Topical antifungals
Pooled trials found every class of topical antifungal cured athlete's foot, jock itch and ringworm far more often than placebo, with terbinafine slightly ahead of azoles. Toenail treatments cured fewer than 1 in 5 people after a year. Ketoconazole cleared seborrheic dermatitis more often than placebo. Mild irritation was the main side effect.
Add to Bio HackChecked 2026-11-14
- Status
- In the US, clotrimazole 1%, miconazole 2%, terbinafine 1% and tolnaftate 1% creams, sprays and powders are sold over the counter for athlete's foot, jock itch and ringworm, ketoconazole 1% shampoo for dandruff, and miconazole and clotrimazole vaginal products for vaginal yeast infections in people previously diagnosed. Ketoconazole 2% cream, ciclopirox (cream, shampoo and 8% nail lacquer) and efinaconazole 10% solution (Jublia, for toenail fungus) are prescription drugs.
- Also called
- clotrimazole, Lotrimin AF, miconazole, Micatin, Monistat, terbinafine cream, Lamisil AT, ketoconazole cream, ketoconazole shampoo, Nizoral, Nizoral A-D, tolnaftate, Tinactin, ciclopirox, Loprox, Penlac, ciclopirox nail lacquer, efinaconazole, Jublia, butenafine, Lotrimin Ultra, antifungal cream, athlete's foot cream, jock itch cream, ringworm cream, yeast infection cream
- Taken for
- athlete's foot, jock itch, ringworm, toenail fungus, fingernail fungus, dandruff, seborrheic dermatitis, tinea versicolor, vaginal yeast infection, hair loss
Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on
Shown to help5
- StrongShown to cure athlete's foot far more often than placebo with every class tested, and terbinafine-type creams cured slightly more than azoles such as clotrimazole.
- StrongShown to cure jock itch and ringworm more often than placebo, with 1 extra cure for every 2 to 3 people treated with terbinafine or clotrimazole.
- ModerateShown to raise complete toenail cure over vehicle with efinaconazole and ciclopirox lacquer, though under 1 in 5 were fully cured after nearly a year.Very common
- ModerateShown to clear seborrheic dermatitis more often than placebo with ketoconazole 2% and ciclopirox 1%, and ketoconazole matched steroid creams with fewer side effects.
- LimitedLimited evidence: small human studies reported thicker hair shafts with ketoconazole shampoo in pattern hair loss, and the reviewers called for randomized trials.
Reported risks6
- ModerateLinked to side effects in about 12% of women using vaginal antifungals, a rate similar to pills, but more often local irritation than stomach upset or headache.Very common
- ModerateLinked to mild irritation, itching or stinging in about 5% on ketoconazole cream against 2.4% on placebo, with no difference between antifungal classes.Common
- ModerateShown to raise ingrown toenails and skin reactions around the nail slightly, 2.3% against 0.7% for ingrown toenail on efinaconazole.Common
- LimitedThe label warns ketoconazole 2% cream contains a sulfite that may cause allergic reactions, including anaphylaxis and asthma attacks, in susceptible people.How often is not known
- LimitedThe label warns that bleeding or bruising may occur when vaginal miconazole is used by people taking the blood thinner warfarin.How often is not known
- LimitedThe label warns vaginal miconazole products can damage condoms and diaphragms, which may then fail to prevent pregnancy or sexually transmitted infections.How often is not known
What people take it for, and what was found
Shown to help5
Athlete's foot
Shown to cure athlete's foot far more often than placebo with every class tested, and terbinafine-type creams cured slightly more than azoles such as clotrimazole.
Compared with placebo cream [1][2]; one another, directly and in a network [1][2][3]
The numbers and sources
- Effect
- Against placebo, the risk of treatment failure on skin of the foot was 0.33 (95% CI 0.24 to 0.44) for allylamines such as terbinafine, 0.30 (95% CI 0.20 to 0.45) for azoles such as clotrimazole and miconazole, 0.27 (95% CI 0.11 to 0.66) for ciclopirox, 0.19 (95% CI 0.08 to 0.44) for tolnaftate and 0.33 (95% CI 0.24 to 0.45) for butenafine. Across 11 trials, allylamines had less treatment failure than azoles (RR 0.63, 95% CI 0.42 to 0.94) [1]. A second review found all topical antifungals better than placebo, with no consistent difference between classes [2]. A network of 65 trials found no difference between antifungals in fungal cure at the end of treatment, while butenafine and terbinafine kept more people cured than clotrimazole, oxiconazole and sertaconazole [3].
- Population
- 67 trials in people with fungal infections of the skin and nails of the foot [1]; 104 trials of skin fungal infections [2]; 65 trials of dermatophyte infections [3].
- Sources
- [1], [2], [3]
- Caveats
- Many trials were old and small. The reviews pooled different durations and outcome times.
Jock itch and ringworm of the body
Shown to cure jock itch and ringworm more often than placebo, with 1 extra cure for every 2 to 3 people treated with terbinafine or clotrimazole.
Compared with placebo cream [4][2]; other antifungal classes and azole plus steroid creams [4]
The numbers and sources
- Effect
- Terbinafine raised clinical cure against placebo (RR 4.51, 95% CI 3.10 to 6.56, number needed to treat 3, 5 trials). Naftifine 1% raised fungal cure (RR 2.38, 95% CI 1.80 to 3.14, number needed to treat 3), and clotrimazole 1% raised fungal cure (RR 2.87, 95% CI 2.28 to 3.62, number needed to treat 2). Azoles and benzylamines did not differ in fungal cure (RR 1.01, 95% CI 0.94 to 1.07) [4]. A second review found all topical antifungals better than placebo [2].
- Population
- 129 trials with 18,086 people with proven ringworm or jock itch [4]; 104 trials [2].
- Sources
- [4], [2]
- Caveats
- Evidence quality was low to very low, and half the trials were at high risk of bias [4].
Toenail fungus
Shown to raise complete toenail cure over vehicle with efinaconazole and ciclopirox lacquer, though under 1 in 5 were fully cured after nearly a year.
Compared with vehicle solution or lacquer [6][7][8]
The numbers and sources
- How common
- Very common: more than 1 in 10 people.
- Effect
- Efinaconazole 10% raised complete cure against vehicle (RR 3.54, 95% CI 2.24 to 5.60, 3 trials, 1,716 people, high quality) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53). Ciclopirox 8% lacquer may raise complete cure (RR 9.29, 95% CI 1.72 to 50.14, low quality) and probably raises fungal cure (RR 3.15, 95% CI 1.93 to 5.12) [6]. In the efinaconazole label trials, complete cure at week 52 was 17.8% against 3.3% and 15.2% against 5.5% on vehicle [7]. In the ciclopirox label trials, with monthly trimming of the nail, a clear nail with negative fungal tests was reached by 5.5% against 0.9% and 8.5% against 0% on vehicle [8].
- Population
- 56 trials with 12,501 people, mostly with mild to moderate toenail infection [6]; 1,236 on efinaconazole and 415 on vehicle for 48 weeks [7]; 228 on ciclopirox and 226 on vehicle for 48 weeks [8].
- Sources
- [6], [7], [8]
- Caveats
- The review authors noted complete cure rates with topical treatments are relatively low [6]. No trial comparing topical nail treatment with oral terbinafine was sourced.
Seborrheic dermatitis and dandruff
Shown to clear seborrheic dermatitis more often than placebo with ketoconazole 2% and ciclopirox 1%, and ketoconazole matched steroid creams with fewer side effects.
Compared with placebo or vehicle [9]; topical steroids [9]; ciclopirox [9]
The numbers and sources
- Effect
- Ketoconazole 2% lowered the risk of failed clearance by 31% against placebo at four weeks (RR 0.69, 95% CI 0.59 to 0.81, 8 trials, low quality), with a median 69% not cleared on placebo. It gave remission similar to steroids (RR 1.17, 95% CI 0.95 to 1.44) with 44% fewer side effects (RR 0.56, 95% CI 0.32 to 0.96). Ciclopirox 1% lowered failed remission against placebo (RR 0.79, 95% CI 0.67 to 0.94, moderate quality). Ketoconazole and ciclopirox did not differ (RR 1.09, 95% CI 0.95 to 1.26) [9].
- Population
- 51 trials with 9,052 adolescents and adults with seborrheic dermatitis of the face or scalp [9].
- Sources
- [9]
- Caveats
- Most trials lasted four weeks or less, and 24 had a possible conflict of interest [9]. The over-the-counter 1% shampoo is labeled for dandruff flaking, scaling and itching [10].
Hair loss with ketoconazole shampoo
Limited evidence: small human studies reported thicker hair shafts with ketoconazole shampoo in pattern hair loss, and the reviewers called for randomized trials.
Compared with comparisons the review abstract does not describe [12]
The numbers and sources
- Effect
- Human studies reported increased hair shaft diameter after ketoconazole use, one reported a higher pilary index (share of growing hairs times diameter), and studies described improvement on photographs and by self-report [12].
- Population
- 5 human studies with 318 participants with androgenetic alopecia, plus 2 mouse studies [12].
- Sources
- [12]
- Caveats
- The review found no adequate randomized trial and gave no pooled effect [12].
Not shown to help2
Vaginal yeast infection: vaginal against oral treatment
Not shown to differ from oral antifungal pills in clearing vaginal yeast symptoms, though pills cleared the fungus itself slightly more often.
Compared with oral imidazole and triazole antifungals such as fluconazole [5]
The numbers and sources
- Effect
- Clinical cure did not differ between oral and vaginal treatment at short-term (OR 1.14, 95% CI 0.91 to 1.43, 13 trials, 1,859 women) or long-term follow-up (OR 1.07, 95% CI 0.77 to 1.50). If 77% are cured short term with vaginal treatment, 75% to 83% would be with oral. Oral treatment raised mycological cure (OR 1.24, 95% CI 1.03 to 1.50 short term, and OR 1.29, 95% CI 1.05 to 1.60 long term) [5].
- Population
- 26 trials with 5,007 women aged 16 or older with uncomplicated vulvovaginal candidiasis [5].
- Sources
- [5]
- Caveats
- The overall risk of bias was high. Trials excluded pregnant, breastfeeding, diabetic and immunocompromised women [5].
Tinea versicolor (pale or dark patches from yeast)
Limited evidence: azole creams and shampoos did not differ from peeling agents such as selenium sulfide in clearing tinea versicolor, on very low quality evidence.
Compared with keratolytic agents such as selenium sulfide, adapalene and salicylic-benzoic acid [11]
The numbers and sources
- Effect
- Azoles (ketoconazole, bifonazole and econazole) did not differ from keratolytics in clinical cure (RR 0.99, 95% CI 0.88 to 1.12, 4 trials, 274 people) or adverse events (RR 0.59, 95% CI 0.17 to 2.06, 6 trials, 536 people) [11].
- Population
- 8 trials with 617 people with active pityriasis versicolor [11].
- Sources
- [11]
- Caveats
- Very low quality evidence with moderate heterogeneity [11].
Doses studied
The over-the-counter terbinafine 1% cream label directs twice-daily use for 1 week between the toes or 2 weeks on the sole or sides of the foot, and once daily for 1 week for jock itch and ringworm, for ages 12 and up, not on nails or scalp [13]. Tolnaftate 1% cream is applied twice daily [14]. Ketoconazole 2% cream is applied once daily for skin fungus and twice daily for 4 weeks for seborrheic dermatitis [15]. The vaginal miconazole kit uses a 200 mg suppository with 2% external cream [16]. Efinaconazole 10% was applied once daily for 48 weeks [7], and ciclopirox 8% lacquer daily for 48 weeks with monthly removal of the loose infected nail [8]. How much reaches the blood: efinaconazole applied to all 10 toenails gave a mean peak plasma level of 0.67 ng/mL [7]. Ciclopirox lacquer gave serum levels of 12 to 80 ng/mL, with under 5% of the dose absorbed [8]. The ketoconazole cream label reports no detectable plasma levels in dogs after 28 days of skin application [15].
Risks
Reported risks6
Side effects of vaginal treatment against oral pills
Linked to side effects in about 12% of women using vaginal antifungals, a rate similar to pills, but more often local irritation than stomach upset or headache.
The numbers and sources
- How common
- Very common: more than 1 in 10 people.
- Effect
- If 12% have side effects with vaginal treatment, 10% to 15% would with oral treatment (OR 1.04, 95% CI 0.84 to 1.29, 16 trials, 3,155 women, low certainty). Vaginal treatments were more often linked to local reactions and oral treatments to gastrointestinal symptoms and headache. Withdrawal for side effects was rare with either (23 trials, 4,637 women, high certainty) [5].
- Population
- Women aged 16 or older with uncomplicated vulvovaginal candidiasis [5].
- Sources
- [5]
- Caveats
- The overall risk of bias was high [5].
Irritation, itching and stinging on the skin
Linked to mild irritation, itching or stinging in about 5% on ketoconazole cream against 2.4% on placebo, with no difference between antifungal classes.
The numbers and sources
- How common
- Common: between 1 in 100 and 1 in 10 people.
- Effect
- In ketoconazole 2% cream trials, 5% of 905 people and 2.4% of 208 on placebo reported side effects, mainly severe irritation, itching and stinging [15]. In ringworm and jock itch trials, side effects were minimal, mainly irritation and burning [4]. No differences in safety or tolerability were found in any direct comparison between antifungals [2]. In seborrheic dermatitis, ketoconazole side effects did not clearly differ from placebo (RR 0.97, 95% CI 0.58 to 1.64, very low quality) [9].
- Population
- 1,113 people in ketoconazole cream trials [15]; 129 trials [4]; 104 trials [2]; 51 trials [9].
- Sources
- [15], [4], [2], [9]
- Caveats
- Side effects were reported inconsistently across trials [4].
Ingrown toenail and skin reactions with nail solutions
Shown to raise ingrown toenails and skin reactions around the nail slightly, 2.3% against 0.7% for ingrown toenail on efinaconazole.
The numbers and sources
- How common
- Common: between 1 in 100 and 1 in 10 people.
- Effect
- On efinaconazole against vehicle, ingrown toenail occurred in 2.3% against 0.7%, application site dermatitis in 2.2% against 0.2%, vesicles in 1.6% against 0% and pain in 1.1% against 0.2% [7]. Pooled, efinaconazole slightly raised adverse events (RR 1.10, 95% CI 1.01 to 1.20, high quality) [6]. On ciclopirox lacquer, skin side effects, mostly redness around the nail, occurred in 8% against 4% on vehicle [8].
- Population
- 1,227 on efinaconazole and 413 on vehicle [7]; 3 trials with 1,701 people [6]; 327 on ciclopirox and 328 on vehicle [8].
- Sources
- [7], [6], [8]
- Caveats
- Trials lasted about one year.
Sulfite allergy with ketoconazole cream
The label warns ketoconazole 2% cream contains a sulfite that may cause allergic reactions, including anaphylaxis and asthma attacks, in susceptible people.
The numbers and sources
- How common
- How often is not known: the sources give no rate.
- Effect
- The cream contains sodium sulfite, which may cause allergic-type reactions including anaphylactic symptoms and life-threatening or milder asthmatic episodes in susceptible people. Rare reports of contact dermatitis have been linked to the cream, sodium sulfite or propylene glycol [15].
- Population
- Labeling statement and postmarketing reports [15].
- Sources
- [15]
- Caveats
- The label states sulfite sensitivity in the general population is unknown and probably low [15].
Vaginal miconazole with warfarin
The label warns that bleeding or bruising may occur when vaginal miconazole is used by people taking the blood thinner warfarin.
The numbers and sources
- How common
- How often is not known: the sources give no rate.
- Effect
- The over-the-counter vaginal miconazole label tells people taking the prescription blood thinner warfarin to ask a doctor or pharmacist before use, because bleeding or bruising may occur [16].
- Population
- Labeling statement [16].
- Sources
- [16]
- Caveats
- The label gives no rate.
Condoms and diaphragms with vaginal antifungals
The label warns vaginal miconazole products can damage condoms and diaphragms, which may then fail to prevent pregnancy or sexually transmitted infections.
The numbers and sources
- How common
- How often is not known: the sources give no rate.
- Effect
- The label states condoms and diaphragms may be damaged and fail to prevent pregnancy or sexually transmitted diseases, and advises against tampons, douches, spermicides and intercourse during use [16].
- Population
- Labeling statement [16].
- Sources
- [16]
- Caveats
- The label gives no rate.
Checked, no increase found1
Liver and hormone effects of oral ketoconazole
The label states the liver injury and lowered testosterone seen with ketoconazole pills have not been seen with the topical cream.
The numbers and sources
- How common
- How often is not known: the sources give no rate.
- Effect
- Hepatitis, at a reported incidence of 1 in 10,000, and at high doses lowered testosterone and adrenal steroid levels have been seen with oral ketoconazole. The label states these effects have not been seen with topical ketoconazole [15].
- Population
- Labeling statement [15].
- Sources
- [15]
- Caveats
- The label does not describe how this was checked in topical users.
Claims tested and not found
- That steroid plus antifungal combination creams clear more fungus than antifungal creams alone. Fungal cure did not differ between azole creams and azole plus steroid creams (RR 0.99, 95% CI 0.93 to 1.05), though the combinations gave more clinical cure at the end of treatment on very low quality evidence [4].
- That one antifungal class kills skin fungus better than the others by the end of treatment. A network of 65 trials found no difference among antifungals in fungal cure at the end of treatment [3], and a second review found no consistent difference between classes [2].
Sources
- Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database of Systematic Reviews. 2007. https://doi.org/10.1002/14651858.cd001434.pub2
- Rotta I, Sanchez A, Gonçalves PR, Otuki MF, Correr CJ. Efficacy and safety of topical antifungals in the treatment of dermatomycosis: a systematic review. British Journal of Dermatology. 2012. https://doi.org/10.1111/j.1365-2133.2012.10815.x
- Rotta I, Ziegelmann PK, Otuki MF, et al. Efficacy of topical antifungals in the treatment of dermatophytosis: a mixed-treatment comparison meta-analysis involving 14 treatments. JAMA Dermatology. 2013. https://doi.org/10.1001/jamadermatol.2013.1721
- El-Gohary M, van Zuuren EJ, Fedorowicz Z, et al. Topical antifungal treatments for tinea cruris and tinea corporis. Cochrane Database of Systematic Reviews. 2014. https://doi.org/10.1002/14651858.cd009992.pub2
- Denison HJ, Worswick J, Bond CM, et al. Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.cd002845.pub3
- Foley K, Gupta AK, Versteeg S, et al. Topical and device-based treatments for fungal infections of the toenails. Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.cd012093.pub2
- FDA label (DailyMed). Jublia (efinaconazole) topical solution 10%. Bausch Health US LLC. 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=922d4d25-c530-11e1-9b21-0800200c9a66
- FDA label (DailyMed). Ciclopirox topical solution USP 8% (nail lacquer). Acella Pharmaceuticals, LLC. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a08137a9-331f-4615-9752-e2cb52b3d8fc
- Okokon EO, Verbeek JH, Ruotsalainen JH, Ojo OA, Bakhoya VN. Topical antifungals for seborrhoeic dermatitis. Cochrane Database of Systematic Reviews. 2015. https://doi.org/10.1002/14651858.cd008138.pub3
- FDA label (DailyMed). Nizoral (ketoconazole 1%) anti-dandruff shampoo, Drug Facts. Kramer Laboratories. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8dd6b2f1-f438-4be1-a6c4-4f6c8902dfb6
- Genuino RNF, Dofitas BL, Batac MCFR, Pascual MBTG, Abrilla AA. Systematic Review and Meta-analysis on Synthetic Antifungal versus Keratolytic Agents for Topical Treatment of Pityriasis Versicolor. Acta Medica Philippina. 2022. https://doi.org/10.47895/amp.vi0.5605
- Fields JR, Vonu PM, Monir RL, Schoch JJ. Topical ketoconazole for the treatment of androgenetic alopecia: A systematic review. Dermatologic Therapy. 2020. https://doi.org/10.1111/dth.13202
- FDA label (DailyMed). Lamisil AT cream (terbinafine hydrochloride 1%), Drug Facts. Voyant Beauty Inc. 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9dea4789-bf1c-1577-e053-2a95a90a5381
- FDA label (DailyMed). Tinactin (tolnaftate 1%) cream, Drug Facts. Bayer HealthCare LLC. 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c3b715a9-233a-401a-ba60-f78c1ddf1ded
- FDA label (DailyMed). Ketoconazole cream 2%. RemedyRepack Inc. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ea56cddf-94c9-46b6-8791-995b741cfbd7
- FDA label (DailyMed). Monistat 3 (miconazole nitrate) suppository and external cream, Drug Facts. Insight Pharmaceuticals LLC. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=674f2e66-e7e3-40ff-aa21-adaf5d55dcda