Efficacy of Oral Voriconazole versus Terbinafine in Patients with Recalcitrant Tinea Cruris: A Single-Center Prospective Study from Peshawar
DOI:
https://doi.org/10.66344/jpad.v36i3.3489Keywords:
Antifungal agents, Efficacy, Terbinafine, Tinea cruris, VoriconazoleAbstract
Background Recalcitrant tinea cruris has emerged as a major therapeutic challenge due to increasing antifungal resistance and insufficient response to conventional therapy (terbinafine, clotrimazole, miconazole and ketoconazole creams). Terbinafine and voriconazole are commonly considered in resistant cases; however, their comparative effectiveness remains uncertain.
Objective To compare the efficacy of voriconazole versus terbinafine in the treatment of recalcitrant tinea cruris.
Methods This comparative prospective cohort study included 300 patients aged 20 to 70 years with recalcitrant tinea cruris who failed to respond to one month of topical antifungal therapy were included in the study. Patients were assigned equally into two groups. Group A received oral voriconazole 400 mg once daily, while Group B received oral terbinafine 250 mg twice daily for four weeks. Treatment efficacy was assessed at eight weeks post-treatment. Data were analyzed using SPSS version 25. The chi-square test was used to compare efficacy with significance set at p≤0.05.
Results The voriconazole group achieved a significantly higher complete resolution rate of 81.3% (n=122) compared to 63.3% (n=95) in the terbinafine group (P<.001). Partial resolution was observed in 14.0% (n=21) patients in the voriconazole group and 24.0% (n=36) in the terbinafine group. No change was observed in 4.7% (n=7) cases in the voriconazole group and 12.7% (n=19) in the terbinafine group. Adverse events were comparable between groups (P=.161).
Conclusion Voriconazole exhibited superior efficacy compared to terbinafine in achieving complete resolution of recalcitrant tinea cruris at eight weeks post-treatment, with an acceptable safety profile.
References
1. Sajewski ET, Benedict K, Caplan AS, Lipner SR, Gold JA. Tinea corporis and tinea cruris incidence, risk factors, and treatments in a cohort of 6.8 million patients with Medicaid, United States. Med Mycol. 2026;64(1):myaf117. DOI:10.1093/mmy/myaf117
2. Tamimi P, Fattahi M, Firooz A, Ghaderi A, Ayatollahi A, Nasiri Kashani M, et al. Recalcitrant dermatophyte infections: identification and risk factors. Int J Dermatol. 2024;63(10):1398-403. DOI: 10.1111/ijd.17145
3. Arora P, Sardana K, Kulhari A, Kaur R, Rawat D, Panesar S. Real world analysis of response rate and efficacy of oral ketoconazole in patients with recalcitrant tinea corporis and cruris. Am J Trop Med Hygiene. 2021;106(1):38-44. DOI:10.4269/ajtmh.21-0505
4. Brigida S, Elizabeth AA. A Comparative Study of Efficacy of Oral Terbinafine and Oralitraconazole in Tinea Corporis/ Tinea Cruris Infection. J Pharm Res Int. 2021;33(20A):94-105. DOI: 10.9734/jpri/2021/v33i20A31352
5. Canete-Gibas CF, Mele J, Patterson HP, Sanders CJ, Ferrer D, Garcia V, et al. Terbinafine-resistant dermatophytes and the presence of Trichophyton indotineae in North America. J Clin Microbiol. 2023;61(8):e00562-23. DOI:10.1128/jcm.00562-23
6. Moreno-Sabater A, Normand AC, Bidaud AL, Cremer G, Foulet F, Brun S, et al. Terbinafine resistance in dermatophytes: a French multicenter prospective study. J Fungi. 2022;8(3):220. DOI:10.3390/jof8030220
7. Firooz A, Lotfali E, Fattahi M, Fattahi M, Miramin Mohammadi A, Shahrzad Kavkani M. A Case of Terbinafine-Resistant Tinea Cruris Caused by Trichophyton tonsurans. Case Rep Dermatol Med. 2021;2021:9611072. DOI: 10.1155/2021/9611072
8. Lal NR, Basu D, Saha A, Ghosh R, Verma R, Bandyopadhyay D. Efficacy and safety of 250 mg versus 500 mg oral terbinafine in the treatment of tinea corporis and cruris: A randomised, assessor-blinded comparative study. Indian J Dermatol Venereol Leprol. 2023;89(5):665-671.
DOI: 10.25259/IJDVL_74_2022
9. Verma N, Verma S, Dayal S, Gupta MC. Efficacy and safety of different terbinafine regimens in patients of recurrent tinea corporis and cruris. Int J Basic Clin Pharmacol. 2021;10(8):911-4. DOI:10.18203/2319-2003.ijbcp20212761
10. BS C, Poojitha DS. Evaluation of efficacy and safety of oral voriconazole in the management of recalcitrant and recurrent dermatophytosis. Clin Exp Dermatol. 2022;47(1):30-6. DOI: 10.1111/ced.14799
11. Ali M, Ahmed N, Khan S. Efficacy of oral voriconazole versus oral itraconazole, in the treatment of dermatophyte infections. J Ayub Med Coll Abbottabad. 2024;36(2):294-8. DOI:10.55519/JAMC-02-12891
12. Shahzad MK, Hassan T, Tahir R, Jawaid K, Khan MF, Naveed MA. Efficacy of Oral Voriconazole in the Treatment of Dermatophyte Infections (Tinea Corporis and Cruris). Pak J Med Health Sci. 2022;16(02):330-2. DOI:10.53350/pjmhs22162330
13. Khurana A, Agarwal A, Agrawal D, Sardana K, Singh A, Chowdhary A. Multidrug resistant tinea corporis/cruris: Response to voriconazole. J Mycol Med. 2022;32(4):101306. DOI: 10.1016/j.mycmed.2022.101306
14. Khattab F, Elkholy BM, Taha M, Abd-Elbaset A, Fawzy M. Voriconazole is superior to combined itraconazole/isotretinoin therapy and itraconazole monotherapy in recalcitrant dermatophytosis. Mycoses. 2022;65(12):1194-1201. DOI: 10.1111/myc.13517
15. Bhatia A, Kanish B, Badyal DK, Kate P, Choudhary S. Efficacy of oral terbinafine versus itraconazole in treatment of dermatophytic infection of skin - A prospective, randomized comparative study. Indian J Pharmacol. 2019;51(2):116-119. DOI: 10.4103/ijp.IJP_578_17
16. Sardana K, Kaur R, Arora P, Goyal R, Ghunawat S. Is antifungal resistance a cause for treatment failure in dermatophytosis: A study focused on tinea corporis and cruris from a tertiary centre?. Indian Dermatol J. 2018;9(2):90. DOI:10.4103/idoj.IDOJ_137_17
17. Naseer M, Devi V, Khan KN, Asad N, Azhar A, Asif MI, et al. Efficacy and Safety of Voriconazole in the Treatment of Tinea Corporis and Cruris Infections. J Pak Assoc Dermatol. 2025;35(1):4-10.
18. Akter T, Khondker L, Rahman M, Nahid A, Islam MS, Chanda T. Comparison between oral voriconazole and terbinafine in treatment of relapse or resistant tinea corporis and cruris. World J Adv Res Rev. 2025;25(1):2005-11. DOI: 10.30574/wjarr.2025.25.1.0216
19. Das S, De A, Saha R, Sharma N, Khemka M, Singh S, et al. The current Indian epidemic of dermatophytosis: a study on causative agents and sensitivity patterns. Indian J Dermatol. 2020;65(2):118-22. DOI: 10.4103/ijd.IJD_203_19
20. Akhter F, Uddin MR, Faisal A. Comparative efficacy of terbinafine monotherapy versus combined terbinafine and voriconazole in treating resistant fungal infections. East Afr Sch Med Sci. 2024;7(11):478-83. DOI:10.36349/easms.2024.v07i11.005
21. Tan XT, Saifuddin SAS, Mohamed Yusof NIS, Teo HG, Tang MM. Recalcitrant dermatophytosis due to Trichophyton indotineae: A case series from Sarawak, Malaysia. Med Mycol Case Rep. 2025;50:100740. DOI: 10.1016/j.mmcr.2025.100740
22. Khan SS, Hay R, Saunte DML. An international survey of recalcitrant and recurrent tinea of the glabrous skin: a potential indicator of antifungal resistance. J Eur Acad Dermatol Venereol. 2025;39(6):1185-91. DOI: 10.1111/jdv.20146
23. Bibi S, Rashid F. Voriconazole in dermatophytic infections: an in-depth examination of its role in tinea treatment. J Islamabad Med Dental Coll. 2025;14(4):401-8. DOI: 10.35787/jimdc.v14i4.1461.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Murad Ali, Sahibzada Mehmood Noor, Samreen Javed, Bashir Ahmad, Sabahat
This work is licensed under a Creative Commons Attribution 4.0 International License.
Submission declaration
Authors retain the copyright to their work and grant the 'Journal of Pakistan Association of Dermatologists (JPAD)' the right of first publication under a Creative Commons Attribution 4.0 International (CC BY 4.0) license. This license allows others to share, adapt, and reuse the work for any purpose, including commercial use, as long as appropriate credit is given to the original authors and the journal.
By submitting a manuscript, authors confirm that the work has not been published previously (except as an abstract, lecture, or academic thesis), is not under review elsewhere, and has been approved by all authors and relevant authorities. Once accepted, the article will be openly accessible under the CC BY 4.0 license, ensuring wide dissemination and reuse with proper attribution.
