Comparative Efficacy of Terbinafine, Itraconazole, and Griseofulvin in Treatment of Steroid-Modified Tinea

BACKGROUND: Steroid-modified tinea or tinea incognito has emerged as a significant challenge in India due to the widespread misuse of topical corticosteroids, leading to chronic, treatment-resistant dermatophytosis. AIM AND OBJECTIVES: This study was performed to compare the efficacy and safety of antifungal drugs: oral terbinafine, itraconazole, and griseofulvin in the treatment of steroid-modified tinea. In addition, patient awareness about steroid misuse and consequent impact on quality of life were also assessed. PATIENTS AND METHODS: A total of 90 potassium hydroxide (KOH)-positive patients ( ≥18 years) with tinea corporis, cruris, or faciei, having a history of prior topical steroid use, were randomly assigned to receive terbinafine (250 mg twice a day), itraconazole (100 mg twice a day), or griseofulvin (500 mg twice a day) for eight weeks ( n = 30 each). Clinical severity scores, cure rates, dermatology life quality index (DLQI) scores, steroid misuse patterns, and any adverse drug reactions reported were recorded for each patient. RESULTS: The group treated with itraconazole showed highest cure rate (70%) at eight weeks, followed by terbinafine (36.7%) and griseofulvin (26.7%) ( P = 0.529). Clinical severity scores reduced significantly in all three groups by the end of eight weeks (within-group comparison P = 0.001). DLQI scores improved most with itraconazole ( P = 0.003). Regarding a prior history of steroid use in the study population, the misuse of clobetasol propionate was seen in 46.7-76.7%, with 90-100% of patients being unaware of steroid content or its side effects. LIMITATIONS: Limited sample size may have limited statistical ability to detect significant cure rates. Despite intention-to-treat analysis, loss of follow-up may introduce bias. Baseline differences in gender and comorbidities among the study groups may have confounded the observed outcomes. Additionally, the lack of blinding may have influenced outcome assessment. CONCLUSION: Itraconazole appears to be the most effective for steroid-modified tinea, with superior clinical and quality-of-life outcomes. Steroid misuse, driven by pharmacist recommendations, underscores the need for public health interventions.