S5: Pharmacology

             Key Unit Competence:

Utilize appropriately antifungal medications to manage different                                                                                                                        health condition at the primary healthcare settings

Introductory activity 4.0
 The images below show different patients with fungal infections                                                                                                                  and they are being treated with different medications. 
                
    
1) Have you ever seen some of the medical conditions above?
2) Which types of medications have you seen being used for these medical 
conditions above?

3) Have you ever seen these medications in the images above?

4.1 Definition and classification of antifungal drugs

       Learning Activity 4.1

      Read the scenario below:

A 35-year-old male patient is on drugs that she applies as a cream between her 
toes. The only explanations she got from the prescribers is to apply the cream 
as prescribed and dry the area before application of the drug. She has limited 
information regarding the intent of the drug, and what she only knows is that the 
drug was prescribed for an infectious disease. She then doubts whether she is 
taking an antibiotic or antifungal or any other drug. She wants you to provide 
detailed information. Answer the following questions to provide explanations to 
him: 
a) Explain what an antifungal drug is.
b) What are different classes of antifungal drugs according to where they 

exert their effects?

CONTENT SUMMARY

Fungal infections in humans range from conditions such as the annoying “athlete’s 
foot” to potentially fatal systemic infections. An infection caused by a fungus is 
called a mycosis. Fungi differ from bacteria in that the fungus has a rigid cell wall 
that is made up of chitin and various polysaccharides and a cell membrane that 
contains ergosterol. The composition of the protective layers of the fungal cell 
makes the organism resistant to antibiotics. Conversely, because of their cellular 
makeup, bacteria are resistant to antifungal drugs. 

The incidence of fungal infections has increased with the rising number of 
immunocompromised individuals-patients with acquired immune deficiency 
syndrome (AIDS) and AIDS-related complex, those taking immunosuppressant 
drugs, those who have undergone transplantation surgery or cancer treatment, and 
members of the increasingly large elderly population, whose body is no longer able 
to protect itself from the many fungi that are found throughout the environment. 
For example, Candida, a fungus that is normally found on mucous membranes, 
can cause yeast infections or “thrush” in the gastrointestinal (GI) tract and yeast 
infections or “vaginitis” in the vagina.

Continued advancement of medical science offers life-saving treatment 
options for a variety of hematologic, oncologic, and rheumatologic conditions. 
Immunosuppression, a common therapeutic side-effect, predisposes patients to 
invasive fungal infections, which are escalating in prevalence. The development of 

effective, well tolerated antifungals has lagged behind the advances of antibacterial 

therapy. Amphotericin B deoxycholate, an antifungal developed in the 1950s, 
marked a major therapeutic advance. Although very effective for the treatment of 
numerous invasive fungal infections, it is not without cost, and its side-effects often 
limit its use.

Antifungal drug can simply be defined as a drug used to treat fungal infections. 
An antifungal agent is a drug that selectively eliminates fungal pathogens from a 
host with minimal toxicity to the host.

Antifungal agents are classified according to either their mechanism of action/
structure or where they exert their effect.
According to where they exert their effects, the antifungal drugs may be classified 
as systemic antifungals or topical antifungals
Most antifungal drugs interfere with biosynthesis or integrity of ergosterol, the major 
sterol in the fungal cell membrane. Others cause disruption of the fungal cell wall. 

According to their mechanism of action or structure, antifungals are categorized 
in 4 main classes. These are azole antifungal drugs, polyene antifungal drugs, 
allylamine and morpholine antifungal drugs, and echinocandin antifungal drugs.

The azoles are a large group of antifungals used to treat systemic and topical fungal 
infections. The azoles include fluconazole, itraconazole, ketoconazole (Nizoral), 
posaconazole, and voriconazole. Although azoles are considered less toxic than 
some other antifungals, such as amphotericin B, they may also be less effective in 
very severe and progressive infections.

The polyene antifungal drugs include amphotericin, nystatin, and pimaricin. They 
interact with sterols in the cell membrane (ergosterol in fungi, cholesterol in humans) 
to form channels through which small molecules leak from the inside of the fungal 
cell to the outside.

Allylamines (naftifine, terbinafine) inhibit ergosterol biosynthesis at the level of 
squalene epoxidase. The morpholine drug, amorolfine, inhibits the same pathway 
at a later step.
The echinocandin antifungals are another group of antifungals. Drugs in this class 

include anidulafungin, caspofungin, and micafungin.

Self-assessment 4.1

3) You have a colleague of class in the associate nursing program who tells 
you that she has an onychomycosis (fungal infection of the nails). She 
has been prescribed an antifungal drug, and the prescribing person told 
her that there are 4 main classes of antifungal drugs according to their 
structure/mechanism of action, with specifications that the drug prescribed 
belongs to one of the classes. However, she does not remember these 
classes of antifungal drugs, and needs your assistance to remind her. 
Which classes of antifungal drugs will you tell your colleague?

4) A patient with a fungal infection asks the nurse why she cannot take 
antibiotics. The nurse explains that the reason for this is that a fungus is 
resistant to antibiotics because: 

a) A fungal cell wall has fewer but more selective protective layers.
b) The composition of the fungal cell wall is highly rigid and protective. 
c) A fungus does not reproduce by the usual methods of cell division. 

d) Antibiotics are developed to affect only bacterial cell walls.

4.2 Antifungal drugs available at the primary health care settings

4.2.1 Systemic antifungals: azole and echinocandin antifungals

5) Read carefully the scenario below:
A 50-year-old female patient is admitted at the healthcare facility with features 
of a fungal infection. The thorough assessment reveals that the patient has an 
infection that can be treated by antifungals for systemic use. You decide to avoid 
using an antifungal for topical use because you think it cannot work appropriately 
for this specific patient. Read the pharmacology book on systemic antifungals, 
with focus on focus on azoles and echinocandin antifungals and come up with at 
least 5 examples of antifungals for systemic use, belonging to these categories.

Guidance: Read the book of pharmacology brought by the teacher in class, on 

topic of antifungal drugs (focus on azoles and echinocandin antifungals)

CONTENT SUMMARY

The drugs used to treat systemic fungal infections can be toxic to the host and are 
not to be used indiscriminately. It is important to get a culture of the fungus causing 
the infection to ensure that the right drug is being used so that the patient is not put 

at additional risk from the toxic adverse effects associated with these drugs.

I. AZOLE ANTIFUNGALS 

The azoles are a large group of antifungals used to treat systemic and topical 
fungal infections. The azoles include fluconazole, itraconazole, ketoconazole, 
posaconazole, and voriconazole (Vfend). Although azoles are considered less 
toxic than some other antifungals, such as amphotericin B, they may also be less 

effective in very severe and progressive infections. 

1) Therapeutic Actions and Indications 

These drugs bind to sterols and can cause cell death (a fungicidal effect) or 
interfere with cell replication (a fungistatic effect), depending on the type of fungus 
being affected and the concentration of the drug. Ketoconazole, fluconazole, and 
itraconazole work by blocking the activity of a sterol in the fungal wall. In addition, 

they may block the activity of human steroids, including testosterone and cortisol. 

Posaconazole is one of the newest antifungals. This drug and voriconazole inhibit 
the synthesis of ergosterol, which leads to the inability of the fungus to form a cell 

wall, which results in cell death. 

Fluconazole is indicated in the treatment of candidiasis, cryptococcal meningitis, 
other systemic fungal infections; prophylaxis for reducing the incidence of 

candidiasis in bone marrow transplant recipients.

Its usual dosage is: 
• Adults: 200–400 mg PO on day 1, followed by 100 mg/d PO; IV route can be 
used, but do not exceed 200 mg/h, 

• Paediatric population: 3–6 mg/kg PO; do not exceed 12 mg/kg.

Ketoconazole (Nizoral) is indicated in the treatment of aspergillosis, leishmaniasis, 
cryptococcosis, blastomycosis, moniliasis, coccidioidomycosis, histoplasmosis, and 
mucormycosis; topical treatment of mycoses (cream), and to reduce the scaling of 

dandruff (shampoo).

Its usual dosage is: 
• Adult: 200 mg/d PO, up to 400 mg/d PO in severe cases 
• Paediatric population (≥2 y): 3.3–6.6 mg/kg/d PO 
• Paediatric (<2 y): Safety has not been established.

 • Topical: as a shampoo and topical agents

Other indications of the azoles for systemic use include treatment of blastomycosis, 
histoplasmosis, and aspergillosis; prophylaxis of invasive Aspergillus and Candida 
infections in adults and children >13 y who are immunosuppressed secondary 
to antineoplastic, chemotherapy, graft-vs.-host disease following transplants, or 

hematological malignancies.

2) Pharmacokinetics 

Ketoconazole, itraconazole and posaconazole are administered orally. Ketoconazole 
is also available as a shampoo and a cream. Fluconazole and voriconazole are 
available in oral and intravenous (IV) preparations, making it possible to start the 
drug intravenously for a serious infection and then switch to an oral form when 
the patient’s condition improves and he or she is able to take oral medications. 
Ketoconazole is absorbed rapidly from the GI tract, with peak levels occurring 
within 1 to 3 hours. It is extensively metabolized in the liver and excreted through 
the feces. 

Fluconazole reaches peak levels within 1 to 2 hours after administration. Most of 
the drug is excreted unchanged in the urine, so extreme caution should be used in 
the presence of renal dysfunction. Itraconazole is slowly absorbed from the GI tract 
and is metabolized in the liver by the CYP450 system. It is excreted in the urine and 
feces. Posaconazole is given orally, has a rapid onset of action, and peaks within 
3 to 5 hours. It is metabolized in the liver and excreted in the feces. Voriconazole 
reaches peak levels in 1 to 2 hours if given orally, and at the onset of the infusion 
if given IV. It is metabolized in the liver with a half-life of 24 hours and is excreted 
in the urine.
3) Contraindications and Cautions
Ketoconazole has been associated with severe hepatic toxicity and should be 
avoided in patients with hepatic dysfunction to prevent serious hepatic toxicity. 
In addition, ketoconazole is not the drug of choice for patients with endocrine or 
fertility problems because of its effects on these processes. Although fluconazole 
should be used with caution in the presence of liver or renal impairment, because it 
could cause liver or renal toxicity, fluconazole is not associated with the endocrine 
problems seen with ketoconazole. 
Because itraconazole has been associated with hepatic failure, should not be used 
in patients with hepatic failure, and should be used with caution in those with hepatic 
impairment. It is not known whether posaconazole crosses the placenta or enters 
breast milk, so it should not be used during pregnancy or lactation unless the benefi 

ts clearly outweigh the potential risks. Caution should be used if posaconazole is 

used in the presence of liver impairment because it can cause liver toxicity. Carefully 
monitor patients for bone marrow suppression and GI and liver toxicity if using this 

drug.

Voriconazole should not be used with any other drugs that prolong the QTc interval 
because that could be worsened and can cause ergotism if taken with ergot alkaloid; 

so it should not be combined with ergots.

4) Adverse Effects 

Many of the azoles are associated with liver toxicity and can cause severe effects 
on a fetus or a nursing baby.
5) Clinically Important Drug–Drug Interactions 
Ketoconazole and fluconazole strongly inhibit the CYP450 enzyme system in the 
liver and are associated with many drug–drug interactions, such as increased 
serum levels of the following agents: cyclosporine, digoxin, oral hypoglycemics, 
warfarin, oral anticoagulants, and phenytoin. If these combinations cannot be 
avoided, closely monitor patients and anticipate the need for dose adjustments. 
A drug guide should be consulted any time one of these drugs is added to or 
removed from a drug regimen. Itraconazole has a black box warning regarding the 
potential for serious cardiovascular effects if it is given with lovastatin, simvastatin, 
triazolam, midazolam, pimozide, or dofetilide. These combinations should be 
avoided. Voriconazole and posaconazole should not be used with any other drugs 
that prolong the QTc interval and can cause ergotism if taken with ergot alkaloids. 

II. ECHINOCANDIN ANTIFUNGALS 
The echinocandin antifungals are another group of antifungals. Drugs in this class 
include anidulafungin, caspofungin, and micafungin.

1) Therapeutic Actions and Indications 
The echinocandins work by inhibiting glucan synthesis. Glucan is an enzyme that is 
present in the fungal cell well but not in human cell walls. If this enzyme is inhibited, 
the fungal cell wall cannot form, leading to death of the cell wall.
 
The echinocandins are mainly used in the treatment of candidemia (infection of the 
blood stream) and other forms of Candida infection, intraabdominal infections, and 
esophageal candidiasis.
They are also used in the treatment of invasive aspergillosis in patients who do not 
respond or are intolerant to other therapies.
Finally, they can be used in the treatment of patients with esophageal candidiasis; 

prophylaxis of Candida infections in patients with hematopoietic stem cell transplant.

The usual dosage of anidulafungin is 100–200 mg IV on day 1, then 50–100 mg/d 

IV for 14 d; with the dose varying with infection being treated.

2) Pharmacokinetics 

Anidulafungin is given as a daily IV infusion for at least 14 days. It has a rapid 
onset of action, is metabolized by degradation, and has half-life of 40 to 50 hours. 
This drug is excreted in the feces. Caspofungin is available for IV use. This drug is 
slowly metabolized in the liver, with half-lives of 9 to 11 hours, then 6 to 48 hours, 
and then 40 to 50 hours. It is bound to protein and widely distributed throughout the 
body. It is excreted through the urine. Micafungin is an IV drug. It has a rapid onset, 
a half-life of 14 to 17 hours, and is excreted in the urine.
3) Contraindications and Cautions 
Anidulafungin may cross the placenta and enter breast milk and should not be 
used by pregnant or lactating women. Caution must be used in the presence of 
hepatic impairment because it can be toxic to the liver. Caspofungin can be toxic 
to the liver; therefore, reduced doses must be used if a patient has known hepatic 
impairment. Caspofungin is embryotoxic in animal studies and is known to enter 
breast milk; therefore, it should be used with great caution during pregnancy and 
lactation. Because of the potential for adverse reactions in the fetus or the neonate, 
micafungin should be used during pregnancy and lactation only if the benefits 
clearly outweigh the risks.
4) Adverse Effects 
Anidulafungin and caspofungin are associated with hepatic toxicity, and liver 
function should be monitored closely when using these drugs. Potentially serious 
hypersensitivity reactions have occurred with micafungin. In addition, bone marrow 
suppression can occur; monitor patients closely
5) Clinically Important Drug-Drug Interactions 
Concurrent use of cyclosporine with caspofungin is contraindicated unless the 

benefit clearly outweighs the risk of hepatic injury.

Self-assessment 4.2.1

6) The antifungal drugs for systemic use are more likely to be less toxic 
compared to the antifungal drugs for topical use. TRUE or FALSE
7) Ketoconazole is an echinocandin antifungal for systemic use. TRUE or 
FALSE
8) Anidulafungin and caspofungin are associated with hepatic toxicity, and 

liver function should be monitored closely when using these drugs.

4.2.2 Systemic antifungals: other antifungal agents

         Learning Activity 4.2.2

      Read carefully the scenario below:

A 5-year-old male patient consults the healthcare facility where you are carrying 
out the clinical practice. He has mouth and tongue ulcerations following longterm use of cephalosporins of third generation. You decide that the patient has a 
fungal condition that requires to be treated with an antifungal known as “nystatin”. 
You then decide to prescribe that antifungal agent.
i) What are the main indications of nystatin?
j) What is the usual dosage of nystatin?
Guidance: Read the book of pharmacology brought by the teacher in class, on 

topic of antifungal drugs.

CONTENT SUMMARY

Other antifungal drugs that are available do not fit into either of these classes. 
These include amphotericin B, flucytosine, griseofulvin, and nystatin.
1) Therapeutic Actions and Indications
Other antifungal agents work to cause fungal cell death or to prevent fungal cell 
reproduction. Amphotericin B is a very potent drug with many unpleasant adverse 
effects. The drug binds to the sterols in the fungus cell wall, changing cell wall 
permeability. This change can lead to cell death (fungicidal effect) or prevent the 
fungal cells from reproducing (fungistatic effect). Because of the many adverse 
effects associated with this agent, its use is reserved for progressive, potentially 
fatal infections. 
Amphotericin B is mainly used in the treatment of aspergillosis, leishmaniasis, 
cryptococcosis, blastomycosis, moniliasis, coccidioidomycosis, histoplasmosis and 
mucormycosis; use is reserved for progressive, potential fatal infections due to 
many associated adverse effects.
The usual dosage for amphotericin B is 0.25–1.5 mg/kg/d IV based on the infection 
being treated.
Flucytosine is a less toxic drug that alters the cell membrane of susceptible fungi, 
causing cell death. The uses of flucytosine are limited to the treatment of systemic 
infections caused by Candida or Cryptococcus. Its usual dosage is 50–150 mg/kg/d 

PO in divided doses at 6-h intervals.

Griseofulvin is an older antifungal that acts in much the same way, changing cell 
membrane permeability and causing cell death. Griseofulvin is usually indicated 
in the treatment of variety of ringworm or tinea infections caused by susceptible 
Trichophyton species, including tinea corporis, tinea pedis, tinea cruris, tinea 
barbae, tinea capitis, and tinea unguium.
The dosage of griseofulvin is as follows:
Tinea corporis, tinea cruris, and tinea capitis: 
Adult: 500 mg (microsize) or 330–375 mg/d (ultramicrosize) PO 
Tinea pedis and tinea unguium: 
Adult: 0.75–1 g (microsize) or 660–750 mg (ultramicrosize) PO daily 
Paediatric population: (>2 y): 11 mg/kg/d (microsize) or 7.3 mg (ultramicrosize) 
PO daily (not recommended for children ≤2 y)
Nystatin binds to sterols in the cell wall, changing membrane permeability and 
allowing leaking of the cellular components, which will result in cell death. Nystatin 
is usually indicated in the treatment of candidiasis (oral form); treatment of local 
candidiasis, vaginal candidiasis, and cutaneous and mucocutaneous infections 
caused by Candida species.
Its usual dosage is 500,000–1,000,000 units t.i.d. PO; continue for 48 h after 
resolution to prevent relapse; also used topically.
1) Pharmacokinetics 
Amphotericin B and flucytosine are available in IV form. They are excreted in the 
urine, with an initial half-life of 24 hours and then a 15-day half-life. Their metabolism 
is not fully understood. Flucytosine is well absorbed from the GI tract, with peak 
levels occurring in 2 hours. Most of the drug is excreted unchanged in the urine 
and a small amount in the feces, with a half-life of 2.4 to 4.8 hours. Griseofulvin is 
administered orally and reaches peak levels in around 4 hours. It is metabolized 
in the liver and excreted in the urine with a half-life of 24 hours. Nystatin is not 
absorbed from the GI tract and passes unchanged in the stool.
2) Contraindications and Cautions
Amphotericin B has been used successfully during pregnancy, but it should be 
used cautiously. It crosses into breast milk and should not be used during lactation 
because of the potential risk to the neonate. Because flucytosine is excreted primarily 
in the urine, extreme caution is needed in the presence of renal impairment because 
drug accumulation and toxicity can occur. Toxicity is associated with serum levels 
higher than 100 mcg/mL. Because of the potential for adverse reactions in the 

fetus or neonate, flucytosine should be used during pregnancy and lactation only

if the benefits clearly outweigh the risks. It is not known whether nystatin crosses 
the placenta or enters breast milk, so it should not be used during pregnancy or 

lactation unless the benefits clearly outweigh the potential risks.

3) Adverse Effects 

Adverse effects of these drugs are related to their toxic effects on the liver and 
kidneys. Patients should be monitored closely for any changes in liver or kidney 
functions. Bone marrow suppression has also been reported with the use of 
these drugs. Rash and dermatological changes have been reported with these 
antifungals. Amphotericin B is associated with severe renal impairment, bone 
marrow suppression, GI irritation with nausea, vomiting, and potentially severe 
diarrhea, anorexia and weight loss, and pain at the injection site with the possibility of 
phlebitis or thrombophlebitis. Adverse effects of griseofulvin are relatively mild, with 

headache and central nervous system (CNS) changes occurring most frequently.

4) Clinically Important Drug-Drug Interactions 

Patients who receive amphotericin B should not take other nephrotoxic drugs such 
as nephrotoxic antibiotics or antineoplastics, cyclosporine, or corticosteroids unless 

absolutely necessary because of the increased risk of severe renal toxicity.

Self-assessment 4.2.2

A 55-year-old male patient is being treated for cryptococcal meningitis following 
his immunosuppression with AIDS. The treating team decides to prescribe 
amphotericin B because they judge it may be beneficial for this patient.
a) What are other indications of amphotericin B?

b) What are the adverse effects of amphotericin B?

4.2.3 Topical antifungal agents

          Learning Activity 4.2.3

A 20-year-old female patient consults the healthcare facility where you are 
carrying out your clinical practice as an associate nurse student. The patient 
complains of ulcerations between toes, itching and pain. He reports that she 
does not usually taker care of her toes properly, and most of the time she does 
not dry her feet adequately after bath, as she rushes for work early morning.
On your physical examination, you realize that the patient has athlete’s foot, and 
you decide to prescribe a topical antifungal agent.
c) Give any three examples of topical azole-type antifungals
d) What are the nursing considerations would you take into account while 
prescribing topical antifungals?
Guidance: Use the book of pharmacology brought by the teacher in class, and 

read on topic of antifungals, subtopic of topical antifungals

CONTENT SUMMARY

Some antifungal drugs are available only in topical forms for treating a variety of 
mycoses of the skin and mucous membranes. Some of the systemic antifungals 
are also available in topical forms. Fungi that cause these mycoses are called 
dermatophytes. These diseases include a variety of tinea infections, which are often 
referred to as ringworm, although the causal organism is a fungus, not a worm. 

These mycoses include tinea infections such as athlete’s foot (tinea pedis), jock 
itch (tinea cruris), and yeast infections of the mouth and vagina often caused by 
Candida. Because the antifungal drugs reserved for use as topical agents are often 
too toxic for systemic administration, care is necessary when using them near open 
or draining wounds that might permit systemic absorption. 

Topical antifungals include the azole-type antifungals such as butoconazole, 
clotrimazole, econazole, ketoconazole, miconazole, oxiconazole, sertaconazole 
nitrate, sulconazole, terconazole, and tioconazole. Topical antifungals also include 
other antifungals such as butenafine, ciclopirox, gentian violet, naftifine, tolnaftate, 
and undecylenic acid.
1) Therapeutic Actions and Indications 
The topical antifungal drugs work to alter the cell permeability of the fungus, 
causing prevention of replication and fungal death. They are indicated only for local 
treatment of mycoses, including tinea infections. 
Butoconazole is available as vaginal cream; applied only once a day for 4 wk. It is 
available over the counter (OTC) for treatment of vaginal Candida infections.
Clotrimazole is available OTC as a cream, lotion, or solution; applied as a thin 
layer twice a day for 2–4 wk. It is used in the treatment of oral and vaginal Candida 
infections; tinea infections.
Ketoconazole is available in cream, gel, foam, and shampoo form; applied once 
to twice daily for 2–4 wk. It is used in the treatment of seborrheic dermatitis, tinea 
corporis, tinea cruris, tinea pedis.
Miconazole is available as an OTC product in several topical forms (vaginal 
suppository, cream, powder, solution, ointment, gel and spray); applied twice daily 
for 2–4 wk. It is used in the treatment of local, topical mycoses, including bladder 
and vaginal infections and athlete’s foot.
Terbinafine is available as a cream or gel; used for 1–4 wk; applied twice daily. It 
is used in the short-term (1–4 wk) treatment of topical mycosis; treatment of tinea 

infections.

Gentian violet is available as a topical solution; applied twice a day to affected 
area. It is used in the treatment of topical mycosis.
Naftifine is available as a cream or gel; applied twice a day for up to 4 wk.                                                                                               hortterm treatment of severe topical mycosis (up to 4 wk). It is used in the short-term 
treatment of severe topical mycosis (up to 4 wk).
2) Pharmacokinetics 
These drugs are not absorbed systemically and do not undergo metabolism or 
excretion in the body.
3) Contraindications and Cautions 
Because these drugs are not absorbed systemically, contraindications are limited 
to a known allergy to any of these drugs and open lesions. Econazole can cause 
intense, local burning and irritation and should be discontinued if these conditions 
become severe. Gentian violet stains skin and clothing bright purple; in addition, 
it is very toxic when absorbed, so it cannot be used near active lesions. Naftifine, 
oxiconazole, and sertaconazole nitrate should not be used for longer than 4 weeks 
due to the risk of adverse effects and possible emergence of resistant strains of 
fungi. Sulconazole should not be used for longer than 6 weeks due to the risk of 
adverse effects and possible emergence of resistant strains of fungi. Terbinafine 
should not be used for longer than 4 weeks. This drug should be stopped when the 
fungal condition appears to be improved or if local irritation and pain become too 
great to avoid toxic effects.
4) Adverse Effects 
When these drugs are applied locally as a cream, lotion, or spray, local effects 
include irritation, burning, rash, and swelling. When they are taken as a suppository 
or troche, adverse effects include nausea, vomiting, and hepatic dysfunction (related 
to absorption of some of the drug by the GI tract) or urinary frequency, burning, and 

change in sexual activity (related to local absorption in the vagina).

Self-assessment 4.2.3

After going through the session of topical antifungals, answer the following 
questions:
1) What are the adverse effects of topical antifungals used as suppositories?

2) Give the indications of topical clotrimazole.

4.3 End unit assessment

End of unit assessment

1) The order reads, “Give nystatin (Mycostatin) suspension, 500,000 units 
by mouth (swish and swallow) 4 times a day for 1 week.” The medication 
is available in a suspension of 100,000 units per mL. How many milliliters 
will the nurse give per dose?
2) The nurse notes in a patient’s medication history that the patient is taking 
terbinafine (Lamisil). Based on this finding, the nurse interprets that the 
patient has which disorder? 
a) Vaginal candidiasis 
b) Cryptococcal meningitis 
c) Invasive aspergillosis 
d) Fungal infection of toenails or fingernails
3) What are the adverse effects of topical antifungal agents?
4) Terbinafine cream should be used in the long-term (at least 10 weeks) 
treatment of topical mycosis in order to get the result. TRUE or FALSE
5) Antifungals in topical forms are used to treat a variety of systemic mycoses 

of the internal body organs. TRUE or FALSE