Systematic review of topical treatments for fungal infections of the skin and nails of the feet

Rachel Hart; Fay Crawford; David J. Torgerson; Philip Young; Ian Russell; Sally E.M. Bell-Syer

doi:10.1136/bmj.319.7202.79

Systematic review of topical treatments for fungal infections of the skin and nails of the feet

Rachel Hart, Fay Crawford, David J. Torgerson, Philip Young, Ian Russell, Sally E.M. Bell-Syer

Health Sciences

Research output: Contribution to journal › Literature review › peer-review

Abstract

OBJECTIVE: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. DESIGN: Systematic review. INTERVENTIONS: Topical treatments for superficial fungal infections. MAIN OUTCOME MEASURES: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. RESULTS: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cure skin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0.11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), but four reports in foreign languages showed no difference between the two drugs (1.01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. CONCLUSIONS: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.

Original language	English
Pages (from-to)	79-82F
Number of pages	10
Journal	British medical journal
Volume	319
Issue number	7202
DOIs	https://doi.org/10.1136/bmj.319.7202.79
Publication status	Published - 10 Jul 1999

Bibliographical note

Keywords

TERBINAFINE 1-PERCENT CREAM
RANDOMIZED CONTROLLED TRIALS
INTERDIGITAL TINEA-PEDIS
NITRATE 2-PERCENT CREAM
DOUBLE-BLIND
COMPARATIVE EFFICACY
MULTICENTER TRIALS
CLINICAL-TRIALS
NAFTIFINE CREAM
AMOROLFINE

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Cite this

@article{25485f925d1843d2b020d9156a8a04e2,

title = "Systematic review of topical treatments for fungal infections of the skin and nails of the feet",

abstract = "OBJECTIVE: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. DESIGN: Systematic review. INTERVENTIONS: Topical treatments for superficial fungal infections. MAIN OUTCOME MEASURES: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. RESULTS: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cure skin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0.11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), but four reports in foreign languages showed no difference between the two drugs (1.01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. CONCLUSIONS: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.",

keywords = "TERBINAFINE 1-PERCENT CREAM, RANDOMIZED CONTROLLED TRIALS, INTERDIGITAL TINEA-PEDIS, NITRATE 2-PERCENT CREAM, DOUBLE-BLIND, COMPARATIVE EFFICACY, MULTICENTER TRIALS, CLINICAL-TRIALS, NAFTIFINE CREAM, AMOROLFINE",

author = "Rachel Hart and Fay Crawford and Torgerson, {David J.} and Philip Young and Ian Russell and Bell-Syer, {Sally E.M.}",

note = "{\textcopyright} BMJ Publishing Group Ltd",

year = "1999",

month = jul,

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doi = "10.1136/bmj.319.7202.79",

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journal = "British medical journal",

issn = "0959-8138",

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TY - JOUR

T1 - Systematic review of topical treatments for fungal infections of the skin and nails of the feet

AU - Hart, Rachel

AU - Crawford, Fay

AU - Torgerson, David J.

AU - Young, Philip

AU - Russell, Ian

AU - Bell-Syer, Sally E.M.

N1 - © BMJ Publishing Group Ltd

PY - 1999/7/10

Y1 - 1999/7/10

N2 - OBJECTIVE: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. DESIGN: Systematic review. INTERVENTIONS: Topical treatments for superficial fungal infections. MAIN OUTCOME MEASURES: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. RESULTS: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cure skin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0.11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), but four reports in foreign languages showed no difference between the two drugs (1.01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. CONCLUSIONS: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.

AB - OBJECTIVE: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. DESIGN: Systematic review. INTERVENTIONS: Topical treatments for superficial fungal infections. MAIN OUTCOME MEASURES: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. RESULTS: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cure skin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0.11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), but four reports in foreign languages showed no difference between the two drugs (1.01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. CONCLUSIONS: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.

KW - TERBINAFINE 1-PERCENT CREAM

KW - RANDOMIZED CONTROLLED TRIALS

KW - INTERDIGITAL TINEA-PEDIS

KW - NITRATE 2-PERCENT CREAM

KW - DOUBLE-BLIND

KW - COMPARATIVE EFFICACY

KW - MULTICENTER TRIALS

KW - CLINICAL-TRIALS

KW - NAFTIFINE CREAM

KW - AMOROLFINE

U2 - 10.1136/bmj.319.7202.79

DO - 10.1136/bmj.319.7202.79

M3 - Literature review

SN - 0959-8138

VL - 319

SP - 79-82F

JO - British medical journal

JF - British medical journal

IS - 7202

ER -