Consensus of the role and positioning of the imidazoles in the treatment of dermatophytosis.

The imidazoles have been appreciated for approximately fifteen years as a family of antifungals. Most derivatives, like the protype compounds, miconazole and clotrimazole, are effective only in a topical dose form. The topical imidazoles are generally thought to be superior to other topical antifungals. The first orally available imidazole, ketoconazole has ushered in a new era of potent, oral, broad-spectrum antifungal therapy. The imidazoles as a class are the treatment of choice for four dermatophyte infection syndromes. They are the preferred alternative therapy in another six syndromes. There is insufficient data to recommend one topical azole over the other. The topicals are inadequate for control of six clinical-anatomical infection syndromes. Griseofulvin remains the standard oral therapy in all situations except chronic, extensive dermatophytosis, where ketoconazole has proven to be more efficacious. The recognition of potential significant adverse effects, namely an idiopathic hepatitis and dose-dependent adrenal and testicular dysfunction have reduced ketoconazole's potential role in the dermatophytoses. Ketoconazole is a useful alternative to griseofulvin when oral therapy is required and the causative organism is insensitive to griseofulvin, or infection fails to respond to griseofulvin, or griseofulvin is contraindicated due to allergy, photosensitivity, porphyrinuria, intolerance, etc.