Efficacy and Safety of Topical Antifungals in the Treatment of Dermatomycosis

A Systematic Review

I. Rotta; A. Sanchez; P.R. Gonçalves; M.F. Otuki; C.J. Correr

Disclosures

The British Journal of Dermatology. 2012;166(5):927-933. 

In This Article

Abstract and Introduction

Abstract

Summary
The analysis of comparative efficacy and safety of topical antifungals in the literature is restricted to the treatment of tinea pedis and onychomycosis. Therefore our objective was to evaluate and compare the efficacy and safety of topical antifungals used in the treatment of dermatomycosis, we performed a comprehensive search for randomized controlled trials (RCTs) in the following databases: Medline, Cochrane Central Register of Controlled Trials, EMBASE, Lilacs and International Pharmaceutical Abstracts, we identified studies that compared the use of topical antifungals with other antifungals or with placebo published up to July 2010 in English, Spanish or Portuguese. The quality of reporting was assessed according to the Jadad scale; only studies with a score of 3 or more were included. The outcomes evaluated were mycological cure at the end of treatment, sustained cure, occurrence of adverse events and tolerability, including withdrawals due to adverse events. A total of 104 RCTs satisfied the inclusion criteria, containing a total of 135 comparisons, with 55 out of 120 possible comparisons among the 16 drugs evaluated. Pooled data on efficacy showed that all the antifungals were better than placebo. There were no significant differences among antifungal classes. No differences were found in safety or tolerability in any direct comparison. Sensitivity analysis indicated the robustness of the findings. Our results indicate the clear superiority of topical antifungals over placebo but that there is no consistent difference among classes. Mixed treatment comparisons are necessary to rank antifungals, as direct comparisons among many of them are lacking.

Introduction

Dermatomycosis are fungal infections that are widespread throughout the world, and they are an important cause of morbidity.[1–3] Dermatophytosis, caused by different species of dermatophytes, is one of the more common infections. However, commensal yeasts such as Malassezia furfur and Candida spp., are also important causative agents of dermatomycosis.[4]

Diagnosis depends on a combination of clinical and laboratory data, including physical examination of the lesions and microscopic visualization of microorganisms in potassium hydroxide and their growth in culture. Treatment consists of the use of topical or oral antifungals or a combination of these, depending on the site, extent of infection and the causative organism.[5–7]

In most episodes of infection, management with topical antifungals is effective; these are available over the counter in most places and are divided in two main classes: azoles and allylamines. These are cheaper than oral formulations and cause minimal adverse effects.[8,9]

Only two quantitative systematic reviews relating to the treatment of dermatomycosis with topical antifungals have been published to date, both limited to the management of tinea pedis.[8,10] For this reason, we performed a comprehensive systematic review and meta-analysis to determine the efficacy and safety of topical antifungals in the treatment of any dermatomycosis.

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