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Fungal Skin Infection

NICE CKS Fungal skin infection - scalp. Last revised: Feb 2025. NICE CKS Fungal skin infection - body and groin. Last revised: Jul 2023. NICE CKS Fungal skin infection - foot. Last revised: Jun 2023.

Overview

The choice of antifungal across the 3 fungal skin infections is similar but not the same, therefore this concise summary is made:
  • Scalp
    • 1st line: oral antifungal (terbinafine or griseofulvin)
 
  • Body + groin + foot (Athlete's foot) are the same
    • 1st line: topical antifungal (terbinafine or imidazole)
    • Oral antifungal (1st line: terbinafine) reserved for severe / extensive disease

NB that this summary does not replace the below sections.

Scalp Infection

  • Suspected kerion - urgent referral
  • Unsuccessful treatment in primary care
  • Severe / extensive / recurrent infection
  • Immunocompromised

Self management:
  • Soften any surface crusts (e.g. moistened dressings), then gently tease away 

Measures to prevent spread and transmission:
  • Discard / disinfect objects that can transmit fungal spores (e.g. hats, scarves, hairbrushes, combs, pillows, blankets, scissors)
  • Do not share towels, and wash frequently
  • If household pet is the suspected source, assess and treat by a vet

Offer oral antifungal if any of the following:
  • +ve microscopy or culture of the skin and hair
  • -ve mycology but suggestive clinical features (but arrange repeat skin and hair sampling)
  • Strong clinical suspicion before mycology results are back

1st line: oral terbinafine or griseofulvin +/- topical antifungal (e.g. ketoconazole shampoo, imidazole cream)
  • Blind treatment (before culture results available)
    • If person lives in urban area → terbinafine for 4 weeks
    • If person lives in rural area → griseofulvin for 4-8 weeks
 
  • Cultured guided treatment (adjust treatment accordingly)
    • If Trichophyton tonsurans → terbinafine
    • If Microsporum species → griseofulvin

2nd line antifungal: oral itraconazole

Review the patient 4-8 weeks after completing oral antifungal therapy. 

If signs of persistent / recurrent infection, or hair regrowth does not occur → repeat skin and hair sampling for fungal microscopy and culture.

Body and Groin Infection

Self management:
  • Wear loose-fitting clothes made of cotton or material designed to keep moisture away from the skin
  • Wash affected skin daily + dry the skin after washing (esp. in the skin folds)
  • Avoid scratching affected skin (as this may spread the infection to other sites)

Measures to prevent spread and transmission:
  • Do not share towels, and wash frequently
  • Wash clothes and bed linen frequently

If a child is affected, it is NOT necessary to exclude them from school or nursery

1st line: topical antifungal cream
  • Terbinafine cream (only if >12 y/o), or
  • Imidazole (e.g. clotrimazole, miconazole, econazole) (for all ages)

Consider a mildly potent topical corticosteroid (e.g. hydrocortisone 1%) if there is associated marked inflammation.

Consider oral antifungal 
  • 1st line: terbinafine
  • 2nd line: itraconazole / griseofulvin

Foot Infection (Athlete's Foot)

Self management:
  • Foot hygiene
    • Wear well-fitting, non-occlusive footwear that keeps the feet cool and dry
    • Wear different pair of shoes every 2-3 days
    • Wear cotton, absorbent socks
    • Dry the skin after washing the feet (esp. between the toes)
  • Avoid scratching affected skin (as this may spread the infection to other sites)

Measures to prevent spread and transmission:
  • Replace old footwear which could be contaminated with fungal spores
  • Do not share towels, and wash frequently
  • Wear protective footwear when using communal bathing places, locker rooms, gyms

If a child is affected, it is NOT necessary to exclude them from school or nursery

1st line: topical antifungal cream
  • Terbinafine cream (only if >12 y/o), or
  • Imidazole (e.g. clotrimazole, miconazole, econazole) (for all ages)

Consider a mildly potent topical corticosteroid (e.g. hydrocortisone 1%) if there is associated marked inflammation.

2nd line options
  • OTCOver the counter undecenoic acid cream, or
  • Topical preparations containing tolnaftate

Consider oral antifungal 
  • 1st line: terbinafine
  • 2nd line: itraconazole / griseofulvin

References

Author: Adams Lau
Reviewer: 
Last edited: 14/07/25