What are antifungal medicines and how do they work?

There are several types of antifungal medicines. They come as creams, sprays, solutions, tablets
designed to go into the vagina (pessaries), shampoos, medicines to take by mouth, and
injections. Most work by damaging the cell wall of the fungus, which causes the fungal cell to die.
People who are prescribed an antifungal injection are usually in hospital and are very ill.

Antifungal creams, liquids or sprays (topical antifungals)

These are used to treat fungal infections of the skin, scalp and nails. They
include clotrimazole, econazole,ketoconazole, miconazole, tioconazole, terbinafine,
andamorolfine. They come in various different brand names.
Sometimes an antifungal cream is combined with other creams when two actions are required.
For example, an antifungal cream is often combined with a mild steroid cream, such as
hydrocortisone, to treat certain rashes. The antifungal cream clears the infection, and the mild
steroid cream reduces the inflammation caused by the infection.

Antifungal shampoo
A shampoo which contains ketoconazole is sometimes used to help treat scalp fungal infections
and certain skin conditions.

Antifungal pessaries
Pessaries are tablets which are designed to be put into the vagina. Some antifungal medicines
are used as pessaries to treat vaginal thrush, particularly clotrimazole, econazole, miconazole,
and fenticonazole

Antifungal medicines taken by mouth

There are various types. For example:
1. Miconazole is available as an oral gel, and nystatin as a liquid. They are applied to the
mouth. They are used to treat thrush (candidal infection) of the mouth and throat.
2. Terbinafine, itraconazole, fluconazole, posaconazole, and voriconazole are available as
tablets, which are absorbed into the body. They are used to treat various fungal
infections. The one chosen depends on what type of infection you have. For example:

Terbinafine is commonly used to treat nail infections which are usually caused by a tinea
type of fungus.

Fluconazole is commonly used to treat vaginal thrush, as an alternative to using

antifungal cream. It is also used to treat and prevent certain fungal infections within the
body.

Antifungal injections
These may be used if you have a serious fungal infection within the body. Amphotericin,
flucytosine, itraconazole, voriconazole, anidulafungin, caspofungin, and micafungin are
medicines that are sometimes used in this way. The one chosen depends on the type of fungus
causing the infection.
Note: antifungal medicines are different to antibiotics, which are antibacterial
medicines.Antibiotics do not kill fungi - they kill other types of germs (called bacteria). In fact, you
are more prone to getting a fungal infection if you take antibiotics. For example, many women
develop thrush after taking a course of antibiotics. This is because the antibiotic may kill the
normal harmless bacteria that live on your skin or vagina and make it easier for fungi to flourish.

What are the possible side-effects?

You should read the information leaflet that comes with your particular brand for a full list of
cautions and possible side-effects. As a general rule:

Antifungal creams, sprays, liquids and shampoos. These usually cause no sideeffects and are easy to use. Occasionally some people get a little bit of itch, burning or
redness where the antifungal preparation has been applied. If this is severe, you should
stop using it. Occasionally, some women develop irritation around the vagina after applying
vaginal antifungal products.

Antifungal medicines by mouth. The most widely used are terbinafine for nail
infections, miconazole, and nystatin for oral thrush, and fluconazole for vaginal thrush.
These usually cause no side-effects. You can even buy fluconazole without a prescription at
pharmacies, as it is considered a medicine which is unlikely to cause problems. Some
antifungal preparations cause liver problems or more serious side-effects in a small number
of people. A few common possible side-effects of some of the more widely used antifungal
medicines are as follows:

Terbinafine sometimes causes tummy aches, loss of appetite, feeling sick

(nausea), tummy upsets, diarrhoea, headache, rash, taste disturbance and muscle or
joint pains.

Fluconazole may cause nausea, tummy ache, diarrhoea, wind, headache, or a

rash.

Miconazole may cause nausea or sickness (vomiting), or a rash.

Nystatin may cause soreness of the mouth.

Antifungal injections. These have more risk of causing side-effects and sometimes

serious problems. However, these are used to treat serious fungal infections and the risk of
side-effects needs to be balanced against the need for treatment.

Table 1. Antifungal drug classes

Class

Mechanism of action

Drugs

Allylamine

Inhibits squalene epoxidase

Terbinafine
Ketoconazole
Fluconazole

Azole

Impairs ergosterol synthesis

Itraconazole
Voriconazole

Echinocandin
Nucleoside
analog

Impairs 1,3 glucan synthesis

Caspofungin

Impairs pyrimidine metabolism

Flucytosine
Amphotericin B deoxycholate

Polyene

Binds to ergosterol

Amphotericin B colloidal dispersion

Amphotericin B lipid complex
Liposomal amphotericin B