#272 Putting the FUN in fungi (Part 2): Topical management of tinea pedis
CLINICAL QUESTION
How effective are topical treatments for tinea pedis (athlete’s foot)?
BOTTOM LINE
Tinea pedis is successfully treated with topical antifungals in 70-75% of patients compared to 20-30% using placebo. Tea tree oil is likely ineffective. Topical terbinafine may result in an absolute improvement of 2-8% more patients cured over other topicals. The majority of patients were treated for 1 week with terbinafine and 4-6 weeks with azoles (like clotrimazole).
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EVIDENCE
Results statistically significant unless indicated.
Compared to placebo:
- Systematic review of 67 randomized controlled trials (RCTs) of mycologically diagnosed onchyomycosis and tinea pedis (reported here). Rates of lab-confirmed treatment failure at 6 weeks:1
- Allylamines (examples terbinafine, naftifine), 9 RCTs, 876 patients, 1-4 (most 4) weeks treatment: 25% versus 80% placebo; number needed to treat (NNT)=2.
- Azoles (examples clotrimazole, miconazole), 6 RCTs, 448 patients, 4-6 weeks treatment: 28% versus 70% placebo; NNT=3.
- Tea tree oil, 1 RCT, 71 patients, 4 weeks treatment: No difference from placebo.
- Systematic review of topical terbinafine versus placebo, 9 RCTs, 986 patients, 1-4 (1 most common) weeks treatment:2
- Clinical cure: 72% terbinafine versus 28% placebo, NNT=3.
- Other systematic reviews found similar.3-5
- Allylamines versus azoles:
- Systematic review, 8 RCTs, 1034 patients, 1-6 weeks (most 1-2) weeks treatment:3
- Mycological cure: 78% allylamines versus 76% azoles, NNT=40.
- Systematic review, 8 RCTs, 1034 patients, 1-6 weeks (most 1-2) weeks treatment:3
- Topical terbinafine (an allylamine) versus other antifungals (mostly azoles):
- Systematic review, 10 RCTs, 1341 patients, 1-4 (most 1) weeks treatment:2
- Clinical cure: 83% terbinafine versus 75% other antifungals (statistical significance reported inconsistently, if difference real, NNT=13).
- Systematic review, 10 RCTs, 1341 patients, 1-4 (most 1) weeks treatment:2
- Topical antifungals suggested as first-line agents reserving oral agents for severe disease (example moccasin-type infection), failed topical treatment, and immunocompromised patients.6
- Unsure whether foot hygiene or changing footwear helps with cure rates.2
- Costs (for 30 grams):7-9
- Clotrimazole 1% cream twice daily: ~$13.
- Miconazole 2% cream twice daily: ~$15.
- Terbinafine 1% cream twice daily: ~$30.
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