (e.g., dermatitis).

Etiology of Tinea Pedis

Dermatophytes are a class of keratinophilic cutaneous fungal organisms that subsist on the stratum corneum, the dead layer of skin, as well as the hair, fingernails, and toenails.3 These mycoses are usually unable to exist on unkeratinized, living layers of skin and mucous membrane. Like other dermatophytes, the organisms responsible for tinea pedis survive optimally in warm, moist areas, such as intertriginous skin (areas that are often or constantly in contact with other skin). Thus, this common dermatophytic skin infection often attacks the areas between the toes. Specific causal organisms include Trichophyton rubrum (responsible for 71.2% of cases), Trichophyton tonsurans (6.9%), Trichophyton mentagrophytes (5.5%), Microsporum canis (4.5%), and Epidermophyton floccosum (1.3%).4,5

Epidemiology of Tinea Pedis

Tinea pedis is more common in adults aged 15 to 40 years than other age groups, and it also prefers males over females.3,6,7 A major epidemiologic risk factor is use of communal bathing facilities, making those who use them prime targets. Shared bathtubs and showers are common in locker rooms, summer camps, college dormitories, municipal swimming pools, gyms, sports clubs, steam rooms, and boarding schools.3,8 The common name of the condition (athlete’s foot) reflects the general awareness that it occurs more frequently in such groups.

A further epidemiologic factor involves choice of footwear. Some who walk on contaminated surfaces escape the condition, while others experience its uncomfortable symptoms. After the fungus reaches target tissues, it requires optimal warmth and humidity to fully begin to infect the host. Wearing socks and shoes creates an ideal environment that is most conducive to fungal growth, and sneakers have been found to be an independent risk factor for acquiring tinea pedis.8 Conversely, going barefoot or wearing sandals allows the foot to dry and cool off, inhibiting tinea pedis pathogens.

Research has also identified owning a pet as a risk factor for tinea pedis.8 In these cases, the pet carries fungal organisms (e.g., M canis) that are capable of existing on human tissues, and normal human-pet interactions allow transfer to the owner. Many owners deny that their pet is the cause, believing that an infected pet will carry visible evidence of infection, such as large spots where its fur is denuded. However, in most cases, the infected pet retains its fur, and owners remain unaware that their pets are carriers of these zoophilic organisms until they contract the infection from them.

Manifestations of Tinea Pedis

When pharmacists field questions about possible tinea pedis, it is critical to be aware of the condition’s visible signs and symptoms in order to fully and capably assist the patient. With the patient’s consent, the pharmacist may be able to view the foot and ankle, facilitating recognition of the condition.

Tinea pedis most often begins on the small toe, or in the groove between the fourth and fifth toes, so these areas should be examined first.3 The reason for this geographic predilection is that the fifth toe is most likely of all to be overcrowded in tight shoes or sneakers, and its continued close proximity to the fourth toe does not allow the interdigital toe web to dry as thoroughly as other surfaces of the foot. Moisture accumulation and maceration present ideal conditions for growth of the organisms following implantation. From that common starting point, tinea pedis is able to branch out and assume several forms.

The most common category is known as interdigital tinea pedis.3,9 In this type, the skin between the patient’s toes (most often the fourth and fifth) begins to itch and break down. Fissures develop, with accompanying maceration to the point of a boggy appearance, increased whitening and thickening, intense pruritus and burning, and the development of a foul odor due to bacterial overgrowth in the open wounds.3,10

Tinea pedis may present in the second form, known as acute vesiculobullous infection. Foul odor and intense pruritus are also present.3,10 The lesions include vesicles and pustules; inflammation and fissuring are also prominent. Patients may be virtually disabled by the symptoms.

The third form of tinea pedis is the moccasin type, most often caused by anthropophilic fungi that are passed from person-to-person. The patient notices a fine scale over the plantar surface, but there are no vesicles, and there may be no symptoms. The name is justified, as the preferential locations (plantar surface, heel, and sides of the foot) are those covered by a moccasin. This form is often chronic, persisting for many years and recurring each summer as conditions (e.g., sweating) become ideal for its emergence.

The pharmacist should also inquire whether one or both hands have begun to appear red, dry, or scaly.3 This is common in patients who habitually attempt to relieve the pruritus of tinea pedis by scratching, transferring the tinea to the hand. The condition, known as tinea manuum, may be present on both hands, but is more common on just one hand, a condition known as “two-foot, one-hand” syndrome. Nonprescription products may not be effective on the hand, as tinea manuum is not an FDA-approved indication.

The pharmacist will often note that tinea pedis is accompanied by toenail infection, a condition known as tinea unguium or onychomycosis.11 Toenails infected with tinea often appear brittle, opaque, yellow, thickened, and crumbled. Infection of the nails may be the reason for persistent tinea pedis, as the organisms remain there to spread out when conditions permit.12 Nonprescription products are unable to treat this condition. Thus, the patient must be urged to see a physician for prescription therapy.

Treatment of Tinea Pedis

Tinea pedis may be treated with topical or systemic prescription therapies. Systemic oral medications (e.g., griseofulvin, itraconazole, ketoconazole, terbinafine) carry the possibility of adverse reactions such as diarrhea or skin rash, making the relatively innocuous OTC products an attractive initial therapeutic choice.3,13-15 When recommending nonprescription products, pharmacists should stress the importance of adhering to the regimen, applying the substance as often as directed, and completing the full course of therapy as suggested on the label.

Nonprescription treatment of tinea pedis is categorized into three generations, with succeeding products presenting significant advantages.3,16 The first generation includes clotrimazole (e.g., Cruex Cream, Lotrimin AF Cream); miconazole (e.g., Cruex Spray Powder, Desenex Powder, Lotrimin AF Powder, Micatin Spray Liquid); and tolnaftate (e.g., Lamisil AF Defense Powder, Tinactin Cream and Spray). These are indicated for patients aged 2 years and above.3 The patient is directed to apply the product twice daily, and it must be applied for 4 weeks. The labels state that the products will cure tinea pedis but do not indicate any difference in efficacy for the three subtypes. These imidazole compounds are not fungicidal, as they only interrupt development of the membrane of growing fungal cells. Thus, they are only bacteriostatic, which accounts for their relatively long application time. Of the three compounds in this class, tolnaftate is the sole agent approved for preventing annual recurrences, but patients who experience yearly recurrences have not achieved the promised cure, making more effective products preferable.

The second generation of OTC antifungals for tinea pedis contains two ingredients: topical butenafine and terbinafine.3,16 Butenafine is a synthetic fungistatic/fungicidal benzylamine, and terbinafine is a fungicidal allylamine. These products warrant separate consideration because they promise cures in a shorter time, and they are not safe in patients below the age of 12 years. Butenafine (e.g., Lotrimin Ultra Cream) will cure tinea pedis between the toes (e.g., the interdigital form) in only 1 week if used twice daily or in 4 weeks if the patient uses it only once daily. Thus, the pharmacist should urge the patient to apply the product each morning and at night. Butenafine is not known to be effective if the patient has tinea pedis on the bottom and sides of the feet (i.e., moccasin type). Topical terbinafine (e.g., Lamisil AT Cream, Spray Pump, Solution) will cure tinea pedis between the toes when used twice daily for 1 week. The cream is also labeled to cure tinea pedis on the bottom and sides of the feet when used twice daily for 2 weeks.

The newest generation of nonprescription tinea pedis products contains only one ingredient: terbinafine in a gel dosage form (e.g., Lamisil AT Gel).16 This product can also cure tinea pedis between the toes in patients aged 12 years and above, but it is in a separate class because the gel requires only once-daily application to produce a cure in 1 week. The reason for its enhanced efficacy is a highly lipophilic/keratophilic nature, allowing it to achieve high therapeutic levels that remain for an additional 7 days beyond its initial 7-day application.16

Preventing Tinea Pedis

Pharmacists can provide advice on preventing tinea pedis.3,17 Patients should keep the feet dry and clean, drying them thoroughly (especially between the toes) before putting on socks and shoes. They should go barefoot whenever possible to allow thorough drying and be urged to wear rubber sandals whenever they walk in communal bathing facilities or any location where people have walked with bare feet. If a toenail becomes infected, they must seek immediate care to prevent the spread of infection to the surrounding skin. Finally, if patients develop tinea in another part of the body, they must take great care to prevent transferring it to the foot (e.g., by washing and drying that part of the body with separate cloths).

Identifying Athlete’s Foot

Athlete’s foot, also known as tinea pedis, is a fungal infection that can appear in several forms. Perhaps you have noticed the area between your fourth and fifth toes has become infected, with fissures, cracking, and a wet look and feel, with whitening and/or thickening of the skin. Itching may be so severe that it requires almost constant scratching. There may also be an intense, foul odor.

You may notice that other spots on the foot are involved as well. Perhaps the sole and sides of the foot are affected with small blisters, scaling, swelling, and open cracking. Your toenails appear white or brittle, with crumbling and cracking of the nail. The nail may even lift up from its nail bed. Finally, tinea pedis that is not cured tends to be less intense during the winter and may seem to almost disappear. However, with the beginning of late spring or summer, it may return again and again unless a total cure is achieved.

How Can You Treat Athlete’s Foot?

There are many noninfective conditions that affect the foot, such as psoriasis and poison ivy. If you are unsure whether your problem is athlete’s foot (i.e., symptoms differ markedly from those previously explained), you should visit a physician. Your pharmacist may also be able to recognize the presence of athlete’s foot. Once athlete’s foot is confirmed, you may treat the problem with nonprescription products. Generally, OTC products are safer than prescription products, as they have fewer side effects. Used properly, nonprescription products may also cure athlete’s foot.

Your pharmacist can provide full counseling information on treatment options for athlete’s foot. You must read the labels carefully and follow all directions provided. Some products (e.g., Lotrimin AF Cream, Micatin Spray Liquid, Tinactin Cream) can be used in anyone aged 2 years and above, but they must be used twice daily for 4 weeks to produce a cure.

Another product (Lotrimin Ultra Cream) must only be used in those aged 12 years and above, but it can cure athlete’s foot between the toes in 1 week if used twice daily or in 4 weeks if you choose to use it only once daily. However, it will not cure athlete’s foot on the bottom or sides of the feet, which is known as moccasin type.

Lamisil AT Cream can also cure athlete’s foot in those aged 12 years and above. The spray pump and solution forms only cure the condition between the toes if used twice daily for 1 week, but the cream can also cure the infection on the bottom and sides of the feet when used twice daily for 2 weeks.

A newer product, Lamisil AT Gel, can cure athlete’s foot between the toes of patients aged 12 years and above when used just once daily for 1 week. This presents enhanced convenience in use, as no other product cures this quickly when used only once daily.

With such an array of OTC options available to treat and even cure athlete’s foot, it is always a good idea to ask your pharmacist for a recommendation for the most appropriate product.

1. Peréz-González M, Torres-Rodríguez JM, Martínez-Roig A, et al. Prevalence of tinea pedis, tinea unguium of toenails and tinea capitis in school children from Barcelona. Rev Iberoam Micol. 2009;26:228-232.
2. Watanabe S, Harada T, Hiruma M, et al. Epidemiological survey of foot diseases in Japan: results of 30,000 foot checks by dermatologists. J Dermatol. 2010;37:397-406.
3. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
4. López-Martínez R, Manzano-Gayosso P, Hernández-Hernández F, et al. Dynamics of dermatophytosis frequency in Mexico: an analysis of 2084 cases. Med Mycol. 2010;48:476-479.
5. Skerlev M, Miklic P. The changing face of Microsporum spp infections. Clin Dermatol. 2010;28:146-150.
6. Pau M, Atzori L, Aste N, et al. Epidemiology of tinea pedis in Cagliari, Italy. G Ital Dermatol Venereol. 2010;145:1-5.
7. What causes athlete’s foot? Mayo Clin Womens Healthsource. 2009;13:8.
8. Flores JM, Castillo VB, Franco FC, et al. Superficial fungal infections: clinical and epidemiological study in adolescents from marginal districts of Lima and Callao, Peru. J Infect Dev Cries. 2009;3:313-317.
9. Borelli C, Korting HC, Bödeker RH, et al. Safety and efficacy of sertaconazole nitrate cream 2% in the treatment of tinea pedis interdigitalis: a subgroup analysis. Cutis. 2010;85:107-111.
10. Kircik LH. Observational evaluation of sertaconazole cream 2% in the treatment of pruritus related to tinea pedis. Cutis. 2009;84:279-283.
11. Bristow IR, Spruce MC. Fungal foot infection, cellulitis and diabetes: a review. Diabet Med. 2009;26:548-551.
12. Walling HW. Subclinical onychomycosis is associated with tinea pedis. Br J Dermatol. 2009;161:746-749.
13. Korting HC, Schöllmann C. The significance of itraconazole for treatment of fungal infections of skin, nails and mucous membranes. J Dtsch Dermatol Ges. 2009;7:11-20.
14. Gianni C. Update on antifungal therapy with terbinafine. G Ital Dermatol Venereol. 2010;145:415-423.
15. Cost of topical products for tinea pedis. Med Lett Drugs Ther. 2010;52:35-36.
16. Pray WS. The role of the pharmacist in managing patients with tinea pedis: enhancing treatment adherence improves patient outcomes. US Pharm. 2007;32(4):69-78. continuing_education/ ceviewtest/lessonid/105450. Accessed June 29, 2010.
17. Jargin SV. Prevention of tinea pedis and onychomycosis: a view from Russia. Acta Microbiol Immunol Hung. 2010;57:69-70.

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Ketoconazole, Oral Tablet

Ketoconazole oral tablet can interact with other medications, vitamins, or herbs you may be taking. An interaction is when a substance changes the way a drug works. This can be harmful or prevent the drug from working well.

To help avoid interactions, your doctor should manage all of your medications carefully. Be sure to tell your doctor about all medications, vitamins, or herbs you’re taking. To find out how this drug might interact with something else you’re taking, talk to your doctor or pharmacist.

Drugs you should not use with ketoconazole

Certain drugs should not be taken with ketoconazole. Doing so can cause dangerous effects in the body. Examples of these drugs include:

  • Antiarrhythmic drugs, such as dofetilide, quinidine, and dronedarone. Taking these drugs with ketoconazole may cause a heart problem called QT prolongation. This is a change in the electrical activity in the heart. It can cause irregular heartbeats and be life-threatening.
  • Methadone. Taking these drugs together may cause a heart problem called QT prolongation. This is a change in the electrical activity in the heart. It can cause irregular heartbeats and be life-threatening.
  • Ranolazine. Taking these drugs together may cause a heart problem called QT prolongation. This is a change in the electrical activity in the heart. It can cause irregular heartbeats and be life-threatening.
  • Simvastatin or lovastatin. Taking ketoconazole with these drugs may cause muscle problems.
  • Triazolam, midazolam, or alprazolam. Taking these drugs together may make you feel very drowsy for a long period of time.
  • Eplerenone. Taking these drugs together may cause low blood pressure and low potassium levels.

Interactions that increase your risk of side effects

Taking certain drugs with ketoconazole raises your risk of side effects.

  • Side effects from ketoconazole: Taking ketoconazole with certain medications raises your risk of side effects from ketoconazole. This is because the amount of ketoconazole in your body is increased. Examples of these drugs include:
    • ritonavir
    • atorvastatin
  • Side effects from other drugs: Taking ketoconazole with certain medications raises your risk of side effects from these drugs. Examples of these drugs include:
    • Pain drugs, such as buprenorphine, fentanyl, and oxycodone. Taking these drugs with ketoconazole may cause slowed breathing.
    • Anticoagulants, such as rivaroxaban, dabigatran, and warfarin. Taking these drugs with ketoconazole may increase your risk of bleeding.
    • Heart drugs, such as felodipine and nisoldipine. Taking these drugs with ketoconazole may cause swelling of your legs or arms and heart failure.
    • Tamsulosin. Taking these drugs together may cause headache, dizziness, and orthostatic hypotension (low blood pressure when you stand up from a sitting or lying position).
    • Digoxin. Taking these drugs together may cause dizziness, headache, and stomach pain. Your doctor may monitor your digoxin blood levels.
    • Eletriptan. Taking these drugs together may cause weakness, nausea, dizziness, and drowsiness.
    • Antipsychotic drugs, such as aripiprazole, buspirone, haloperidol, quetiapine, and risperidone. Taking these drugs with ketoconazole may cause dizziness, drowsiness, and headaches.
    • Ramelteon. Taking these drugs together may cause dizziness, drowsiness, and fatigue.
    • Antivirals such as indinavir, maraviroc, and saquinavir. Taking these drugs with ketoconazole may cause stomach pain, nausea, and headaches.
    • Blood pressure drugs, such as verapamil and aliskiren.Taking these drugs with ketoconazole may cause low blood pressure, low heart rate, and dizziness.
    • Drugs for erectile dysfunction, such as sildenafil, tadalafil, and vardenafil. Taking these drugs with ketoconazole may cause headaches, upset stomach, and muscle pain.
    • Drugs for urine problems, such as solifenacin and tolterodine. Taking these drugs with ketoconazole may cause dry mouth, headaches, and dizziness.

Interactions that can make your drugs less effective

  • When ketoconazole is less effective: When ketoconazole is used with certain drugs, it may not work as well to treat your condition. This is because the amount of ketoconazole in your body may be decreased. Examples of these drugs include:
    • Ranitidine, famotidine, cimetidine, pantoprazole, omeprazole, and rabeprazole. You should take ketoconazole with an acidic beverage, such as a non-diet soda, if you take these drugs together.
    • Aluminum hydroxide. You should take this drug 1 hour before or 2 hours after taking ketoconazole.
    • Antibiotics, such as isoniazid and rifabutin
    • Anticonvulsants, such as carbamazepine and phenytoin
    • Antivirals, such as efavirenz and nevirapine
    • Carbamazepine. Your doctor may monitor your carbamazepine levels.

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs interact differently in each person, we cannot guarantee that this information includes all possible interactions. This information is not a substitute for medical advice. Always speak with your healthcare provider about possible interactions with all prescription drugs, vitamins, herbs and supplements, and over-the-counter drugs that you are taking.

The U.S. Food and Drug Administration (FDA) is warning health care professionals to avoid prescribing the antifungal medicine ketoconazole oral tablets to treat skin and nail fungal infections. Use of this medication carries the risk of serious liver damage, adrenal gland problems, and harmful interactions with other medicines that outweigh its benefit in treating these conditions, which are not approved uses of the drug.

We approved label changes for oral ketoconazole tablets in 2013 to reflect these serious risks and to remove the indication for treatment of skin and nail fungal infections. However, an FDA safety review found that oral ketoconazole continues to be prescribed for these types of conditions. In the 18 months ending in June 2015, skin and nail fungal infections were the only diagnoses1 cited for the use of oral ketoconazole in an office-based physician surveys database.2 Since the 2013 labeling change, one patient death has been reported to the FDA due to liver failure associated with oral ketoconazole prescribed to treat a fungal infection of the nails.

Health care professionals should use ketoconazole tablets only to treat serious fungal infections when no other antifungal therapies are available. Skin and nail fungal infections in otherwise healthy persons are not life-threatening, and so the risks associated with oral ketoconazole outweigh the benefits. Other treatment options are available over-the-counter and by prescription, but are also associated with risks that should be weighed against their benefits.

Patients should discuss with their health care professionals the risks and benefits of available therapies before using any medicine to treat skin and nail fungal infections. Patients taking ketoconazole tablets should seek medical attention right away if they experience any of these signs and symptoms of liver problems, which include loss of appetite, nausea, vomiting, or abdominal discomfort; yellowing of the skin or the whites of the eyes (jaundice); unusual darkening of the urine or lightening of the stools; or pain and discomfort in the right upper abdomen where the liver is located.

Ketoconazole in tablet form is indicated to treat serious infections caused by fungi and should be used only when other effective therapy is not available or tolerated. It works by killing the fungus or preventing it from growing. During the 12-month period ending in June 2015, approximately 217,000 patients received dispensed prescriptions for oral ketoconazole from U.S. outpatient retail pharmacies.3 Ketoconazole is only available as a generic. The topical forms of ketoconazole that are applied to the skin or nails have not been associated with liver damage, adrenal problems, or drug interactions.

In a July 2013 Drug Safety Communication, we warned that ketoconazole tablets should not be used as a first-line treatment for any fungal infection because it can cause severe liver injury and adrenal gland problems, and advised it can lead to harmful interactions with other medicines. We determined that the risks outweigh the benefits for treating skin and nail fungal infections and approved label changes removing this indication from the drug label and limited its labeled indication to treating only serious fungal infections.

We urge health care professionals and patients to report side effects involving ketoconazole to the FDA MedWatch program, using the information in the “Contact FDA” box at the bottom of the page.

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