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Do testosterone injections increase libido for elderly hypogonadal patients?
Yes, testosterone therapy is effective in improving libido for elderly hypogonadal males (strength of recommendation [SOR]: B, based on small randomized controlled trials [RCTs]). Testosterone combined with estrogen can also improve libido for postmenopausal women, but it’s not approved by the US Food and Drug Administration (FDA) for this purpose (SOR: B, based on small RCTs).
Offer testosterone replacement—and candid talk about risks and alternatives
Robert K. Persons, DO, FAAFP
Eglin Air Force Base Family Medicine Residency, Eglin Air Force Base, Fla
Sexual dysfunction is a relatively frequent complaint from elderly patients, and its multifactorial nature must be investigated. If you discover low or hypogonadal testosterone levels in a male patient, offer replacement therapy. Be sure, too, to discuss the risks and the alternatives (including psychological aspects of care and partner communication). If your patient is a postmenopausal woman who is interested in combination estrogen and testosterone therapy, you should counsel her on the estimated 17% increased risk of breast cancer per year of use.1
Evidence summary
Sexual dysfunction includes desire, arousal, orgasmic, and sex pain disorders. In the US, 43% of women and 31% of men experience sexual dysfunction. Since sexual dysfunction increases with age, the prevalence will likely increase with the aging American population.2
Testosterone helps men, but long-term risks are unclear
Several cross-sectional and longitudinal studies3,4 demonstrate that serum total and free testosterone concentrations in men decline with age. Although the decline is gradual, by the eighth decade 30% of men have total testosterone values in the hypogonadal range and 50% have low free testosterone values.4
In randomized, placebo-controlled trials5,6 of older men with low testosterone concentrations, testosterone administration was associated with a sustained increase in testosterone levels over 1 to 3 years. Regardless of the route of administration (gel, transdermal patch, or intramuscular injection), testosterone replacement results in improved libido and sexual function for men with low testosterone levels.6-8 The caveat, though, is that testosterone trials of older men are characterized by very small sample sizes (n=10–50), disparate outcome measures, and the inclusion of men who were not uniformly testosterone-deficient and were asymptomatic.
In addition, these studies did not have sufficient power to detect either meaningful gains in patient-important outcomes or changes in prostate or cardiovascular event rates.5,6,8,9 Thus, the long-term benefit/risk ratio of testosterone replacement therapy for aging hypogonadal men is unknown.
Less evidence for women
Up to 50% of postmenopausal women experience sexual dysfunction,10 and a low testosterone level is correlated with a decreased coital frequency.11 Some studies suggest that testosterone at supraphysiological doses—by injections, implants, or pill (in combination with estrogen)—improves libido and sexual function.12-14
The downside is that these studies are very small and have several methodological shortcomings. The pharmacokinetics of testosterone formulations for women are unclear, and the assays for the measurement of total and free testosterone concentrations in women lack accuracy and sensitivity. Long-term safety studies on breast cancer and cardiovascular events are lacking.
Testosterone’s major adverse effects include virilization (oily skin, acne, hirsutism, alopecia, deep voice), liver toxicity, polycythemia, breast carcinoma, and unfavorable changes in cardiovascular risk markers such as reduction in high-density lipoprotein cholesterol or insulin sensitivity.5-8,12-15
Recommendations from others
American Association of Clinical Endocrinologists guidelines for menopause16 recommends against the general use of testosterone therapy at menopause, except for women with continuing symptoms during adequate estrogen therapy.
The Endocrine Society17 recommends that clinicians consider offering testosterone therapy on an individualized basis to older men with low testosterone levels and significant symptoms of testosterone androgen deficiency. Before administration, it’s important to discuss the uncertainties, risks, and benefits of testosterone therapy in older men.
The Endocrine Society also recommends against starting testosterone therapy for patients with breast or prostate cancer, a palpable prostate nodule or induration or prostate-specific antigen >3 ng/mL without further urological evaluation, erythrocytosis (hematocrit >50%), hyperviscosity, untreated obstructive sleep apnea, severe lower urinary tract symptoms with an International Prostate Symptom Score (IPSS) >19, or class III or IV heart failure. When testosterone therapy is instituted, the goal should be to achieve testosterone levels in the midnormal range. This guideline recommends evaluating the patient 3 months after treatment initiation and then annually to assess whether he or she has responded to treatment and whether the patient is suffering any adverse effects.17
The Institute of Medicine examined the effectiveness and safety of testosterone therapy for older men. The report18 states that its use is appropriate only for those conditions approved by the FDA (primary and secondary hypogonadism among men), and that it is inappropriate to use testosterone replacement therapy to prevent possible future disease for otherwise healthy older men. The committee found no compelling evidence of major adverse effects resulting from testosterone therapy.18
1. Tamimi RM, Hankinson SE, Chen WY, Rosner B, Colditz GA. Combined estrogen and testosterone use and risk of breast cancer in postmenopausal women. Arch Intern Med 2006;166:1483-1489.
2. Laumann EO, Paik A, Rosen RD. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
3. Feldman HA, Longcope C, Derby CA, et al. Age trends in the level of serum testosterone and other hormones in middle-aged men: longitudinal results from the Massachusetts Male Aging Study. J Clin Endocrinol Metab 2002;87:589-598.
4. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab 2001;86:724-731.
5. Amory JK, Watts NB, Easley KA, et al. Exogenous testosterone or testosterone with finasteride increases bone mineral density in older men with low serum testosterone. J Clin Endocrinol Metab 2004;89:503-510.
6. Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on body composition and muscle strength in men over 65 years of age. J Clin Endocrinol Metab 1999;84:2647-2653.
7. Cavallini G, Caracciolo S, Vitali G, Modenini F, Biagiotti G. Carnitine versus androgen administration in the treatment of sexual dysfunction, depressed mood, and fatigue associated with male aging. Urology 2004;63:641-646.
8. Page ST, Amory JK, Bowman FD, et al. Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab 2005;90:1502-1510.
9. Sih R, Morley JE, Kaiser FE, Perry HM, 3rd, Patrick P, Ross C. Testosterone replacement in older hypogonadal men: a 12-month randomized controlled trial. J Clin Endocrinol Metab 1997;82:1661-1667.
10. Bachmann GA, Leiblum SR, Sandler B, et al. Correlates of sexual desire in post-menopausal women. Maturitas 1985;7:211-216.
11. McCoy NL, Davidson JM. A longitudinal study of the effects of menopause on sexuality. Maturitas 1985;7:203-210.
12. Davis SR, McCloud P, Strauss BJ, Burger H. Testosterone enhances estradiol’s effects on postmenopausal bone density and sexuality. Maturitas 1995;21:227-236.
13. Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy. Sexual behavior and neuroendocrine responses. J Reprod Med 1998;43:847-856.
14. Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective, crossover study of sex steroid administration in the surgical menopause. Psychosom Med 1985;47:339-351.
15. Gelfand MM, Wiita B. Androgen and estrogen-androgen hormone replacement therapy: a review of the safety literature, 1941 to 1996. Clin Ther 1997;19:383-404.
16. AACE Menopause Guidelines Revision Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract 2006;12:315-337.
17. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2006;91:1995-2010.
18. Liverman CT, Blazer DG (eds). Testosterone and Aging: Clinical Research Directions. Washington, DC: National Academies Press, 2004.
Yes, testosterone therapy is effective in improving libido for elderly hypogonadal males (strength of recommendation [SOR]: B, based on small randomized controlled trials [RCTs]). Testosterone combined with estrogen can also improve libido for postmenopausal women, but it’s not approved by the US Food and Drug Administration (FDA) for this purpose (SOR: B, based on small RCTs).
Offer testosterone replacement—and candid talk about risks and alternatives
Robert K. Persons, DO, FAAFP
Eglin Air Force Base Family Medicine Residency, Eglin Air Force Base, Fla
Sexual dysfunction is a relatively frequent complaint from elderly patients, and its multifactorial nature must be investigated. If you discover low or hypogonadal testosterone levels in a male patient, offer replacement therapy. Be sure, too, to discuss the risks and the alternatives (including psychological aspects of care and partner communication). If your patient is a postmenopausal woman who is interested in combination estrogen and testosterone therapy, you should counsel her on the estimated 17% increased risk of breast cancer per year of use.1
Evidence summary
Sexual dysfunction includes desire, arousal, orgasmic, and sex pain disorders. In the US, 43% of women and 31% of men experience sexual dysfunction. Since sexual dysfunction increases with age, the prevalence will likely increase with the aging American population.2
Testosterone helps men, but long-term risks are unclear
Several cross-sectional and longitudinal studies3,4 demonstrate that serum total and free testosterone concentrations in men decline with age. Although the decline is gradual, by the eighth decade 30% of men have total testosterone values in the hypogonadal range and 50% have low free testosterone values.4
In randomized, placebo-controlled trials5,6 of older men with low testosterone concentrations, testosterone administration was associated with a sustained increase in testosterone levels over 1 to 3 years. Regardless of the route of administration (gel, transdermal patch, or intramuscular injection), testosterone replacement results in improved libido and sexual function for men with low testosterone levels.6-8 The caveat, though, is that testosterone trials of older men are characterized by very small sample sizes (n=10–50), disparate outcome measures, and the inclusion of men who were not uniformly testosterone-deficient and were asymptomatic.
In addition, these studies did not have sufficient power to detect either meaningful gains in patient-important outcomes or changes in prostate or cardiovascular event rates.5,6,8,9 Thus, the long-term benefit/risk ratio of testosterone replacement therapy for aging hypogonadal men is unknown.
Less evidence for women
Up to 50% of postmenopausal women experience sexual dysfunction,10 and a low testosterone level is correlated with a decreased coital frequency.11 Some studies suggest that testosterone at supraphysiological doses—by injections, implants, or pill (in combination with estrogen)—improves libido and sexual function.12-14
The downside is that these studies are very small and have several methodological shortcomings. The pharmacokinetics of testosterone formulations for women are unclear, and the assays for the measurement of total and free testosterone concentrations in women lack accuracy and sensitivity. Long-term safety studies on breast cancer and cardiovascular events are lacking.
Testosterone’s major adverse effects include virilization (oily skin, acne, hirsutism, alopecia, deep voice), liver toxicity, polycythemia, breast carcinoma, and unfavorable changes in cardiovascular risk markers such as reduction in high-density lipoprotein cholesterol or insulin sensitivity.5-8,12-15
Recommendations from others
American Association of Clinical Endocrinologists guidelines for menopause16 recommends against the general use of testosterone therapy at menopause, except for women with continuing symptoms during adequate estrogen therapy.
The Endocrine Society17 recommends that clinicians consider offering testosterone therapy on an individualized basis to older men with low testosterone levels and significant symptoms of testosterone androgen deficiency. Before administration, it’s important to discuss the uncertainties, risks, and benefits of testosterone therapy in older men.
The Endocrine Society also recommends against starting testosterone therapy for patients with breast or prostate cancer, a palpable prostate nodule or induration or prostate-specific antigen >3 ng/mL without further urological evaluation, erythrocytosis (hematocrit >50%), hyperviscosity, untreated obstructive sleep apnea, severe lower urinary tract symptoms with an International Prostate Symptom Score (IPSS) >19, or class III or IV heart failure. When testosterone therapy is instituted, the goal should be to achieve testosterone levels in the midnormal range. This guideline recommends evaluating the patient 3 months after treatment initiation and then annually to assess whether he or she has responded to treatment and whether the patient is suffering any adverse effects.17
The Institute of Medicine examined the effectiveness and safety of testosterone therapy for older men. The report18 states that its use is appropriate only for those conditions approved by the FDA (primary and secondary hypogonadism among men), and that it is inappropriate to use testosterone replacement therapy to prevent possible future disease for otherwise healthy older men. The committee found no compelling evidence of major adverse effects resulting from testosterone therapy.18
Yes, testosterone therapy is effective in improving libido for elderly hypogonadal males (strength of recommendation [SOR]: B, based on small randomized controlled trials [RCTs]). Testosterone combined with estrogen can also improve libido for postmenopausal women, but it’s not approved by the US Food and Drug Administration (FDA) for this purpose (SOR: B, based on small RCTs).
Offer testosterone replacement—and candid talk about risks and alternatives
Robert K. Persons, DO, FAAFP
Eglin Air Force Base Family Medicine Residency, Eglin Air Force Base, Fla
Sexual dysfunction is a relatively frequent complaint from elderly patients, and its multifactorial nature must be investigated. If you discover low or hypogonadal testosterone levels in a male patient, offer replacement therapy. Be sure, too, to discuss the risks and the alternatives (including psychological aspects of care and partner communication). If your patient is a postmenopausal woman who is interested in combination estrogen and testosterone therapy, you should counsel her on the estimated 17% increased risk of breast cancer per year of use.1
Evidence summary
Sexual dysfunction includes desire, arousal, orgasmic, and sex pain disorders. In the US, 43% of women and 31% of men experience sexual dysfunction. Since sexual dysfunction increases with age, the prevalence will likely increase with the aging American population.2
Testosterone helps men, but long-term risks are unclear
Several cross-sectional and longitudinal studies3,4 demonstrate that serum total and free testosterone concentrations in men decline with age. Although the decline is gradual, by the eighth decade 30% of men have total testosterone values in the hypogonadal range and 50% have low free testosterone values.4
In randomized, placebo-controlled trials5,6 of older men with low testosterone concentrations, testosterone administration was associated with a sustained increase in testosterone levels over 1 to 3 years. Regardless of the route of administration (gel, transdermal patch, or intramuscular injection), testosterone replacement results in improved libido and sexual function for men with low testosterone levels.6-8 The caveat, though, is that testosterone trials of older men are characterized by very small sample sizes (n=10–50), disparate outcome measures, and the inclusion of men who were not uniformly testosterone-deficient and were asymptomatic.
In addition, these studies did not have sufficient power to detect either meaningful gains in patient-important outcomes or changes in prostate or cardiovascular event rates.5,6,8,9 Thus, the long-term benefit/risk ratio of testosterone replacement therapy for aging hypogonadal men is unknown.
Less evidence for women
Up to 50% of postmenopausal women experience sexual dysfunction,10 and a low testosterone level is correlated with a decreased coital frequency.11 Some studies suggest that testosterone at supraphysiological doses—by injections, implants, or pill (in combination with estrogen)—improves libido and sexual function.12-14
The downside is that these studies are very small and have several methodological shortcomings. The pharmacokinetics of testosterone formulations for women are unclear, and the assays for the measurement of total and free testosterone concentrations in women lack accuracy and sensitivity. Long-term safety studies on breast cancer and cardiovascular events are lacking.
Testosterone’s major adverse effects include virilization (oily skin, acne, hirsutism, alopecia, deep voice), liver toxicity, polycythemia, breast carcinoma, and unfavorable changes in cardiovascular risk markers such as reduction in high-density lipoprotein cholesterol or insulin sensitivity.5-8,12-15
Recommendations from others
American Association of Clinical Endocrinologists guidelines for menopause16 recommends against the general use of testosterone therapy at menopause, except for women with continuing symptoms during adequate estrogen therapy.
The Endocrine Society17 recommends that clinicians consider offering testosterone therapy on an individualized basis to older men with low testosterone levels and significant symptoms of testosterone androgen deficiency. Before administration, it’s important to discuss the uncertainties, risks, and benefits of testosterone therapy in older men.
The Endocrine Society also recommends against starting testosterone therapy for patients with breast or prostate cancer, a palpable prostate nodule or induration or prostate-specific antigen >3 ng/mL without further urological evaluation, erythrocytosis (hematocrit >50%), hyperviscosity, untreated obstructive sleep apnea, severe lower urinary tract symptoms with an International Prostate Symptom Score (IPSS) >19, or class III or IV heart failure. When testosterone therapy is instituted, the goal should be to achieve testosterone levels in the midnormal range. This guideline recommends evaluating the patient 3 months after treatment initiation and then annually to assess whether he or she has responded to treatment and whether the patient is suffering any adverse effects.17
The Institute of Medicine examined the effectiveness and safety of testosterone therapy for older men. The report18 states that its use is appropriate only for those conditions approved by the FDA (primary and secondary hypogonadism among men), and that it is inappropriate to use testosterone replacement therapy to prevent possible future disease for otherwise healthy older men. The committee found no compelling evidence of major adverse effects resulting from testosterone therapy.18
1. Tamimi RM, Hankinson SE, Chen WY, Rosner B, Colditz GA. Combined estrogen and testosterone use and risk of breast cancer in postmenopausal women. Arch Intern Med 2006;166:1483-1489.
2. Laumann EO, Paik A, Rosen RD. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
3. Feldman HA, Longcope C, Derby CA, et al. Age trends in the level of serum testosterone and other hormones in middle-aged men: longitudinal results from the Massachusetts Male Aging Study. J Clin Endocrinol Metab 2002;87:589-598.
4. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab 2001;86:724-731.
5. Amory JK, Watts NB, Easley KA, et al. Exogenous testosterone or testosterone with finasteride increases bone mineral density in older men with low serum testosterone. J Clin Endocrinol Metab 2004;89:503-510.
6. Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on body composition and muscle strength in men over 65 years of age. J Clin Endocrinol Metab 1999;84:2647-2653.
7. Cavallini G, Caracciolo S, Vitali G, Modenini F, Biagiotti G. Carnitine versus androgen administration in the treatment of sexual dysfunction, depressed mood, and fatigue associated with male aging. Urology 2004;63:641-646.
8. Page ST, Amory JK, Bowman FD, et al. Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab 2005;90:1502-1510.
9. Sih R, Morley JE, Kaiser FE, Perry HM, 3rd, Patrick P, Ross C. Testosterone replacement in older hypogonadal men: a 12-month randomized controlled trial. J Clin Endocrinol Metab 1997;82:1661-1667.
10. Bachmann GA, Leiblum SR, Sandler B, et al. Correlates of sexual desire in post-menopausal women. Maturitas 1985;7:211-216.
11. McCoy NL, Davidson JM. A longitudinal study of the effects of menopause on sexuality. Maturitas 1985;7:203-210.
12. Davis SR, McCloud P, Strauss BJ, Burger H. Testosterone enhances estradiol’s effects on postmenopausal bone density and sexuality. Maturitas 1995;21:227-236.
13. Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy. Sexual behavior and neuroendocrine responses. J Reprod Med 1998;43:847-856.
14. Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective, crossover study of sex steroid administration in the surgical menopause. Psychosom Med 1985;47:339-351.
15. Gelfand MM, Wiita B. Androgen and estrogen-androgen hormone replacement therapy: a review of the safety literature, 1941 to 1996. Clin Ther 1997;19:383-404.
16. AACE Menopause Guidelines Revision Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract 2006;12:315-337.
17. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2006;91:1995-2010.
18. Liverman CT, Blazer DG (eds). Testosterone and Aging: Clinical Research Directions. Washington, DC: National Academies Press, 2004.
1. Tamimi RM, Hankinson SE, Chen WY, Rosner B, Colditz GA. Combined estrogen and testosterone use and risk of breast cancer in postmenopausal women. Arch Intern Med 2006;166:1483-1489.
2. Laumann EO, Paik A, Rosen RD. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
3. Feldman HA, Longcope C, Derby CA, et al. Age trends in the level of serum testosterone and other hormones in middle-aged men: longitudinal results from the Massachusetts Male Aging Study. J Clin Endocrinol Metab 2002;87:589-598.
4. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab 2001;86:724-731.
5. Amory JK, Watts NB, Easley KA, et al. Exogenous testosterone or testosterone with finasteride increases bone mineral density in older men with low serum testosterone. J Clin Endocrinol Metab 2004;89:503-510.
6. Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on body composition and muscle strength in men over 65 years of age. J Clin Endocrinol Metab 1999;84:2647-2653.
7. Cavallini G, Caracciolo S, Vitali G, Modenini F, Biagiotti G. Carnitine versus androgen administration in the treatment of sexual dysfunction, depressed mood, and fatigue associated with male aging. Urology 2004;63:641-646.
8. Page ST, Amory JK, Bowman FD, et al. Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab 2005;90:1502-1510.
9. Sih R, Morley JE, Kaiser FE, Perry HM, 3rd, Patrick P, Ross C. Testosterone replacement in older hypogonadal men: a 12-month randomized controlled trial. J Clin Endocrinol Metab 1997;82:1661-1667.
10. Bachmann GA, Leiblum SR, Sandler B, et al. Correlates of sexual desire in post-menopausal women. Maturitas 1985;7:211-216.
11. McCoy NL, Davidson JM. A longitudinal study of the effects of menopause on sexuality. Maturitas 1985;7:203-210.
12. Davis SR, McCloud P, Strauss BJ, Burger H. Testosterone enhances estradiol’s effects on postmenopausal bone density and sexuality. Maturitas 1995;21:227-236.
13. Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy. Sexual behavior and neuroendocrine responses. J Reprod Med 1998;43:847-856.
14. Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective, crossover study of sex steroid administration in the surgical menopause. Psychosom Med 1985;47:339-351.
15. Gelfand MM, Wiita B. Androgen and estrogen-androgen hormone replacement therapy: a review of the safety literature, 1941 to 1996. Clin Ther 1997;19:383-404.
16. AACE Menopause Guidelines Revision Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract 2006;12:315-337.
17. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2006;91:1995-2010.
18. Liverman CT, Blazer DG (eds). Testosterone and Aging: Clinical Research Directions. Washington, DC: National Academies Press, 2004.
Evidence-based answers from the Family Physicians Inquiries Network
What is the best way to treat tinea cruris?
After clinical diagnosis and microscopic confirmation, tinea cruris is best treated with a topical allylamine or an azole antifungal (strength of recommendation: A, based on multiple randomized controlled trials [RCTs]). Differences in current comparison data are insufficient to stratify the 2 groups of topical antifungals. Determining which group to use depends on patient compliance, medication accessibility, and cost. The fungicidal allylamines (naftifine and terbinafine) and butenafine (allylamine derivative) are a more costly group of topical tinea treatments, yet they are more convenient as they allow for a shorter duration of treatment compared with fungistatic azoles (clotrimazole, econazole, ketoconazole, oxiconazole, miconazole, and sulconazole).
Choice of treatment should reflect cost and convenience to the patient
Dan Hunter-Smith, MD
Adventist LaGrange Family Medicine Residency, LaGrange, Ill
This review illustrates that the “best way” to treat a problem can have more to do with the needs of a given patient than intrinsic differences between treatments. All reviewed treatments were roughly therapeutically equivalent and equally safe. This leaves the choice of treatment to reflect the importance of cost and convenience to the patient. If cost is an issue for the patient, the frugal way to treat tinea cruris is to have the patient go to the vaginitis treatment section of the pharmacy and pick up a 15-g tube of miconazole or clotrimazole cream for $7 to $10. Terbinafine cream or spray costs $10 to $13 over the counter, but it reduces the onus of compliance to once-a-day for 1 week. If terbinafine 1% solution is preferred, a 30-mL bottle costs $77. Most of the time, I let the patient make their own choice.
Evidence summary
Tinea cruris (“jock itch”) is a superficial dermatophyte infection of the groin and surrounding skin. Obese adult men are affected more than women, and it is rarely seen in children. Because excessive perspiration is the most common predisposing factor, patient education on proper hygiene makes intuitive sense for successful treatment, yet it has not been studied.1Trichophyton rubrum is the most common source of tinea cruris, as well as tinea corporis (“ringworm”), in the United States.2 Most studies involving patients with tinea cruris combine data with tinea corporis.
Although more than 25 RCTs document the safety and efficacy of antifungal treatments, few head-to-head trials are available. Several topical preparations are approved for the treatment of tinea cruris. Selection should be based on patient compliance (duration of treatment), overall cost, and tolerability. The 2 main classes of antifungals are allylamines and azoles.
Allylamines. Allylamines offer a shorter duration of therapy, lower relapse rates, and work independent of the cytochrome P450 system. Multiple RCTs have documented the efficacy and safety of the 2 available allylamine antifungals, terbinafine and naftifine, when compared with placebo and various azoles.
Terbinafine is available in several 1% formulations (emulsion-gel, cream, and solution/spray), all studied and dosed once daily for 1 week. One placebo controlled trial showed the 1% emulsion-gel version (Lamisil) was effective in 89% of the study population vs 23% of the placebo group (NNT=1.5); it was particularly suitable on hairy skin. Seven weeks post-treatment, 84% of the intent-to-treat population of the Lamisil group remained mycologically negative.3 Data combined from 2 other RCTs yielded 83% efficacy 3 weeks post-treatment when 66 patients were treated with terbinafine 1% cream, compared with 12% efficacy for 73 patients using the vehicle cream (NNT=1.4).4 Another placebo-controlled study of 66 patients demonstrated 100% microscopic cure of terbinafine 1% solution by week 2 and maintaining 90% cure at 4 weeks.5
In a multicenter, double-blind RCT funded by the manufacturers of terbinafine, bifonazole 1% cream for 3 weeks was compared with terbinafine 1% cream used daily for 1 week (followed by 2 weeks of its vehicle cream). Mycological and clinical cure rates were greater than 95% in both groups at 3 weeks. At the 8-week follow-up, no statistically significant differences were seen in KOH positivity rates (20.24% of patients in the bifonazole-treated group were KOH-positive vs 11.76% in the terbinafine group). Symptom relapse rates at 8 weeks were not available.6
In a 4-week study involving 104 patients, naftifine 1% cream (Naftin) was compared with econazole 1% cream (Spectazole) (both applied twice daily). At the end of the study, naftifine 1% cream had a higher (but not statistically significant) mycological and clinical cure rate of 78% compared with 68% with econazole 1% cream.7 Similar results (79% mycological cure) were seen in a placebo-controlled trial with 70 patients using once daily naftifine 1% cream after 2 weeks of treatment (NNT=2).8
Butenafine (Mentax), a benzylamine antifungal, was 88% to 93% mycologically effective in a noncomparative study, when used twice daily for 2 weeks.9 Similar results were found in a study of 76 patients with tinea cruris; after 2 weeks of daily application, 78% (modified intent-to-treat group) were mycologically cured. Mycological cure plus “cleared” or “excellent” clinical evaluation remained for 73% at day 42 vs 5% of the placebo group (NNT=1.47).10
Azoles. Azoles are less expensive than allylamines, but require longer treatment periods, theoretically compromising patient adherence to therapy. One of the more popular azoles is clotrimazole (Lotrimin, Mycelex), one of the oldest antifungal treatments. One RCT compared cure rates for 139 patients for clotrimazole 1% cream compared with ciclopirox olamine 1% cream when both were applied twice daily for 28 days. By the end of the 4-week period, 69% of the clotrimazole group was clinically and mycologically cured compared with 64% of the ciclopirox group.11
Miconazole 2% cream (Micatin, Monistat) (used twice daily for 2 weeks by inmates in a Florida prison) demonstrated 75.5% clinical clearing (against tinea cruris, pedis, or corporis, or Candida cutaneous infections) when compared with placebo (NNT=1.57). Of the 99 patients evaluated, 48 were diagnosed with tinea cruris; however, results were not broken down into diagnostic category. The length of follow-up for these patients was not disclosed.12
Alternative therapy. Ajoene 0.6% gel (isolated from garlic), was as effective as terbinafine 1% cream (both applied twice daily for 2 weeks) in a RCT of 60 Venezuelan Army soldiers.13 Sixty days after treatment, 73% of the Ajoene-treated patients and 71% in the terbinafine group were asymptomatic. An open-pilot study of 14 patients with tinea cruris demonstrated 71% mycological cure with a honey, olive oil, and beeswax (1:1:1) mixture, applied 3 times daily up to 3 weeks, likely due to honey’s inhibitory effect on fungus and beeswax’s anti-inflammatory properties.14
Recommendations from others
The Sanford Guide to Antimicrobial Therapy (2005) recommends topical butenafine and terbinafine as primary agents of choice for tinea cruris due to their fungicidal activity.15 The American Academy of Family Physicians recommends any of the topical antifungal treatments as first-line treatment for tinea cruris.16 A systematic review on tinea pedis topical therapy acknowledges the higher cure rates by allylamines, compared with azoles, but concludes that azoles remain the most costeffective in the treatment of tinea pedis.17 No recent guidelines from the American Academy of Dermatology are available.
1. Gupta AK, Chaudhry M, Elewski BE. Tinea corporis, tinea cruris, tinea nigra, and piedra. Dermatol Clin 2003;21:395-400.
2. Foster KW, Ghannoum MA, Elewski BE. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol 2004;30:748-752.
3. van Heerden JS, Vismer HF. Tinea corporis/cruris: new treatment options. Dermatology 1997;194(Suppl 1):14-18.
4. Zaias N, Berman B, Cordero CN, et al. Efficacy of a 1-week, once daily regimen of terbinafine 1% cream in the treatment of tinea cruris and tinea corporis. J Am Acad Dermatol 1993;29:646-648.
5. Lebwohl M, Elewski B, Eisen D, Savin RC. Efficacy and safety of terbinafine 1% solution in the treatment of interdigital tinea pedis and tinea corporis or tinea cruris. Cutis 2001;67:261-266.
6. Budimulja U. Terbinafine 1% cream vs. bifonazole 1% cream in the treatment of tinea cruris. Int J Dermatol 1998;37:871-873.
7. Millikan LE, Galen WK, Gewirtzman GB, et al. Naftifine cream 1% versus econazole cream 1% in the treatment of tinea cruris and tinea corporis. J Am Acad Dermatol 1988;18(1 Pt 1):52-56.
8. Jordan RE, Rapini RP, Rex IH, Jr, et al. Once-daily naftine cream 1% in the treatment of tinea cruris and tinea corporis. Int J Dermatol 1990;29:441-442.
9. Saple DG, Amar AK, Ravichandran G, Korde KM, Desai A. Efficacy and safety of butenafine in superficial dermatophytoses (tinea pedis, tinea cruris, tinea corporis). J Indian Med Assoc 2001;99:274-275.
10. Lescher JL, Babel DE, Stewart DM, et al. Butenafine 1% cream in the treatment of tinea cruris: A multicenter, vehicle-controlled, double-blind trial. J Am Acad Dermatol 1997;36:S20-S24.
11. Bogaert H, Cordero C, Ollague W, Savin RC, Shalita AR, Zaias N. Multicentre double-blind clinical trials of ciclopirox olamine cream 1% in the treatment of tinea corporis and tinea cruris. J Int Med Res 1986;14:210-216.
12. Fulton JE, Jr. Miconazole therapy for endemic fungal disease. Srch Dermatology 1975;111:596-598.
13. Ledezma E, Lopez JC, Marin P, et al. Ajoene in the topical short-term treatment of tinea cruris and tinea corporis in humans. Randomized comparative study with terbinafine. Arzneimittelforschung 1999;49:544-547.
14. Al-Waili NS. An alternative treatment for pityriasis versicolor, tinea cruris, tinea corporis and tinea faciei with topical application of honey, olive oil and beeswax mixture: an open pilot study. Complement Ther Med 2004;12:45-47.
15. The Sanford Guide to Antimicrobial Therapy. 35th ed. Hyde Park, Vt: Antimicrobial Therapy; 2005.
16. Noble S, Forbes R, Stamm P. Diagnosis and management of common tinea infections. Am Fam Physician 1998;58:163-178.Available at: www.aafp.org/afp/980700ap/noble.html. Accessed on February 9, 2006.
17. Crawford F, Hart R, Bell-Syer S, Togerson D, Young P, Russell I. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 1999;(3):CD001434.
After clinical diagnosis and microscopic confirmation, tinea cruris is best treated with a topical allylamine or an azole antifungal (strength of recommendation: A, based on multiple randomized controlled trials [RCTs]). Differences in current comparison data are insufficient to stratify the 2 groups of topical antifungals. Determining which group to use depends on patient compliance, medication accessibility, and cost. The fungicidal allylamines (naftifine and terbinafine) and butenafine (allylamine derivative) are a more costly group of topical tinea treatments, yet they are more convenient as they allow for a shorter duration of treatment compared with fungistatic azoles (clotrimazole, econazole, ketoconazole, oxiconazole, miconazole, and sulconazole).
Choice of treatment should reflect cost and convenience to the patient
Dan Hunter-Smith, MD
Adventist LaGrange Family Medicine Residency, LaGrange, Ill
This review illustrates that the “best way” to treat a problem can have more to do with the needs of a given patient than intrinsic differences between treatments. All reviewed treatments were roughly therapeutically equivalent and equally safe. This leaves the choice of treatment to reflect the importance of cost and convenience to the patient. If cost is an issue for the patient, the frugal way to treat tinea cruris is to have the patient go to the vaginitis treatment section of the pharmacy and pick up a 15-g tube of miconazole or clotrimazole cream for $7 to $10. Terbinafine cream or spray costs $10 to $13 over the counter, but it reduces the onus of compliance to once-a-day for 1 week. If terbinafine 1% solution is preferred, a 30-mL bottle costs $77. Most of the time, I let the patient make their own choice.
Evidence summary
Tinea cruris (“jock itch”) is a superficial dermatophyte infection of the groin and surrounding skin. Obese adult men are affected more than women, and it is rarely seen in children. Because excessive perspiration is the most common predisposing factor, patient education on proper hygiene makes intuitive sense for successful treatment, yet it has not been studied.1Trichophyton rubrum is the most common source of tinea cruris, as well as tinea corporis (“ringworm”), in the United States.2 Most studies involving patients with tinea cruris combine data with tinea corporis.
Although more than 25 RCTs document the safety and efficacy of antifungal treatments, few head-to-head trials are available. Several topical preparations are approved for the treatment of tinea cruris. Selection should be based on patient compliance (duration of treatment), overall cost, and tolerability. The 2 main classes of antifungals are allylamines and azoles.
Allylamines. Allylamines offer a shorter duration of therapy, lower relapse rates, and work independent of the cytochrome P450 system. Multiple RCTs have documented the efficacy and safety of the 2 available allylamine antifungals, terbinafine and naftifine, when compared with placebo and various azoles.
Terbinafine is available in several 1% formulations (emulsion-gel, cream, and solution/spray), all studied and dosed once daily for 1 week. One placebo controlled trial showed the 1% emulsion-gel version (Lamisil) was effective in 89% of the study population vs 23% of the placebo group (NNT=1.5); it was particularly suitable on hairy skin. Seven weeks post-treatment, 84% of the intent-to-treat population of the Lamisil group remained mycologically negative.3 Data combined from 2 other RCTs yielded 83% efficacy 3 weeks post-treatment when 66 patients were treated with terbinafine 1% cream, compared with 12% efficacy for 73 patients using the vehicle cream (NNT=1.4).4 Another placebo-controlled study of 66 patients demonstrated 100% microscopic cure of terbinafine 1% solution by week 2 and maintaining 90% cure at 4 weeks.5
In a multicenter, double-blind RCT funded by the manufacturers of terbinafine, bifonazole 1% cream for 3 weeks was compared with terbinafine 1% cream used daily for 1 week (followed by 2 weeks of its vehicle cream). Mycological and clinical cure rates were greater than 95% in both groups at 3 weeks. At the 8-week follow-up, no statistically significant differences were seen in KOH positivity rates (20.24% of patients in the bifonazole-treated group were KOH-positive vs 11.76% in the terbinafine group). Symptom relapse rates at 8 weeks were not available.6
In a 4-week study involving 104 patients, naftifine 1% cream (Naftin) was compared with econazole 1% cream (Spectazole) (both applied twice daily). At the end of the study, naftifine 1% cream had a higher (but not statistically significant) mycological and clinical cure rate of 78% compared with 68% with econazole 1% cream.7 Similar results (79% mycological cure) were seen in a placebo-controlled trial with 70 patients using once daily naftifine 1% cream after 2 weeks of treatment (NNT=2).8
Butenafine (Mentax), a benzylamine antifungal, was 88% to 93% mycologically effective in a noncomparative study, when used twice daily for 2 weeks.9 Similar results were found in a study of 76 patients with tinea cruris; after 2 weeks of daily application, 78% (modified intent-to-treat group) were mycologically cured. Mycological cure plus “cleared” or “excellent” clinical evaluation remained for 73% at day 42 vs 5% of the placebo group (NNT=1.47).10
Azoles. Azoles are less expensive than allylamines, but require longer treatment periods, theoretically compromising patient adherence to therapy. One of the more popular azoles is clotrimazole (Lotrimin, Mycelex), one of the oldest antifungal treatments. One RCT compared cure rates for 139 patients for clotrimazole 1% cream compared with ciclopirox olamine 1% cream when both were applied twice daily for 28 days. By the end of the 4-week period, 69% of the clotrimazole group was clinically and mycologically cured compared with 64% of the ciclopirox group.11
Miconazole 2% cream (Micatin, Monistat) (used twice daily for 2 weeks by inmates in a Florida prison) demonstrated 75.5% clinical clearing (against tinea cruris, pedis, or corporis, or Candida cutaneous infections) when compared with placebo (NNT=1.57). Of the 99 patients evaluated, 48 were diagnosed with tinea cruris; however, results were not broken down into diagnostic category. The length of follow-up for these patients was not disclosed.12
Alternative therapy. Ajoene 0.6% gel (isolated from garlic), was as effective as terbinafine 1% cream (both applied twice daily for 2 weeks) in a RCT of 60 Venezuelan Army soldiers.13 Sixty days after treatment, 73% of the Ajoene-treated patients and 71% in the terbinafine group were asymptomatic. An open-pilot study of 14 patients with tinea cruris demonstrated 71% mycological cure with a honey, olive oil, and beeswax (1:1:1) mixture, applied 3 times daily up to 3 weeks, likely due to honey’s inhibitory effect on fungus and beeswax’s anti-inflammatory properties.14
Recommendations from others
The Sanford Guide to Antimicrobial Therapy (2005) recommends topical butenafine and terbinafine as primary agents of choice for tinea cruris due to their fungicidal activity.15 The American Academy of Family Physicians recommends any of the topical antifungal treatments as first-line treatment for tinea cruris.16 A systematic review on tinea pedis topical therapy acknowledges the higher cure rates by allylamines, compared with azoles, but concludes that azoles remain the most costeffective in the treatment of tinea pedis.17 No recent guidelines from the American Academy of Dermatology are available.
After clinical diagnosis and microscopic confirmation, tinea cruris is best treated with a topical allylamine or an azole antifungal (strength of recommendation: A, based on multiple randomized controlled trials [RCTs]). Differences in current comparison data are insufficient to stratify the 2 groups of topical antifungals. Determining which group to use depends on patient compliance, medication accessibility, and cost. The fungicidal allylamines (naftifine and terbinafine) and butenafine (allylamine derivative) are a more costly group of topical tinea treatments, yet they are more convenient as they allow for a shorter duration of treatment compared with fungistatic azoles (clotrimazole, econazole, ketoconazole, oxiconazole, miconazole, and sulconazole).
Choice of treatment should reflect cost and convenience to the patient
Dan Hunter-Smith, MD
Adventist LaGrange Family Medicine Residency, LaGrange, Ill
This review illustrates that the “best way” to treat a problem can have more to do with the needs of a given patient than intrinsic differences between treatments. All reviewed treatments were roughly therapeutically equivalent and equally safe. This leaves the choice of treatment to reflect the importance of cost and convenience to the patient. If cost is an issue for the patient, the frugal way to treat tinea cruris is to have the patient go to the vaginitis treatment section of the pharmacy and pick up a 15-g tube of miconazole or clotrimazole cream for $7 to $10. Terbinafine cream or spray costs $10 to $13 over the counter, but it reduces the onus of compliance to once-a-day for 1 week. If terbinafine 1% solution is preferred, a 30-mL bottle costs $77. Most of the time, I let the patient make their own choice.
Evidence summary
Tinea cruris (“jock itch”) is a superficial dermatophyte infection of the groin and surrounding skin. Obese adult men are affected more than women, and it is rarely seen in children. Because excessive perspiration is the most common predisposing factor, patient education on proper hygiene makes intuitive sense for successful treatment, yet it has not been studied.1Trichophyton rubrum is the most common source of tinea cruris, as well as tinea corporis (“ringworm”), in the United States.2 Most studies involving patients with tinea cruris combine data with tinea corporis.
Although more than 25 RCTs document the safety and efficacy of antifungal treatments, few head-to-head trials are available. Several topical preparations are approved for the treatment of tinea cruris. Selection should be based on patient compliance (duration of treatment), overall cost, and tolerability. The 2 main classes of antifungals are allylamines and azoles.
Allylamines. Allylamines offer a shorter duration of therapy, lower relapse rates, and work independent of the cytochrome P450 system. Multiple RCTs have documented the efficacy and safety of the 2 available allylamine antifungals, terbinafine and naftifine, when compared with placebo and various azoles.
Terbinafine is available in several 1% formulations (emulsion-gel, cream, and solution/spray), all studied and dosed once daily for 1 week. One placebo controlled trial showed the 1% emulsion-gel version (Lamisil) was effective in 89% of the study population vs 23% of the placebo group (NNT=1.5); it was particularly suitable on hairy skin. Seven weeks post-treatment, 84% of the intent-to-treat population of the Lamisil group remained mycologically negative.3 Data combined from 2 other RCTs yielded 83% efficacy 3 weeks post-treatment when 66 patients were treated with terbinafine 1% cream, compared with 12% efficacy for 73 patients using the vehicle cream (NNT=1.4).4 Another placebo-controlled study of 66 patients demonstrated 100% microscopic cure of terbinafine 1% solution by week 2 and maintaining 90% cure at 4 weeks.5
In a multicenter, double-blind RCT funded by the manufacturers of terbinafine, bifonazole 1% cream for 3 weeks was compared with terbinafine 1% cream used daily for 1 week (followed by 2 weeks of its vehicle cream). Mycological and clinical cure rates were greater than 95% in both groups at 3 weeks. At the 8-week follow-up, no statistically significant differences were seen in KOH positivity rates (20.24% of patients in the bifonazole-treated group were KOH-positive vs 11.76% in the terbinafine group). Symptom relapse rates at 8 weeks were not available.6
In a 4-week study involving 104 patients, naftifine 1% cream (Naftin) was compared with econazole 1% cream (Spectazole) (both applied twice daily). At the end of the study, naftifine 1% cream had a higher (but not statistically significant) mycological and clinical cure rate of 78% compared with 68% with econazole 1% cream.7 Similar results (79% mycological cure) were seen in a placebo-controlled trial with 70 patients using once daily naftifine 1% cream after 2 weeks of treatment (NNT=2).8
Butenafine (Mentax), a benzylamine antifungal, was 88% to 93% mycologically effective in a noncomparative study, when used twice daily for 2 weeks.9 Similar results were found in a study of 76 patients with tinea cruris; after 2 weeks of daily application, 78% (modified intent-to-treat group) were mycologically cured. Mycological cure plus “cleared” or “excellent” clinical evaluation remained for 73% at day 42 vs 5% of the placebo group (NNT=1.47).10
Azoles. Azoles are less expensive than allylamines, but require longer treatment periods, theoretically compromising patient adherence to therapy. One of the more popular azoles is clotrimazole (Lotrimin, Mycelex), one of the oldest antifungal treatments. One RCT compared cure rates for 139 patients for clotrimazole 1% cream compared with ciclopirox olamine 1% cream when both were applied twice daily for 28 days. By the end of the 4-week period, 69% of the clotrimazole group was clinically and mycologically cured compared with 64% of the ciclopirox group.11
Miconazole 2% cream (Micatin, Monistat) (used twice daily for 2 weeks by inmates in a Florida prison) demonstrated 75.5% clinical clearing (against tinea cruris, pedis, or corporis, or Candida cutaneous infections) when compared with placebo (NNT=1.57). Of the 99 patients evaluated, 48 were diagnosed with tinea cruris; however, results were not broken down into diagnostic category. The length of follow-up for these patients was not disclosed.12
Alternative therapy. Ajoene 0.6% gel (isolated from garlic), was as effective as terbinafine 1% cream (both applied twice daily for 2 weeks) in a RCT of 60 Venezuelan Army soldiers.13 Sixty days after treatment, 73% of the Ajoene-treated patients and 71% in the terbinafine group were asymptomatic. An open-pilot study of 14 patients with tinea cruris demonstrated 71% mycological cure with a honey, olive oil, and beeswax (1:1:1) mixture, applied 3 times daily up to 3 weeks, likely due to honey’s inhibitory effect on fungus and beeswax’s anti-inflammatory properties.14
Recommendations from others
The Sanford Guide to Antimicrobial Therapy (2005) recommends topical butenafine and terbinafine as primary agents of choice for tinea cruris due to their fungicidal activity.15 The American Academy of Family Physicians recommends any of the topical antifungal treatments as first-line treatment for tinea cruris.16 A systematic review on tinea pedis topical therapy acknowledges the higher cure rates by allylamines, compared with azoles, but concludes that azoles remain the most costeffective in the treatment of tinea pedis.17 No recent guidelines from the American Academy of Dermatology are available.
1. Gupta AK, Chaudhry M, Elewski BE. Tinea corporis, tinea cruris, tinea nigra, and piedra. Dermatol Clin 2003;21:395-400.
2. Foster KW, Ghannoum MA, Elewski BE. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol 2004;30:748-752.
3. van Heerden JS, Vismer HF. Tinea corporis/cruris: new treatment options. Dermatology 1997;194(Suppl 1):14-18.
4. Zaias N, Berman B, Cordero CN, et al. Efficacy of a 1-week, once daily regimen of terbinafine 1% cream in the treatment of tinea cruris and tinea corporis. J Am Acad Dermatol 1993;29:646-648.
5. Lebwohl M, Elewski B, Eisen D, Savin RC. Efficacy and safety of terbinafine 1% solution in the treatment of interdigital tinea pedis and tinea corporis or tinea cruris. Cutis 2001;67:261-266.
6. Budimulja U. Terbinafine 1% cream vs. bifonazole 1% cream in the treatment of tinea cruris. Int J Dermatol 1998;37:871-873.
7. Millikan LE, Galen WK, Gewirtzman GB, et al. Naftifine cream 1% versus econazole cream 1% in the treatment of tinea cruris and tinea corporis. J Am Acad Dermatol 1988;18(1 Pt 1):52-56.
8. Jordan RE, Rapini RP, Rex IH, Jr, et al. Once-daily naftine cream 1% in the treatment of tinea cruris and tinea corporis. Int J Dermatol 1990;29:441-442.
9. Saple DG, Amar AK, Ravichandran G, Korde KM, Desai A. Efficacy and safety of butenafine in superficial dermatophytoses (tinea pedis, tinea cruris, tinea corporis). J Indian Med Assoc 2001;99:274-275.
10. Lescher JL, Babel DE, Stewart DM, et al. Butenafine 1% cream in the treatment of tinea cruris: A multicenter, vehicle-controlled, double-blind trial. J Am Acad Dermatol 1997;36:S20-S24.
11. Bogaert H, Cordero C, Ollague W, Savin RC, Shalita AR, Zaias N. Multicentre double-blind clinical trials of ciclopirox olamine cream 1% in the treatment of tinea corporis and tinea cruris. J Int Med Res 1986;14:210-216.
12. Fulton JE, Jr. Miconazole therapy for endemic fungal disease. Srch Dermatology 1975;111:596-598.
13. Ledezma E, Lopez JC, Marin P, et al. Ajoene in the topical short-term treatment of tinea cruris and tinea corporis in humans. Randomized comparative study with terbinafine. Arzneimittelforschung 1999;49:544-547.
14. Al-Waili NS. An alternative treatment for pityriasis versicolor, tinea cruris, tinea corporis and tinea faciei with topical application of honey, olive oil and beeswax mixture: an open pilot study. Complement Ther Med 2004;12:45-47.
15. The Sanford Guide to Antimicrobial Therapy. 35th ed. Hyde Park, Vt: Antimicrobial Therapy; 2005.
16. Noble S, Forbes R, Stamm P. Diagnosis and management of common tinea infections. Am Fam Physician 1998;58:163-178.Available at: www.aafp.org/afp/980700ap/noble.html. Accessed on February 9, 2006.
17. Crawford F, Hart R, Bell-Syer S, Togerson D, Young P, Russell I. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 1999;(3):CD001434.
1. Gupta AK, Chaudhry M, Elewski BE. Tinea corporis, tinea cruris, tinea nigra, and piedra. Dermatol Clin 2003;21:395-400.
2. Foster KW, Ghannoum MA, Elewski BE. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol 2004;30:748-752.
3. van Heerden JS, Vismer HF. Tinea corporis/cruris: new treatment options. Dermatology 1997;194(Suppl 1):14-18.
4. Zaias N, Berman B, Cordero CN, et al. Efficacy of a 1-week, once daily regimen of terbinafine 1% cream in the treatment of tinea cruris and tinea corporis. J Am Acad Dermatol 1993;29:646-648.
5. Lebwohl M, Elewski B, Eisen D, Savin RC. Efficacy and safety of terbinafine 1% solution in the treatment of interdigital tinea pedis and tinea corporis or tinea cruris. Cutis 2001;67:261-266.
6. Budimulja U. Terbinafine 1% cream vs. bifonazole 1% cream in the treatment of tinea cruris. Int J Dermatol 1998;37:871-873.
7. Millikan LE, Galen WK, Gewirtzman GB, et al. Naftifine cream 1% versus econazole cream 1% in the treatment of tinea cruris and tinea corporis. J Am Acad Dermatol 1988;18(1 Pt 1):52-56.
8. Jordan RE, Rapini RP, Rex IH, Jr, et al. Once-daily naftine cream 1% in the treatment of tinea cruris and tinea corporis. Int J Dermatol 1990;29:441-442.
9. Saple DG, Amar AK, Ravichandran G, Korde KM, Desai A. Efficacy and safety of butenafine in superficial dermatophytoses (tinea pedis, tinea cruris, tinea corporis). J Indian Med Assoc 2001;99:274-275.
10. Lescher JL, Babel DE, Stewart DM, et al. Butenafine 1% cream in the treatment of tinea cruris: A multicenter, vehicle-controlled, double-blind trial. J Am Acad Dermatol 1997;36:S20-S24.
11. Bogaert H, Cordero C, Ollague W, Savin RC, Shalita AR, Zaias N. Multicentre double-blind clinical trials of ciclopirox olamine cream 1% in the treatment of tinea corporis and tinea cruris. J Int Med Res 1986;14:210-216.
12. Fulton JE, Jr. Miconazole therapy for endemic fungal disease. Srch Dermatology 1975;111:596-598.
13. Ledezma E, Lopez JC, Marin P, et al. Ajoene in the topical short-term treatment of tinea cruris and tinea corporis in humans. Randomized comparative study with terbinafine. Arzneimittelforschung 1999;49:544-547.
14. Al-Waili NS. An alternative treatment for pityriasis versicolor, tinea cruris, tinea corporis and tinea faciei with topical application of honey, olive oil and beeswax mixture: an open pilot study. Complement Ther Med 2004;12:45-47.
15. The Sanford Guide to Antimicrobial Therapy. 35th ed. Hyde Park, Vt: Antimicrobial Therapy; 2005.
16. Noble S, Forbes R, Stamm P. Diagnosis and management of common tinea infections. Am Fam Physician 1998;58:163-178.Available at: www.aafp.org/afp/980700ap/noble.html. Accessed on February 9, 2006.
17. Crawford F, Hart R, Bell-Syer S, Togerson D, Young P, Russell I. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database Syst Rev 1999;(3):CD001434.
Evidence-based answers from the Family Physicians Inquiries Network