Charlotte83 Posted July 17, 2011 Hello, I have encountered a problem when I tried to prescribe oral antifungal meds for my pt. Hope somebody can help me with this case. I have a 40 y/o male with widespread pruritic rash on trunk x 2years. His PCP prescribed Itraconazole 200mg x 1 day. Pt. states the rash went away for a few days but returned with a vengeance. When I looked at the rash, it has an erythematous, annular pattern with central clearing and also has hypopigmented patches and fine scales. This looks like a combination of Tinea corporis and Tinea versicolor. I would like to start him on Ketoconazole but he is currently on oxycodone. I am afraid of the drug interaction. I am thinking about rx Itraconzaole x 1 week but pt states the med was not covered and refused to take it. Should I try to stick with the topical regimen? Is there other azole that has less interaction? Thank you so much!!
Charlotte83 Posted July 17, 2011 Author Hello, I have encountered a problem when I tried to prescribe oral antifungal meds for my pt. Hope somebody can help me with this case. I have a 40 y/o male with widespread pruritic rash on trunk x 2years. His PCP prescribed Itraconazole 200mg x 1 day. Pt. states the rash went away for a few days but returned with a vengeance. When I looked at the rash, it has an erythematous, annular pattern with central clearing and also has hypopigmented patches and fine scales. This looks like a combination of Tinea corporis and Tinea versicolor. I would like to start him on Ketoconazole but he is currently on oxycodone. I am afraid of the drug interaction. I am thinking about rx Itraconzaole x 1 week but pt states the med was not covered and refused to take it. Should I try to stick with the topical regimen? Is there other azole that has less interaction? Thank you so much!!
Moderator ventana Posted July 17, 2011 Moderator I always use topicals first line (even for some wider spread rashes) due to the interactions with almost everything that the azoles have. BID topical lotrimin or lamisil - could try lotrisone for a little steroid exposure - I tell them to lather on the OTC antifungals for a few weeks to see if it makes it better - would make a lot of sense to do a scraping to confirm Dx also consider sporenix (sp)
Moderator ventana Posted July 17, 2011 Moderator I always use topicals first line (even for some wider spread rashes) due to the interactions with almost everything that the azoles have. BID topical lotrimin or lamisil - could try lotrisone for a little steroid exposure - I tell them to lather on the OTC antifungals for a few weeks to see if it makes it better - would make a lot of sense to do a scraping to confirm Dx also consider sporenix (sp)
Acebecker Posted July 18, 2011 I second the skin scraping to confirm a Dx of tinea. Very easy procedure, low risk to the patient, relatively low cost. If you see fungal elements, confirms Dx and you know the azoles are the right course. The reason I am thinking you need to take another step to establish the Dx is that this sounds like it may be consistent with nummular eczema and in that case triamcinolone topical would be first line Tx. Best of luck - I hate derm. Andrew
Acebecker Posted July 18, 2011 I second the skin scraping to confirm a Dx of tinea. Very easy procedure, low risk to the patient, relatively low cost. If you see fungal elements, confirms Dx and you know the azoles are the right course. The reason I am thinking you need to take another step to establish the Dx is that this sounds like it may be consistent with nummular eczema and in that case triamcinolone topical would be first line Tx. Best of luck - I hate derm. Andrew
sk732 Posted July 20, 2011 If you're worried about Tinea Versicolor, it usually responds to simple, reasonably inexpensive topical stuff like Nizoral (ketaconazole) or Selsun shampoos - if tinea corporis is also an issue, stick with the topicals and use the Nizoral shampoo...no issues with interactions this way. If you're really worried it might not be fungal, you could try a steroid, but do a patch test with it alone first to make sure it doesn't bloom on you. $0.02 SK
sk732 Posted July 20, 2011 If you're worried about Tinea Versicolor, it usually responds to simple, reasonably inexpensive topical stuff like Nizoral (ketaconazole) or Selsun shampoos - if tinea corporis is also an issue, stick with the topicals and use the Nizoral shampoo...no issues with interactions this way. If you're really worried it might not be fungal, you could try a steroid, but do a patch test with it alone first to make sure it doesn't bloom on you. $0.02 SK
Hemegroup Posted July 20, 2011 The reason I am thinking you need to take another step to establish the Dx is that this sounds like it may be consistent with nummular eczema and in that case triamcinolone topical would be first line Tx. Yup, my general rule of thumb is to try the steroid, which if it's fungal will make the rash worse. But that's a bit sloppier than scraping, I'll admit. Throw in some antihistamines for good measure. lol If it does turn out that the patient needs an oral anti-fungal, don't forget to run hepatic labs on him first to make there's no compromise to the liver.
Hemegroup Posted July 20, 2011 The reason I am thinking you need to take another step to establish the Dx is that this sounds like it may be consistent with nummular eczema and in that case triamcinolone topical would be first line Tx. Yup, my general rule of thumb is to try the steroid, which if it's fungal will make the rash worse. But that's a bit sloppier than scraping, I'll admit. Throw in some antihistamines for good measure. lol If it does turn out that the patient needs an oral anti-fungal, don't forget to run hepatic labs on him first to make there's no compromise to the liver.
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