Limited Evidence Supporting the Efficacy of Antifungals for Atopic Dermatitis

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A novel systemic review found that topical and oral antifungal medications are insufficient for treating children and adults with atopic dermatitis (AD).¹ When used on their own, these antimycotic medications did not demonstrate great efficacy in managing the disease.

Investigators searched the databases of PubMed, MEDLINE, Embase, Scopus, LILACS, Cochrane, CINAHL, GREAT, and ClinicalTrials.gov and included all literature published up to June 15, 2022. Initially, 35,591 studies were found. After the selection and extraction processes, only 7 were included in the final review. All were interventional, randomized controlled trials published in English.

The primary measures included AD severity (lesion, itch, and sleep quality) using the SCORing Atopic Dermatitis (SCORAD), Verbal Rating Scale (VRS-Itch), and the Eczema Area and Severity Index (EASI). Patient-reported outcomes were also evaluated using the Dermatology Life Quality Index (DLQI) and Patient Oriented Eczema Measure (POEM). Treatment duration and subsequent follow-ups ranged from 2 weeks to 11 months.

Topical antifungals only showed limited improvement when compared to placebo or corticosteroid treatments. These treatments, including sertaconazole, miconazole, and ciclopirox olamine, had low systemic absorption and were generally not effective. This was demonstrated through several double-blind, randomized trials.

Overall, no significant differences in SCORAD and VRS-Itch were observed. Furthermore, several studies combined miconazole cream with hydrocortisone cream and found no significant improvement compared to hydrocortisone on its own. However, there were fewer adverse effects. Any mild irritation, redness, itching, and stinging were localized to the application sites.

Oral antifungals were also inconsistent in terms of efficacy. For example, in a randomized control trial, only 8 of 36 patients who took 200 mg or 400 mg of itraconazole demonstrated more than 50% SCORAD improvement on the head and neck. However, another trial testing 200 mg of ketoconazole saw a significant improvement in SCORAD, especially in females with P. ovale growth and a total IgE level of < 5000 kU/I.

Compared to topicals, oral medications had a higher risk of systemic adverse events including hepatotoxicity, nephrotoxicity, gastrointestinal upset, QT prolongation, and arrhythmias. This, along with the mixed efficacy results, confirms that there is a lack of notable clinical benefit.

The low number of clinical trials made it impossible for investigators to perform a meta-analysis with quantifiable, objective measures. Future research should utilize larger sample sizes with standardized assessments in severity and adverse events to determine if these could be potential AD treatments.

Besides bacteria, fungi such as Malassezia are among the most common microbes on the skin of patients with AD and could potentially exacerbate the disease.² Despite this, previous studies evaluating the efficacy of antifungal treatments have been inconsistent. The researchers concluded that other non-antifungal therapies are more appropriate for AD management. In patients with AD, antifungals are appropriate for comorbid fungal and yeast infections, like dermatophyte infections.

“Based on the risks of systemic adverse effects and lack of consistent evidence supporting their efficacy, oral antifungals should not be recommended as a treatment for AD per se,” the authors wrote. “There are multiple other currently approved topical, injectable, and oral therapies for treating AD.”

References

1. Andrade LF, Ju T, Abdi P, et al. Lack of evidence for the efficacy of antifungal medications to treat atopic dermatitis: A systematic review. JEADV Clinical Practice. December 24, 2024. doi:10.1002/jvc2.604

2. Serrano L, Patel KR, Silverberg JI. Association between atopic dermatitis and extracutaneous bacterial and mycobacterial infections: A systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(4):904-912. doi:10.1016/j.jaad.2018.11.028