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#272 Putting the FUN in fungi (Part 2): Topical management of tinea pedis


CLINICAL QUESTION
QUESTION CLINIQUE
How effective are topical treatments for tinea pedis (athlete’s foot)?


BOTTOM LINE
RÉSULTAT FINAL
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
DONNÉES PROBANTES
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
Direct comparisons: 
  • 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. 
  • 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). 
Adverse events: Burning, stinging and itching sensations most common (but not quantified).1  Limitations: Some RCTs1 and one systematic review2 were industry funded, clinical cure less commonly reported than mycological cure.  Context: 
  • 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. 


Gilbert Bretecher June 5, 2023

antifungals effective


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Author(s)
Auteur(s)
  • Betsy Thomas BSc. Pharm
  • Jamison Falk PharmD
  • G. Michael Allan MD CCFP

1. Crawford F, Hollis S. Cochrane Database Syst Rev. 2007; (3):CD001434.

2. Korting HC, Kiencke P, Nelles S, et al. Am J Clin Dermatol. 2007; 8:357-64.

3. Rotta I, Otuki MF, Sanches AC, et al. Rev Assoc Med Bras (1992). 2012; 58:308-18.

4. Crawford F. BMJ Clin Evid. 2009 Jul 20; 2009: 1712.

5. Rotta I, Sanchez A, Gonçalves PR, et al. Br J Dermatol. 2012; 166:927-33.

6. Ely JW, Rosenfeld S, Seabury Stone M. Am Fam Physician. 2014; 90:702-10.

7. Calculations using data from Alberta Health Interactive Drug Benefit List. Available at: https://idbl.ab.bluecross.ca/idbl/load.do Accessed March 21, 2020.

8. Walmart Corportation. 2020. Available at: https://www.walmart.ca/en/ip/micatin-cream-2-miconzole-nitrate-cream-usp-30-g/6000189068419. Accessed July 13, 2020.

9. Walmart Corportation. 2020. Available at: https://www.walmart.ca/en/ip/bayer-healthcare-consumer-care-canesten-1-topical-antifungal-cream/6000017348217. Accessed July 13, 2020. 

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.