Table 7.

Consensus recommendation for the various facets of treatment of glabrous tinea

	Comments	Recommendation
Indications
Glabrous tinea	Most cases in the current scenario require systemic therapy	Involvement of multiple sites
		Extensive disease based on clinical judgement
		Chronic dermatophytosis
		Recurrent dermatophytosis
		Steroid modified dermatophytosis/ Tinea incognito
		Failure of topical therapy
		Associated nail and hair involvement
		Immunocompromised states like hematological malignancies and therapy with immunosuppressive drugs
Choice of systemic drug
First line	Best option considering overall efficacy and safety	Itraconazole, Terbinafine,
Alternate drugs	Prolonged duration of treatment required	Griseofulvin, Fluconazole
Complementary topical therapy
Choice and rationale	Topical antifungal without corticosteroid and antibacterial components.	Systemic antifungal therapy should preferably be combined with topical antifungal therapy which may be of same or different class
	There are limited laboratory/clinical studies on the efficacy and utility of combination antifungals (systemic with topical OR two systemic) for dermatophytosis of the glabrous skin
Response
Failure	No improvement or worsening of symptoms and signs at 3 weeks	Assessment of factors responsible for it and if detected to be corrected; if not, antifungal therapy to be changed
Total response	Complete subsidence of symptoms and signs with or without post-inflammatory changes anytime during the treatment	Completion of therapy for the stipulated period or as per the individual response
Partial Response	Partial subsidence of symptoms and signs at the end of 3 weeks	Extended duration of treatment to be considered with appropriate laboratory monitoring; double dosing of terbinafine may be considered
Cure
Clinical cure	Complete subsidence of symptoms and signs with or without post-inflammatory changes at the end of treatment	Follow up must be at 4 weeks after apparent clinical cure to look for recurrence
Mycological cure	Complete subsidence of symptoms and signs with negative mycology reports (direct microscopy with/without culture) at the end of the treatment	Follow up must be at 4 weeks after apparent clinical cure to look for recurrence
Laboratory monitoring
Hepatotoxicity	All systemic antifungals are hepatotoxic	Monitoring hepatic function if the treatment is extended or if the dose is doubled
Renal toxicity	Systemic drugs used in the management of dermatophytosis do not commonly cause renal toxicity	Renal monitoring may be considered if indicated on clinical grounds
Follow up
First follow up visit	To assess clinical response	At 3 weeks, if inadequate response
Final follow up visit	To assess recurrence	At 4 weeks after apparent clinical cure
Special situations
Pregnancy	Teratogenicity of the drugs should be addressed	Topical antifungals with established safety [Table 8]
		Oral terbinafine (routine use should be avoided)
Lactating mother	Safety of the infant should be addressed	Topical antifungals
		Oral fluconazole
Children under 2 years	Safety with respect to hepatotoxicity, GI intolerance and other adverse effects should be addressed	Topical antifungals with established safety
		Oral fluconazole
Children above 2 years	Safety with respect to hepatotoxicity, GI intolerance and other adverse effects should be assessed	Topical antifungals with established safety
		Oral terbinafine, itraconazole, fluconazole and griseofulvin
Hepatic dysfunction	Monitoring of the hepatic function is mandatory	Topical antifungals
		Oral fluconazole
Renal dysfunction	Renal function monitoring if terbinafine is used (dose reduction if creatinine clearance is <50 ml/ min)	Topical antifungals
		Oral itraconazole
Cardiac dysfunction	Cardiotoxicity of drugs should be addressed	Topical antifungals
		Oral terbinafine