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Evidence summaries

Oral Treatments for Fungal Infections of the Skin of the Foot

Oral terbinafine and itraconazole may be more effective than placebo for moccasin type tinea pedis. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 15 studies with a total of 1 438 adult subjects. Six oral treatments were examined: terbinafine, itraconazole, ketoconazole, fluconazole, griseofulvin, and bovine lactoferrin. Two studies compared active treatments (terbinafine, itraconazole) with placebo, 1 study compared different doses of the same drug (fluconazole), 1 study compared different brands of the same drug (itraconazole), and 11 studies evaluated head-to-head comparisons.

Oral terbinafine or itraconazole compared with placebo for moccasin type tinea pedis

OutcomeRelative effect (95% CI)Cured (intervention)Cured (placebo)Participants (studies)
Oral terbinafine 250 mg/day for 6 weeks compared with placebo
Cured at 8 weeksRR 24.54 (1.57 to 384.32)15/23
65%
0/18
0%
41 (1 study)
Oral itraconazole 400 mg/day for 1 week compared with placebo
Cured at 9 weeksRR 6.67 (2.17 to 20.48)20/36
56%
3/36
8%
72 (1 study)

The studies comparing antifungal treatments (terbinafine and itraconazole) with placebo demonstrated that the cure rate continued to improve beyond the end of treatment; in the case of terbinafine, 65% of participants were cured 2 weeks after the end of the 6-week treatment period, and for itraconazole, 55% of participants were cured 8 weeks after the 1-week treatment period (table T1).

Allylamines versus azoles: Oral terbinafine 250 mg/day for 2 weeks versus oral itraconazole 100 mg/day for 4 weeks

OutcomeRelative effect (95% CI)Cured (terbinafine)Cured (itraconazole)Participants (studies)
Cured (follow up varied from 4 to over 12 weeks)RR 1.07 (0.92 to 1.25)84/110
76%
80/112
71%
222 (3 studies*)
*plantar type tinea pedis (1 study), moccasin type tinea pedis (1 study), and tinea pedis with no further information (1 study)
No significant difference was detected between terbinafine and itraconazole (table T2). Terbinafine had higher cure rates than griseofulvin (RR 2.26, 95% CI 1.49 to 3.44; 2 studies, n=71). No significant difference was detected between fluconazole and either itraconazole and ketoconazole; or between griseofulvin and ketoconazole, although the trials were generally small. Adverse effects were reported for all drugs, with gastrointestinal effects most commonly reported.

Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding) and by imprecise results (few patients and wide confidence intervals).