Topical treatments for fungal infections of the skin and nails of the foot.

tions is sparse. Combining data from 2 trials of ciclopiroxolamine
versus placebo found treatments failure rates of 61% and 64%
for ciclopiroxolamine. These outcomes followed long treatment
times (48 weeks) and this makes ciclopiroxolamine a poor choice
for nail infections. Better results were observed with the use of
amorolfine lacquer; 6% treatment failure rates were found after 1
month of treatment but these data were collected on a very small
sample of people and these high rates of success might be unreliable.
Butenafine 2% produced a treatment failure rate of 20%.
There is limited evidence about the efficacy of tea tree oil for skin
infections; it was evaluated in only one small trial however it was
found to be ineffective for fungal nail conditions when compared
with topical butenafine.
Quality of the evidence
The randomised controlled trials in this review were generally well
reported, and follow up rates were reasonable for such a condition.
Since no trial reported the species obtained from participants who
were resistant to treatment we cannot draw conclusions about susceptibility
to individual compounds to help clinical decision-making.
Little data was available about the long term outcomes associated
with the use of antifungal creams and there is uncertainty
about rates of reinfection and relapse.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
All antifungal compounds demonstrated some success in curing
athlete’s foot. The best results were observed with the use of allylamines
and there is a small amount of evidence that butenafine
may be similarly good. Azoles are also very effective and participants
should be advised that although all azoles appear to be similarly
effective, using an azole cream for four weeks is likely to produce
better results than using it for one week. Azoles may also be
References to studies included in this review
Ablon 1996 {published data only}
Ablon G, Rosen T, Spedale J. Comparative efficacy of naftifine
oxiconazole and terbinafine in short term treatment of tinea pedis.
International Journal of Dermatology 1996;35(8):591–3.
Akers 1989 {published data only}
Akers WA, Lane A, Lynfield Y, Greenberg J, Hall J, Mangan C, et
al.Sulconazole nitrate 1% cream in the treatment of chronic
moccasin type tinea pedis caused by trichophyton rubrum. Journal
the of American Academy of Dermatology 1989;21(4):686–9.
R E F E R E N C E S
Topical treatments for fungal infections of the skin and nails of the foot. (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
more efficacious than tolnaftate but they seem no more efficacious
than undecanoic acid. There is limited evidence about the efficacy
of tea tree oil for skin infections.
There is little evidence that topical anti-fungals are effective in the
management of onychomycosis or fungally infected toe nails. The
majority of available data demonstrate low cure rates after long
treatment times with ciclopiroxolamine. Amorolfine and butenafine
may be much more effective than ciclopiroxolamine and
tea tree oil but only a few observations are available.
Implications for research
The estimates of effectiveness of allylamines and azoles relative
to placebo have conclusively demonstrated these drugs to be of
greater effectiveness and we recommend that no more placebo
controlled trials of allylamines or azoles should be conducted.
More direct comparisons of undecanoic acid and tolnaftate with
allylamines and azoles for athlete’s foot are required. Large randomised
controlled trials comparing the effectiveness of topical
amorolfine and butenafine are needed to establish an alternative
to oral treatments for toe nail infections.
A C K N O W L E D G E M E N T S
For help with the update of this review and the previous version
we thank: Sally Bell-Syer, Kath Cross, Zelda Di Blasi, Alison Eastwood,
Annelise Emmans, Jill Ferrari, Nick Freemantle, Simon
Gilbody, Mark Goodfield, Rod Hay, Mark Petticrew, Daphne Russell,
Ian Russell, David Torgerson, Trevor Sheldon, Fujian Song,
Wendy Tyrrell, Hywel Williams and the Cochrane Skin Group,
and Philip Young. The first version of this review was funded by
the Wales Office of Research and Development for Health and
Social Care (WORD)
We would also like to thank Rachael Hart for helping with the
first version of the review and some data extraction for this update.
Aly 2003 {published data only}
∗ Aly R, Fisher G, Katz HI, Levine N, Lookingbill DP, Lowe N, et
al.Ciclopirox gel in the treatment of patients with interdigital tinea
pedis. International Journal of Dermatology 2003;42(Suppl 1):
29–35.
Bagatell 1986 {published data only}
Bagatell FK. Elimination of dermatophytes causing tinea pedis
interdigitalis with once daily application of bifonazole 1% solution.
Advances in Therapeutics 1986;3:265–71.
23