Antifungal Creams: OTC, Prescription, and How to Choose

Antifungal creams are topical medications used to treat fungal skin infections. Low-potency antifungal creams are available over the counter (OTC) to treat milder cases of athlete's foot, ringworm, or jock itch. High-potency antifungal creams, gels, or ointments are available by prescription for infections that do not respond to OTC options.

High potency doesn't necessarily mean that an antifungal is better at clearing a fungal skin infection. In the end, the best topical antifungal is the one that treats the infection with the lowest dose, duration of treatment, and side effects.

How Antifungal Cream Works

There are seven major classes of topical antifungals used in the U.S., each of which has slightly different mechanisms of action:

Azoles are a class of antifungals that block the production of ergosterol, a structural fat that makes up the walls of fungi. The lack of ergosterol causes fungi to weaken, collapse, and die.
Allylamines are a class of antifungals that block the integration of a fat called squalene into ergosterol. The accumulation of squalene is toxic to fungi, killing the cells directly.
Naphthalenes work similarly to allylamines, also blocking squalene integration into ergosterol albeit in a slightly different manner.
Polyenes are a class of antifungals that directly disrupt the structure of ergosterol in fungal walls, punching holes in them and causing them to leak and die.
Benzylamines are a type of antifungal that blocks the replication of fungal DNA. This disrupts the growth and metabolism of fungal cells, causing them to die.
Morphonlines used for toenail fungus work similarly to allylamines, blocking the integration of fat called ignosterol into ergosterol. As with squalene, ignosterol is toxic to fungal cells.

Hydroxypyridinones are a type of antifungal whose action is not fully understood, although it is thought to disrupt iron essential to the survival of fungal cells.
Oxaboroles are a newer class of topical fungal that work similarly to benzylamines, disrupting RNA and the metabolism and growth of fungal cells.

Types of Topical Antifungals

With consistent use, topical antifungals can kill the fungus at the site of the infection. This differs from oral antifungals that deliver the medication systemically (throughout the whole body).

There are no less than 30 topical antifungals approved for use in the U.S., used either on their own or in combination with an oral antifungal.

Class	Drug	Formulation and Standard Dosage
Azoles	Cotrimoxazole	1% cream, twice daily for 4-6 weeks
	Ketoconazole	2% cream or gel, twice daily for 2-4 weeks
	Econazole	1% cream, once daily for 2-4 weeks
	Miconazole	2% cream or gel, twice daily for 4-6 weeks
	Bifonazole	1% cream, once daily for 4 weeks
	Oxiconazole	1% cream or lotion, once daily for 4-6 weeks
	Tioconazole	1% cream, twice daily for 4 weeks
	Sertaconazole	2% cream, twice daily for 4 weeks
	Luliconazole	1% cream, once daily for 1-4 weeks
	Eberconazole	1% cream, once daily for 2-4 weeks
	Sulconazole	1% cream, once or twice daily for 3 weeks
	Fenticonazole	2% cream, twice daily for 4 weeks
	Fluconazole	0.5% gel, twice daily for 4 weeks
	Efinaconazole	10% nail solution, once daily for 48 weeks
Allylalmines	Terbinafine	1% cream, twice daily for 1-4 weeks
	Naftifine	1% cream, twice daily for 4 weeks
Naphthalenes	Tolnaftate	1% cream or lotion, twice daily for 4 weeks
Polyenes	Amphotericin B	0.1% cream, one to four times daily for 1-4 weeks
	Nystatin	Oral suspension or lozenges, three to six times daily for up to 2 weeks
Benzylamines	Butenafine	1% cream, twice daily for 2-4 weeks
Morpholines	Amorolfine	5% nail lacquer, once or twice weekly for 6-12 months
Hydroxypyridinones	Ciclopirox 8%	8% nail lacquer, once weekly for up to 4 months
	Ciclopirox 1%	1% cream, once or twice daily for up to 48 weeks
Oxaboroles	Tavaborole	5% nail solution, once daily for up to 48 weeks

Over-the-Counter Antifungals and Their Uses

OTC topical antifungals are effective in treating most uncomplicated fungal skin infections, including those affecting the genitals and anus.

These include common fungal infections like:

Ringworm (tinea corporis)
Athlete’s foot (tinea pedis)
Jock itch (tinea cruris)
Scalp ringworm (tinea capitis)
Yeast infections (candidiasis), including vaginal, penile, and anal yeast infections
Tinea versicolor

There are six OTC options used to treat these and other conditions:

Drug	Brands name(s)	Conditions treated
Clotrimazole	Lotrimin AF, Trivagizole 3	Athlete's foot Ringworm Jock itch Yeast infections Tinea versicolor
Miconazole	Monistat, Vagistat, Micatin	Yeast infections Athlete's foot Ringworm Scalp ringworm Jock itch Tinea versicolor
Ketoconazole	Nizoral, Extina, Xolegel	Athlete's foot Ringworm Scalp ringworm Jock itch
Tolnaftate	Tinactin, Lamisil AF	Athlete's foot Jock itch
Terbinafine	Lamisil AT	Athlete's foot Ringworm Jock itch Tinea versicolor
Butenafine	Lotrimin Ultra	Athlete's foot Jock itch

When Prescription Topical Antifungals Are Needed

Prescription topical antifungals are typically prescribed when an infection does not clear with an OTC product. They may also be used in combination with an oral antifungal to treat a severe local infection or a systemic infection (such as can occur in people who are immunocompromised).

They are often used to treat severe oral yeast infections (thrush) or fungal nail infections (which are typically hard to treat).

In severe cases, a topical antifungal may be combined with a corticosteroid drug like triamcinolone to help ease inflammation, itching, and pain that can accompany the infection.

The choice of drug can vary by the infection. Examples include:

Condition	Prescription drug options
Oral thrush	Nystatin oral solution or lozenges Miconazole oral gel Amphotericin B cream
Yeast infections	Clotrimazole vaginal suppository Clotrimazole 10% vaginal cream Econazole cream Tioconazole cream Amphotericin B
Scalp ringworm	Ciclopirox liquid or shampoo
Fungal nail infection	Amorolfine nail lacquer Econazole solution Ciclopirox nail lacquer Bifonazole cream Efinaconazole nail solution Tavaborole nail solution

How to Choose the Best Topical Antifungal

The general aim of any antifungal therapy is to use the lowest possible dose for the shortest period to clear the infection. The stronger the dose or longer the treatment, the more likely you are to experience side effects.

To illustrate the concern, here is how the side effects of one of the most common OTC antifungals, Lotrimin AF (clotrimazole), compares to Mytrex (nystatin + triamcinolone), one of the stronger prescription formulations:

Lotrimin AF (Clotrimazole)

Redness
Itching
Swelling
Burning or stinging
Tenderness
Tiny, pimple-like bumps
Skin dryness and flaking

Mytrex (Nystatin + Triamcinolone)

Redness
Itching
Swelling
Burning or stinging
Tenderness or pain
Severe blistering
Rash or hives
Skin peeling
Changes in skin color
Skin thinning
Easy bruising
Stretch marks
Anaphylaxis (a severe whole-body allergy)

This is why treatment is generally staged, using an OTC topical antifungal before moving on to a prescription topical and/or oral antifungal.

Summary

Antifungal creams are used to treat a variety of fungal skin infections. There are many different types of topical antifungals, both over-the-counter and prescription, that vary in their strength, mechanism of action, duration of treatment, and recommended uses.

The best antifungal cream is the one that can clear the infection quickly at the lowest possible dose. Speak with your healthcare provider to choose the option best suited for your type of infection.

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