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Sulconazole Nitrate

Class: Azoles
ATC Class: D01AC09
VA Class: DE102
Chemical Name: (±)-1-[2-[[(4-Chlorophenyl)methyl]thio]-2-(2,4-dichlorophenyl)ethyl]-1H-imidazole mononitrate
Molecular Formula: C18H15Cl3N2S•HNO3
CAS Number: 61318-91-0
Brands: Exelderm

Introduction

Antifungal; azole (imidazole derivative).1 2 3 18

Uses for Sulconazole Nitrate

Dermatophytoses

Treatment of tinea corporis (body ringworm) and tinea cruris (jock itch) caused by Epidermophyton floccosum, Microsporum canis, Trichophyton mentagrophytes, or T. rubrum.1 2 3 5 11 12 13 14 15 20 21 25 26 27 39 40 43 45 56

Treatment of tinea pedis (athlete’s foot) 3 5 11 12 13 14 20 21 25 27 39 40 43 45 caused by E. floccosum, M. canis, T. mentagrophytes, or T. rubrum.2 3 5 11 12 13 14 15 20 21 25 26 27 39 40 43 45 56

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Topical antifungals usually effective for treatment of uncomplicated tinea corporis or tinea cruris.40 58 An oral antifungal may be necessary when tinea corporis or tinea cruris is extensive, dermatophyte folliculitis is present, infection does not respond to topical therapy, or patient is immunocompromised because of coexisting disease or concomitant therapy.39 40 43 44 45 56

Topical antifungals usually effective for treatment of uncomplicated tinea pedis.45 56 59 An oral antifungal may be necessary for treatment of hyperkeratotic areas on the soles, for chronic moccasin-type (dry-type) tinea pedis,15 and for tinea unguium (fingernail or toenail dermatophyte infections, onychomycosis).40 45 56

Pityriasis (Tinea) Versicolor

Treatment of pityriasis (tinea) versicolor caused by Malassezia furfur (Pityrosporum orbiculare or P. ovale).1 2 3 8 10

Topical antifungals usually effective;39 41 42 44 53 60 an oral antifungal (with or without a topical antifungal) may be necessary in patients who have extensive or severe infections or failed to respond to or have frequent relapses with topical therapy.41 42 44 53 58

Cutaneous Candidiasis

Treatment of cutaneous candidiasis caused by Candida albicans.9 22

Sulconazole Nitrate Dosage and Administration

Administration

Topical Administration

Apply topically to the skin as a 1% cream or solution.1 3

Do not apply to the eye or administer orally or intravaginally.1 3 19

Apply a sufficient amount of cream or solution; rub gently into affected area and immediately surrounding healthy skin.1 3 14 15 26

Dosage

Adults

Dermatophytoses
Tinea Corporis or Tinea Cruris
Topical

Apply 1% cream or solution once or twice daily1 3 14 15 26 for 3 weeks.1 3

If clinical improvement does not occur after 4–6 weeks of treatment, reevaluate diagnosis.3 58

Tinea Pedis
Topical

Apply 1% cream twice daily3 14 15 26 for 4 weeks.1 3 58

If clinical improvement does not occur after 4–6 weeks of treatment, reevaluate diagnosis.3 58 Chronic moccasin-type (dry-type) tinea pedis may require 4–8 weeks or longer.15 40

Pityriasis (Tinea) Versicolor
Topical

Apply 1% cream or solution once or twice daily1 3 14 15 26 for 3 weeks.1 3

If clinical improvement does not occur after 4–6 weeks of treatment, reevaluate diagnosis.1 3

Special Populations

No special population dosage recommendations at this time.1 3

Cautions for Sulconazole Nitrate

Contraindications

Known hypersensitivity to sulconazole or any ingredient in the formulation.1 3 19 58

Warnings/Precautions

Warnings

Application Precautions

For external use only.1 3 Use only for topical application to the skin; not for ophthalmic or intravaginal use.1 3 19

Fetal/Neonatal Morbidity and Mortality

Embryotoxicity demonstrated in animals receiving oral sulconazole.1 3 19

Sensitivity Reactions

Hypersensitivity Reactions

Contact dermatitis reported following topical application of sulconazole2 11 or other imidazole-derivative azole antifungals.5 28 29 30 46 47 48

If irritation or sensitivity occurs, discontinue the drug and initiate appropriate therapy.1 3

Possible cross-sensitization among the imidazoles.4 28 29 30 46 47 48

General Precautions

Selection and Use of Antifungals

Prior to initiation of treatment, confirm diagnosis by direct microscopic examination of scrapings from infected tissue mounted in potassium hydroxide (KOH) or by culture.39 40 45 56 58

Specific Populations

Pregnancy

Category C.1 3 (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether distributed into milk.1 3 Caution advised.1 3

Pediatric Use

Safety and efficacy not established.1 3

Geriatric Use

Insufficient data from clinical studies to determine whether patients ≥65 years of age respond differently than younger adults.1 3 Clinical experience to date has not identified differences in responses between geriatric patients and younger adults.1 3

Common Adverse Effects

Pruritus,2 3 5 8 9 10 15 22 burning,1 3 5 8 10 15 22 25 stinging,1 3 10 15 erythema.2 3 5 8 10 22

Interactions for Sulconazole Nitrate

Weak inducer of CYP1A1 and CYP2B1.35

Drugs Metabolized by Hepatic Microsomal Enzymes

Potential pharmacokinetic interaction with drugs metabolized by CYP1A1 or 2B1;38 interaction unlikely with topical administration of sulconazole58 since only low amounts absorbed following topical application to skin.2 16 19 34

Sulconazole Nitrate Pharmacokinetics

Absorption

Bioavailability

Low amounts of sulconazole are absorbed systemically following topical application to skin.2 16 19 34

Distribution

Extent

Not known whether sulconazole is distributed into milk.1 3

Elimination

Elimination Route

Systemically absorbed drug is excreted in urine (6.7%) and feces (2%).16

Stability

Storage

Topical

Cream

≤40°C.3

Solution

≤40°C; protect from light.1 3

Actions and Spectrum

  • Imidazole-derivative azole antifungal.1 2 3 18

  • Usually fungistatic; may be fungicidal at high concentrations against very susceptible organisms.2 7

  • Presumably exerts its antifungal activity by altering cellular membranes, resulting in increased membrane permeability, secondary metabolic effects, and growth inhibition.2 24 Fungistatic activity may result from interference with ergosterol synthesis.2 43 57

  • Spectrum of antifungal activity includes many fungi, including yeasts and dermatophytes.1 2 3 7 17 18 23 37 Also has in vitro activity against some gram-positive bacteria.1 2 3 18 37

  • Dermatophytes: Active in vitro against Epidermophyton floccosum,1 2 3 18 Microsporum audouinii,18 M. canis,1 2 3 M. gypseum,2 18 Trichophyton mentagrophytes,1 2 3 18 T. rubrum,1 2 3 18 T. tonsurans,2 18 and T. violaceum.2

  • Candida: Active in vitro against Candida albicans,2 7 17 18 23 C. glabrata (formerly Torulopsis glabrata),2 C. guilliermondii,2 17 C. krusei,2 17 C. parapsilosis,2 17 C. pseudotropicalis,2 17 and C. tropicalis.2 17

  • Other fungi: Active in vitro against Malassezia furfur (Pityrosporum orbiculare or P. ovale).1 2 3 Also active in vitro against Aspergillus,2 Blastomyces dermatitidis,2 Cryptococcus neoformans,2 18 Histoplasma capsulatum,2 and Paracoccidioides brasiliensis.2 17 23

  • Bacteria: Active in vitro against Bacillus subtilis,2 Clostridium perfringens,2 C. tetani,2 C. botulinum,2 Enterococcus faecalis,2 Erysipelothrix rhusiopathiae,6 Micrococcus luteus,2 Propionibacterium acnes,18 Staphylococcus aureus,2 S. epidermidis,2 and S. saprophyticus.2

  • Cross-resistance can occur among the azole antifungals.23 Some C. albicans isolates from patients undergoing long-term azole antifungal therapy show decreased in vitro susceptibility to sulconazole and other imidazole-derivative antifungals as well as to triazole derivatives.23

Advice to Patients

  • Importance of completing full course of treatment, even if symptoms improve.1 3

  • Importance of contacting clinician if skin condition worsens during treatment or if improvement does not occur after completing full course of therapy.1 3

  • Importance of discontinuing use and consulting clinician if treated area becomes irritated.1 3

  • Importance of applying to affected areas as directed1 3 and avoiding contact with eyes and not applying intravaginally.1 3 19

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.1 3

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 3

  • Importance of informing patients of other important precautionary information.1 3 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Sulconazole Nitrate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Topical

Cream

1%

Exelderm (with propylene glycol)

Westwood-Squibb

Solution

1%

Exelderm (with propylene glycol)

Westwood-Squibb

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Exelderm 1% Cream (RANBAXY LABORATORIES): 30/$95.05 or 90/$268.30

Exelderm 1% Solution (RANBAXY LABORATORIES): 30/$92.99 or 90/$255.96

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions July 1, 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. Westwood Squibb Pharmaceuticals. Exelderm (sulconazole nitrate) 1% solution prescribing information. Princeton, NJ; 2006 Apr.

2. Benfield P, Clissold SP. Sulconazole: a review of its antimicrobial activity and therapeutic use in superficial dermatomycoses. Drugs. 1988; 35:143-53. [IDIS 239722] [PubMed 3281821]

3. Westwood Squibb Pharmaceuticals. Exelderm (sulconazole nitrate) 1% cream prescribing information. Buffalo, NY; 2003 May 29.

4. Bigardi AS, Pigatto PD, Altomare G. Allergic contact dermatitis due to sulconazole. Contact Dermatitis. 1992; 26:281-2. [PubMed 1395584]

5. Tanenbaum L, Anderson C, Rosenberg MJ et al. Sulconazole nitrate 1.0 percent cream: a comparison with miconazole in the treatment of tinea pedis and tinea cruris/corporis. Cutis. 1982; 30:105-7, 115, 118. [PubMed 6749440]

6. Nolting S, Strauss WB. Treatment of impetigo and ecthyma: a comparison of sulconazole with miconazole. Int J Dermatol. 1988; 27:716-9. [PubMed 3069760]

7. Beggs WH. Influence of growth phase on the susceptibility of Candida albicans to butoconazole, oxiconazole, and sulconazole. J Antimicrob Chemother. 1985; 16:397-9. [PubMed 3902762]

8. Tham SN. Treatment of pityriasis versicolor: comparison of sulconazole nitrate 1% solution and clotrimazole 1% solution. Australas J Dermatol. 1987; 28:123-5. [PubMed 3332758]

9. Rajan VS, Thirumoorthy T. Treatment of cutaneous candidiasis: a double blind, parallel comparison of sulconazole nitrate 1% cream and clotrimazole 1% cream. Australas J Dermatol. 1983;24:33-6.

10. Tanenbaum L, Anderson C, Rosenberg MJ et al. 1% sulconazole cream v 2% miconazole cream in the treatment of tinea versicolor. Arch Dermatol. 1984; 120:216-9. [IDIS 181082] [PubMed 6364994]

11. Lassus A, Forström S, Salo O. A double-blind comparison of sulconazole nitrate 1% cream with clotrimazole 1% cream in the treatment of dermatophytoses. Br J Dermatol. 1983; 108:195-8. [IDIS 166239] [PubMed 6337618]

12. Avila JM. Treatment of dermatomycoses with sulconazole 1% nitrate cream or miconazole nitrate 2% cream: a double-blind comparative study. Curr Ther Res. 1985; 38:328-33.

13. Woscoff A, Carabeli S. Treatment of tinea pedis with sulconazole nitrate 1% cream or miconazole nitrate 2% cream. Curr Ther Res. 1986; 39:753-7.

14. Cuce LC. Sulconazole nitrate 1% cream vs clotrimazole 1% cream in the treatment of tinea pedis. Curr Ther Res. 1989; 45:421-7.

15. Akers WA, Lane A, Lynfield Y et al. Sulconazole nitrate 1% cream in the treatment of chronic moccasin-type tinea pedis caused by Trichophyton rubrum. J Am Acad Dermatol. 1989; 21:686-9. [PubMed 2681281]

16. Franz TJ, Lehman P. Percutaneous absorption of sulconazole nitrate in humans. J Pharm Sci. 1988; 77:489-91. [IDIS 242452] [PubMed 3171926]

17. Hernández Molina JM, Llosá J, Martinez Brocal A et al. In vitro activity of cloconazole, sulconazole, butoconazole, isoconazole, fenticonazole, and five other antifungal agents against clinical isolates of Candida albicans and Candida spp. Mycopathologia. 1992; 118:15-21. [PubMed 1406898]

18. Westwood Squibb Pharmaceuticals. Exelderm (sulconazole nitrate 1%) cream and solution product monograph. Buffalo, NY.

19. Westwood Squibb Pharmaceuticals. Exelderm (sulconazole nitrate) product information. Buffalo, NY; 1990 Aug.

20. McVie DH, Littlewood S, Allen BR et al. Sulconazole versus clotrimazole in the treatment of dermatophytosis. Clin Exp Dermatol. 1986; 11:613-8. [PubMed 3311492]

21. Lassus A, Forsström S. A double-blind parallel study comparing sulconazole with econazole in the treatment of dermatophytoses. Mykosen. 1984; 27:592-8. [PubMed 6395015]

22. Tanenbaum L, Anderson C, Rosenberg M et al. A new treatment for cutaneous candidiasis: sulconazole nitrate cream 1%. Intl J Dermatol. 1983; 22:318-20.

23. Odds FC, Webster CE, Abbott AB. Antifungal relative inhibition factors: BAY 1-9139, bifonazole, butoconazole, isoconazole, itraconazole (R 51211), oxiconazole, Ro 14-4767/002, sulconazole, terconazole and vibunazole (BAY n-7133) compared in vitro with nine established antifungal agents. J Antimicrob Chemother. 1984; 14:105-14. [PubMed 6094418]

24. Sud IJ, Chou DL, Feingold DS. Effect of free fatty acids on liposome susceptibility to imidazole antifungals. Antimicrob Agents Chemother. 1979; 16:660-3. [PubMed 393166]

25. Gip L, Forsström S. A double-blind parallel study of sulconazole nitrate 1% cream compared with miconazole nitrate 2% cream in dermatophytoses. Mykosen. 1983; 26:231-41. [PubMed 6877272]

26. Tanenbaum L, Taplin D, Lavelle C et al. Sulconazole nitrate cream 1 percent for treating tinea cruris and corporis. Cutis. 1989; 44:344-7. [PubMed 2805811]

27. Qadripur SA. Double-blind parallel comparison of sulconazole nitrate, 1% cream and powder, with econazole, 1% cream and powder, in the treatment of cutaneous dermatophytoses. Curr Ther Res. 1984; 35:753-8.

28. Machet L, Vaillant L, Muller C et al. Contact dermatitis and cross-sensitivity from sulconazole nitrate. Contact Dermatitis. 1992; 26:352-3. [PubMed 1395603]

29. Raulin C, Frosch PJ. Contact allergy to imidazole antimycotics. Contact Dermatitis. 1988; 18:76-80. [PubMed 2966706]

30. Raulin C, Frosch PJ. Contact allergy to oxiconazole. Contact Dermatitis. 1987; 16:39-40. [PubMed 3816206]

31. Thomas AH. Suggested mechanisms for the antimycotic activity of the polyene antibiotics and the N-substituted imidazoles. J Antimicrob Chemother. 1986; 17:269-79. [PubMed 3516967]

32. Sud IJ, Feingold DS. Mechanisms of action of the antimycotic imidazoles. J Invest Dermatol. 1981; 76:438-41. [IDIS 133194] [PubMed 7017013]

33. Bristol-Myers Squibb. Vagistat-1 (tioconazole) 6.5% vaginal ointment prescribing information. In: Physicians’ desk reference. 51st ed. Montvale, NJ: Medical Economics Company Inc; 1997:783.

34. Fujihara M, Hirakoso K, Harigaya S. Pharmacokinetics of sulconazole nitrate (1) fate in rats after application to the skin. Oyo Yakuri Pharmacomet. 1984; 28:145-54.

35. Raffali F, Rougier A, Roguet R. Measurement and modulation of cytochrome-P450- dependent enzyme activity in cultured human keratinocytes. Skin Pharmacol. 1994; 7: 345-54. [PubMed 7946378]

36. Richardson K, Cooper K, Marriott MS et al. Discovery of fluconazole, a novel antifungal agent. Clin Infect Dis. 1990; 12(Suppl 3):S267-1.

37. Fromtling RA. Overview of medically important antifungal azole derivatives. Clin Microbiol Rev. 1988; 1:187-217. [PubMed 3069196]

38. Cropp JS, Bussey HI. A review of enzyme induction of warfarin metabolism with recommendations for patient management. Pharmacotherapy. 1997; 17: 917-28.

39. Gupta AK, Einarson TR, Summerbell RC et al. An overview of topical antifungal therapy in dermatomycoses: a North American perspective. Drugs. 1998; 55:645-74. [PubMed 9585862]

40. Piérard GE, Arrese JE, Piérard-Franchimont C. Treatment and prophylaxis of tinea infections. Drugs. 1996; 52:209-24. [PubMed 8841739]

41. Sunenshine PJ, Schwartz RA, Janniger CK. Tinea versicolor: an update. Cutis. 1998; 61:65-72. [PubMed 9515210]

42. Assaf RR, Weil ML. The superficial mycoses. Dermatol Clin. 1996; 14:57- 67. [PubMed 8821158]

43. Lesher JL. Recent developments in antifungal therapy. Dermatol Clin. 1996; 14:163-9. [PubMed 8821170]

44. Hay RJ. Dermatophytosis and other superficial mycoses. In: Mandel GL, Douglas RG Jr, Bennett JE, eds. Principles and practices of infectious disease. 4th ed. New York: Churchill Livingston; 1995: 2375-86.

45. Drake LA, Dincehart SM, Farmer ER et al. Guidelines of care for superficial mycotic infections of the skin: tinea corporis, tinea cruris, tinea faciei, tinea manuum, and tinea pedis. J Am Acad Dermatol. 1996; 34:282-6. [IDIS 363962] [PubMed 8642094]

46. Jones SK, Kennedy CTC. Contact dermatitis from tioconazole. Contact Dermatitis. 1990; 22:122-3. [PubMed 2138969]

47. Baes H. Contact sensitivity to miconazole with ortho-chloro cross-sensitivity to other imidazoles. Contact Dermatitis. 1991; 24:89-93. [PubMed 1828223]

48. Marren P, Powell S. Contact sensitivity to tioconazole and other imidazoles. Contact Dermatitis. 1992; 27:129-30. [PubMed 1395626]

49. Ortho. Monistat 3 (miconazole nitrate) 200 mg vaginal suppositories prescribing information. In: Physicians’ desk reference. 51st ed. Montvale, NJ: Medical Economics Company Inc; 1997:1903-4.

50. Ortho. Spectazole (econazole nitrate) 1% cream prescribing information (dated 1996 Jun). In: Physicians’ desk reference. 52nd ed. Montvale, NJ: Medical Economics Company Inc; 1998:1989.

51. Janssen Pharmaceutica. Nizoral (ketoconazole) tablets prescribing information (dated 1996 Jun). In: Physicians’ desk reference. 52nd ed. Montvale, NJ: Medical Economics Company Inc; 1998:1306-8.

52. Alexander BD, Perfect JR. Antifungal resistance trends towards the year 2000: implications for therapy and new approaches. Drugs. 1997; 54:657-78. [PubMed 9360056]

53. Drake LA, Dincehart SM, Farmer ER et al. Guidelines of care for superficial mycotic infections of the skin: pityriasis (tinea) versicolor. J Am Acad Dermatol. 1996; 34:287-9. [IDIS 363963] [PubMed 8642095]

54. Drake LA, Dincehart SM, Farmer ER et al. Guidelines of care for superficial mycotic infections of the skin: tinea capitis and tinea barbae. J Am Acad Dermatol. 1996; 34:290-4. [IDIS 363964] [PubMed 8642096]

55. Elewski B. Tinea capitis. Dermatol Clin. 1996; 14:23-31. [PubMed 8821154]

56. Crissey JT. Common dermatophyte infections: a simple diagnostic test and current management. Postgrad Med. 1998; 103:191-205. [IDIS 401902] [PubMed 9479316]

57. Anon. Antifungal agents and their use in Candida infections. In: Odds FC, ed. Candida and candidosis. 2nd ed. Philadelphia: Bailliere Tindall; 1988:293-313.

58. Reviewers’ comments (personal observations).

59. Naftifine Gel Study Group. Naftifine gel in the treatment of tinea pedis: two double- blind multicenter studies. Cutis. 1991; 48:85-8. [PubMed 1868748]

60. Aste N, Pau M, Pinna AL et al. Clinical efficacy and tolerability of terbinafine in patients with pityriasis versicolor. Mycoses. 1991; 34:353-7. [PubMed 1803242]

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