Tools for Practice


#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
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. 


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Author(s):

  • Betsy Thomas BSc. Pharm
  • G. Michael Allan MD CCFP
  • Jamison Falk PharmD

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.