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With the widespread use of antifungals to treat superficial mycoses, reports of antifungal resistance are increasing. Antifungal resistance is becoming a public health challenge and needs to be addressed in parallel with antibacterial and antiviral resistance. We review the growing resistance of fungal pathogens such as  Trichophyton  species and the emergence of novel pathogens, including multidrug-resistant strains in superficial mycoses. We also discuss the importance of laboratory diagnosis and antifungal susceptibility testing (AFST) in the management of recalcitrant infections. Antifungal resistance can occur naturally or develop over time when fungi are exposed to antifungals. The frequency of terbinafine-resistant  Trichophyton  isolates is increasing. Opportunistic pathogens such as  Aspergillus  and  Candida  species have developed resistance to classic azoles such as itraconazole and fluconazole, and the newer azoles such as posaconazole and voriconazole. Although uncommon, topical antifungals such as efinaconazole and tavaborole have shown to induce resistance in  Trichophyton rubrum . The emergence of multidrug-resistant  Trichophyton mentagrophytes/interdigitale ,  Candida auris , and  Aspergillus  species causing severe infections is highly concerning. Routine AFST should be considered to determine the most effective treatment, especially if there is failure to therapy. Combination treatment of oral and topical antifungals may be a consideration for managing recalcitrant infections.

Antifungal resistance in superficial mycoses