Comparative study of terbinafin or itraconazole monotherapy versus combined therapy in dermatophytosis

Authors

  • Nadia Islam Department of Pharmacology and Therapeutics, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
  • Sohail Mirza Department of Dermatology and Venereology, Shaheed Tajuddin Ahmad Medical College Hospital, Gazipur, Bangladesh
  • Morshed Nasir Department of Pharmacology and Therapeutics, Holy Family Red Crescent Medical College, Dhaka, Bangladesh

DOI:

https://doi.org/10.18203/issn.2455-4529.IntJResDermatol20261456

Keywords:

Tinea infections, Terbinafine, Itraconazole, Combination therapy

Abstract

Background: Dermatophytosis, is a very frequent fungal infection of skin prevailing in underprivileged countries. As drug resistance of monotherapy is rising rapidly, combination therapy is blooming as the preferred choice. Itraconazole and terbinafine are widely used antifungal drugs in Bangladesh. Although many studies on monotherapy of these drugs have been done for the treatment of fungal infections, but study on their combined use showing difference with cure rates and recurrence rates in our country is still inadequate. Objectives were to determine and compare the clinical outcome of monotherapy with terbinafin or itraconazole comparing with combined therapy in various dermatophytosis (tinea infections).

Methods: Clinically diagnosed patients suffered from various tinea infections at multiple private clinics in Gazipur district of Bangladesh were treated from January to June 2025. Total 150 patients were divided into three groups (Itraconazole only, terbinafine only and combination of both). The therapeutic effects were evaluated by clinical cure rate by clinical symptoms, mycological cure rate by mycology examination, adverse effects, and recurrence rates of disease.

Results: The data of patients were evaluated biweekly period and at 4 and at end of 8 weeks of therapy. In the combined group, the symptoms were significantly cured, in comparison to the terbinafine or itraconazole group (p1<0.05 and p2<0.05). The clinical cure rate, mycological cure rate, recurrence rate showed 92%, 90% and 4% in combined group, 78%, 74% and 14% in terbinafine group, 74%, 70% and 18% in Itraconazole group respectively. The combination therapy achieved better results. Adverse effects were less in each group during follow-up. The 96% patients was satisfied with combined treatment.

Conclusions: Combination therapy is more efficacious than monotherapy for treatment of tinea infections and demonstrates more successful strategy for treating resistant dermatophytosis.

References

Gaurav V, Bhattacharya SN, Sharma N, Datt S, Kumar P, Rai G, et al. Terbinafine resistance in dermatophytes: time to revisit alternate antifungal therapy. J Mycol Med. 2021;31(1):101087.

Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia. 2008;166(5-6):353-67.

Hay RJ. Therapy of skin, hair, and nail fungal infections. J Am Acad Dermatol. 1993;29(4):S55-9.

Gupta AK, Ryder JE, Chow M, Cooper EA. Dermatophytosis: the management of fungal infections. Skinmed. 2005;4(5):305-10.

Saunte DM, Hare RK, Jørgensen KM, Jørgensen R, Deleuran M, Zachariae CO, et al. Emerging terbinafine resistance in Trichophyton: clinical characteristics, squalene epoxidase gene mutations, and a reliable EUCAST method for detection. Antimicrob Agents Chemother. 2019;63(10):e01126-9.

Jones TC. Itraconazole in the management of fungal infection. J Am Acad Dermatol. 1997;36(6):S7-11.

Krishnan-Natesan S. Terbinafine: a pharmacological and clinical review. Expert Opin Pharmacother. 2009;10(16):2723-33.

Ryder NS. Terbinafine: mode of action and properties of squalene epoxidase inhibition. Br J Dermatol. 1992;126(39):2-7.

Bhattacharjee R, Dogra S. “End of the road for terbinafine” in dermatophytosis: is it a valid conclusion? Indian J Dermatol Venereol Leprol. 2018;84(6):706-7.

Gupta KA, Chow M, Daniel CR, Aly R. Treatments of tinia pedis. Dermatologic Clinics 2003;21(3):431-62.

Campitelli M, Zeineddine N, Samaha G, Maslak S. Combination Antifungal Therapy: A Review of Current Data. J Clin Med Res. 2017;9(6):451-6.

De Doncker P, Pande S, Richarz U, Garodia N. Itraconazole: what clinicians should know. Indian J Drugs Dermatol. 2017;3(1):4-10.

Ebert A, Monod M, Salamin K, Burmester A, Uhrlaß S, Wiegand C, et al. Alarming India-wide phenomenon of antifungal resistance in dermatophytes: a multicentre study. Mycoses. 2020;63(7):717-28.

Singh A, Masih A, Khurana A, Singh PK, Gupta M, Hagen F, et al. High terbinafine resistance in Trichophyton interdigitale isolates in Delhi, India harbouring mutations in the squalene epoxidase gene. Mycoses. 2018;61:477-84.

Panda S, Verma S. The menace of dermatophytosis in India: the evidence that we need. Indian J Dermatol Venereol Leprol. 2017;83(3):281-4.

Saunte DML, Pereiro-Ferreirós M, Rodríguez-Cerdeira C, Sergeev AY, Arabatzis M, Prohić A, et al. Emerging antifungal treatment failure of dermatophytosis in Europe: take care or it may become endemic. J Eur Acad Dermatol Venereol. 2021;35(7):1582-6.

Hutton B, Salanti G, Caldwell DM, Anna C, Christopher HS, Chris C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. Ann Intern Med. 2015;162(11):777-84.

Ryder NS, Favre B. Antifungal activity and mechanism of action of terbinafine. J AntimicrobChemother. 1997;39(A):1-7.

Lesher JL. Oral therapy of common superficial fungal infections of the skin. J Am Acad Dermatol. 1999;40:31-4.

Seebacher C, Olafsson JH, Steinsson JB, Paul C, Billstein S, Evans EGV. Long-term effectiveness and safety of terbinafine and itraconazole in the treatment of fungal infections. Mycoses. 2007;50(2):112-8.

Sardana K, Khurana A, Singh A. Scientific rationale of antifungal drug combination including oral itraconazole and terbinafine in recalcitrant dermatophytoses. J Dermatolog Treat. 2020;31:43-5.

Ryder NS, Wagner S, Leitner I. In vitro activities of terbinafine against cutaneous isolates of Candida albicans and other pathogenic yeasts. Antimicrob Agents Chemother. 1998;42:1057-61.

Sheehan DJ, Hitchcock CA, Sibley CM. Current and emerging azole antifungal agents. Clin Microbiol Rev. 1999;12(1):40-79.

Vitale RG, Afeltra J, Dannaoui E. Antifungal combinations. Methods Mol Med. 2005;118:143-52.

Sigurgeirsson B. Prognostic factors for cure following treatment of onychomycosis. J Am Acad Dermatol. 2002;47(4):551-6.

Faergemann J, Baran R. Epidemiology, clinical presentation and diagnosis of onychomycosis. Br J Dermatol. 2003;149(65):1-4.

Baran R, Faergemann J, Hay RJ. Superficial white onychomycosis-a syndrome with different fungal causes and paths of infection. J Am Acad Dermatol. 2007;57(5):879-82.

Gupta AK, MacLeod MA, Foley KA, Gupta G, Friedlander SF. Fungal Skin Infections. Pediatr Rev. 2017;38(1):8-22.

Zhang D, Liao W, Chen C, Lai H, Liu S. Terbinafine hydrochloride combined with itraconazole for fungal skin diseases: a randomized controlled trial. Am J Ther. 2021;28:e179-86.

Sharma P, Bhalla M, Thami GP, Chander J. Evaluation of efficacy and safety of oral terbinafine and itraconazole combination therapy in dermatophytosis. J Dermatolog Treat. 2020;31:749-53.

Bidaud AL, Schwarz P, Chowdhary A, Dannaoui E. In vitro antifungal combination of terbinafine with itraconazole against isolates of Trichophyton species. Antimicrob Agents Chemother. 2022;66(1):e01449-21.

Choudhary S, Bisati S, Singh J, Koley D. Efficacy and safety of terbinafine hydrochloride 1% cream versus sertaconazole nitrate 2% cream in tinea corporis and tinea cruris. Indian J Dermatol. 2013;58(3):457.

Thomas J, Jacobson GA, Narkowicz CK, Peterson GM, Burnet H, Sharpe C. Toenail onychomycosis: an important global disease burden. J Clin Pharm Ther. 2010;35(5):497-519.

Dolton MJ, Perera V, Pont LG, McLachlan AJ. Terbinafine in combination with other antifungal agents for resistant or refractory mycoses: a physiologically based pharmacokinetic model. Antimicrob Agents Chemother. 2014;58(1):48-54.

Khurana A, Sardana K, Chowdhary A. Antifungal resistance in dermatophytes: recent trends and therapeutic implications. Fungal Genet Biol. 2019;132:103255.

Sardana K, Khurana A, Gupta A. Parameters that determine dissolution and efficacy of itraconazole and relevance to recalcitrant dermatophytoses. Expert Rev Clin Pharmacol. 2019;12(5):443-52.

Pasqualotto AC, Denning DW. Generic substitution of itraconazole resulting in sub-therapeutic levels and resistance. Int J Antimicrob Agents. 2007;30(1):93-4.

Sardana K, Kaur R, Arora P, Goyal R, Ghunawat S. Is antifungal resistance a cause for treatment failure in dermatophytosis? Indian Dermatol Online J. 2018;9(2):90-5.

Brunke S, Mogavero S, Kasper L, Hube B. Virulence factors in fungal pathogens of man. Curr Opin Microbiol. 2016;32:89-95.

Ameen M. Epidemiology of superficial fungal infections. Clin Dermatol. 2010;28(2):197-201.

Gnat S, Łagowski D, Nowakiewicz A, Dyląg M. A global view on fungal infections in humans and animals: opportunistic infections and microsporidioses. J Appl Microbiol. 2021;131(5):2095-113.

Downloads

Published

2026-05-04

How to Cite

Islam, N., Mirza, S., & Nasir, M. (2026). Comparative study of terbinafin or itraconazole monotherapy versus combined therapy in dermatophytosis. International Journal of Research in Dermatology. https://doi.org/10.18203/issn.2455-4529.IntJResDermatol20261456

Issue

Section

Original Research Articles