El-Gohary M, van Zuuren EJ, Fedorowicz Z, Burgess H, Doney L, Stuart B, Moore M, Little P, et al.
The Cochrane database of systematic reviews. Date of publication 2014 Aug 4;volume (8):CD009992.
1. Cochrane Database Syst Rev. 2014 Aug 4;(8):CD009992. doi:
10.1002/14651858.CD009992.pub2.
Topical antifungal treatments for tinea cruris and tinea corporis.
El-Gohary M(1), van Zuuren EJ, Fedorowicz Z, Burgess H, Doney L, Stuart B, Moore
M, Little P.
Author information:
(1)Primary Care and Population Sciences, Faculty of Medicine, Aldermoor Health
Centre, University of Southampton, Aldermoor Close, Southampton, UK, SO16 5ST.
BACKGROUND: Tinea infections are fungal infections of the skin caused by
dermatophytes. It is estimated that 10% to 20% of the world population is
affected by fungal skin infections. Sites of infection vary according to
geographical location, the organism involved, and environmental and cultural
differences. Both tinea corporis, also referred to as 'ringworm' and tinea cruris
or 'jock itch' are conditions frequently seen by primary care doctors and
dermatologists. The diagnosis can be made on clinical appearance and can be
confirmed by microscopy or culture. A wide range of topical antifungal drugs are
used to treat these superficial dermatomycoses, but it is unclear which are the
most effective.
OBJECTIVES: To assess the effects of topical antifungal treatments in tinea
cruris and tinea corporis.
SEARCH METHODS: We searched the following databases up to 13th August 2013: the
Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013,
Issue 7), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We
also searched five trials registers, and checked the reference lists of included
and excluded studies for further references to relevant randomised controlled
trials. We handsearched the journal Mycoses from 1957 to 1990.
SELECTION CRITERIA: Randomised controlled trials in people with proven
dermatophyte infection of the body (tinea corporis) or groin (tinea cruris).
DATA COLLECTION AND ANALYSIS: Two review authors independently carried out study
selection, data extraction, assessment of risk of bias, and analyses.
MAIN RESULTS: Of the 364 records identified, 129 studies with 18,086 participants
met the inclusion criteria. Half of the studies were judged at high risk of bias
with the remainder judged at unclear risk. A wide range of different comparisons
were evaluated across the 129 studies, 92 in total, with azoles accounting for
the majority of the interventions. Treatment duration varied from one week to two
months, but in most studies this was two to four weeks. The length of follow-up
varied from one week to six months. Sixty-three studies contained no usable or
retrievable data mainly due to the lack of separate data for different tinea
infections. Mycological and clinical cure were assessed in the majority of
studies, along with adverse effects. Less than half of the studies assessed
disease relapse, and hardly any of them assessed duration until clinical cure, or
participant-judged cure. The quality of the body of evidence was rated as low to
very low for the different outcomes.Data for several outcomes for two individual
treatments were pooled. Across five studies, significantly higher clinical cure
rates were seen in participants treated with terbinafine compared to placebo
(risk ratio (RR) 4.51, 95% confidence interval (CI) 3.10 to 6.56, number needed
to treat (NNT) 3, 95% CI 2 to 4). The quality of evidence for this outcome was
rated as low. Data for mycological cure for terbinafine could not be pooled due
to substantial heterogeneity.Mycological cure rates favoured naftifine 1%
compared to placebo across three studies (RR 2.38, 95% CI 1.80 to 3.14, NNT 3,
95% CI 2 to 4) with the quality of evidence rated as low. In one study, naftifine
1% was more effective than placebo in achieving clinical cure (RR 2.42, 95% CI
1.41 to 4.16, NNT 3, 95% CI 2 to 5) with the quality of evidence rated as
low.Across two studies, mycological cure rates favoured clotrimazole 1% compared
to placebo (RR 2.87, 95% CI 2.28 to 3.62, NNT 2, 95% CI 2 to 3).Data for several
outcomes were pooled for three comparisons between different classes of
treatment. There was no difference in mycological cure between azoles and
benzylamines (RR 1.01, 95% CI 0.94 to 1.07). The quality of the evidence was
rated as low for this comparison. Substantial heterogeneity precluded the pooling
of data for mycological and clinical cure when comparing azoles and allylamines.
Azoles were slightly less effective in achieving clinical cure compared to azole
and steroid combination creams immediately at the end of treatment (RR 0.67, 95%
CI 0.53 to 0.84, NNT 6, 95% CI 5 to 13), but there was no difference in
mycological cure rate (RR 0.99, 95% CI 0.93 to 1.05). The quality of evidence for
these two outcomes was rated as low for mycological cure and very low for
clinical cure.All of the treatments that were examined appeared to be effective,
but most comparisons were evaluated in single studies. There was no evidence for
a difference in cure rates between tinea cruris and tinea corporis. Adverse
effects were minimal - mainly irritation and burning; results were generally
imprecise between active interventions and placebo, and between different classes
of treatment.
AUTHORS' CONCLUSIONS: The pooled data suggest that the individual treatments
terbinafine and naftifine are effective. Adverse effects were generally mild and
reported infrequently. A substantial number of the studies were more than 20
years old and of unclear or high risk of bias; there is however, some evidence
that other topical antifungal treatments also provide similar clinical and
mycological cure rates, particularly azoles although most were evaluated in
single studies.There is insufficient evidence to determine if Whitfield's
ointment, a widely used agent is effective.Although combinations of topical
steroids and antifungals are not currently recommended in any clinical
guidelines, relevant studies included in this review reported higher clinical
cure rates with similar mycological cure rates at the end of treatment, but the
quality of evidence for these outcomes was rated very low due to imprecision,
indirectness and risk of bias. There was insufficient evidence to confidently
assess relapse rates in the individual or combination treatments.Although there
was little difference between different classes of treatment in achieving cure,
some interventions may be more appealing as they require fewer applications and a
shorter duration of treatment. Further, high quality, adequately powered trials
focusing on patient-centred outcomes, such as patient satisfaction with treatment
should be considered.
DOI: 10.1002/14651858.CD009992.pub2
PMID: 25090020 [Indexed for MEDLINE]
