Expert Insights on Managing Fungal Skin Infections: Adam Friedman, MD

In a recent interview at the Dermatology Education Foundation’s DERM 2025 NP/PA CME Conference, Dr. Adam Friedman, Professor and Chair of Dermatology at George Washington University School of Medicine, provided crucial insights into the management of fungal skin infections, specifically tinea, also known as dermatophytosis. This group of commonly occurring fungal infections is often overlooked in clinical practice, posing significant risks of antifungal resistance when not properly addressed.

Dermatophytosis encompasses a variety of cutaneous infections caused by dermatophyte fungi. According to Dr. Friedman, its prevalence is high, yet discussions surrounding these infections are scarce, primarily due to their perceived lack of clinical novelty. “Dermatophytosis is super common, but is not commonly discussed because it just isn't ‘sexy.’ And I get it, who wants to talk about fungal infections?” he stated during the interview. “But we can’t put our heads in the sand. We need to be able to make the right diagnosis, but also consider the potential for antifungal resistance if we don’t treat the right thing, or if we’re not thoughtful about how we use our antifungals, of which we unfortunately don’t have a huge amount.”

Dr. Friedman emphasized that clinical inspection alone is insufficient for accurate diagnosis. He advocated for the use of potassium hydroxide (KOH) preparations, scrapings, cultures, and biopsies to identify and treat dermatophyte infections effectively. “I know we pride ourselves as master diagnosticians, but we have proven time and again in the published literature that clinical inspection is not enough,” he explained. “Use my favorite tool of all time, your potassium hydroxide prep... By defining the disease, you can purposely select the correct treatment regimen, which will then make your patient happy and will prevent fungi from developing resistance to the limited things we have.”

Moreover, Dr. Friedman raised concerns regarding the rising resistance to antifungals, particularly azole antifungals such as econazole and fluconazole. He stressed the necessity for antifungal stewardship comparable to antibacterial stewardship due to the limited number of new antifungal treatments available. “When we think about our antifungal armamentarium, most of them are what are called static... And when you are inhibiting one thing, the problem is, the fungus among us can become kind of clever and pivot. That, in essence, is where resistance occurs,” he cautioned.

The implications of Dr. Friedman’s insights extend beyond clinical practice into public health considerations. The rising trend of antifungal resistance poses significant challenges not only for dermatologists but also for healthcare systems globally, as ineffective treatments could lead to increased morbidity and healthcare costs.

As healthcare providers continue to grapple with the complexities of managing dermatophytosis, Dr. Friedman’s recommendations underscore the importance of rigorous diagnostic practices and responsible antifungal use. The growing recognition of fungal infections within the medical community may lead to improved patient outcomes and a better understanding of antifungal resistance mechanisms.

In conclusion, Dr. Friedman’s contributions at DERM 2025 highlight the urgent need for enhanced awareness, education, and research regarding dermatophytosis and antifungal resistance. Addressing these critical issues will be essential in safeguarding patient health and ensuring the efficacy of available antifungal therapies.