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


METHODS
Systematic review.


METHODS
Topical treatments for superficial fungal infections.


METHODS
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.
Faculty of Community Health Sciences, University of Wales Institute Cardiff, Cardiff CF5 2SG.
R
R
Hart
S E
SE
Bell-Syer
F
F
Crawford
D J
DJ
Torgerson
P
P
Young
I
I
Russell
D000287:Administration, Topical; D000499:Allylamine / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D000935:Antifungal Agents / Q000008:administration & dosage* / Q000191:economics / Q000627:therapeutic use; D001393:Azoles / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003881:Dermatomycoses / Q000188:drug therapy*; D005533:Foot Dermatoses / Q000188:drug therapy*; D006801:Humans; D004366:Nonprescription Drugs / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D014009:Onychomycosis / Q000188:drug therapy; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
D000935:Antifungal Agents; D001393:Azoles; D004366:Nonprescription Drugs; D000499:Allylamine