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Topical antifungal treatments for tinea cruris and tinea corporis

Topical antifungal treatments for tinea cruris and tinea corporis
Topical antifungal treatments for tinea cruris and tinea corporis
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.
1469-493X
1-426
El-Gohary, Magdy
392c5e6d-a761-4577-967f-2f36054aa653
van Zuuren, Esther
d2c9f89a-9957-4713-b7cb-c6fd6c624dc3
Fedorowicz, Zbys
3f8ff6ca-dc88-4aaa-86c4-bce5e5289f3d
Burgess, Hana
c103e930-9676-49d6-bbab-ca29eb7c4222
Doney, Liz
e483bef9-c836-4599-a678-92a2a5bc0c6a
Stuart, Beth
626862fc-892b-4f6d-9cbb-7a8d7172b209
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
El-Gohary, Magdy
392c5e6d-a761-4577-967f-2f36054aa653
van Zuuren, Esther
d2c9f89a-9957-4713-b7cb-c6fd6c624dc3
Fedorowicz, Zbys
3f8ff6ca-dc88-4aaa-86c4-bce5e5289f3d
Burgess, Hana
c103e930-9676-49d6-bbab-ca29eb7c4222
Doney, Liz
e483bef9-c836-4599-a678-92a2a5bc0c6a
Stuart, Beth
626862fc-892b-4f6d-9cbb-7a8d7172b209
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777

El-Gohary, Magdy, van Zuuren, Esther, Fedorowicz, Zbys, Burgess, Hana, Doney, Liz, Stuart, Beth, Moore, Michael and Little, Paul (2014) Topical antifungal treatments for tinea cruris and tinea corporis. Cochrane Database of Systematic Reviews, 8 (CD009992), 1-426. (doi:10.1002/14651858.CD009992.pub2).

Record type: Article

Abstract

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.

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More information

Published date: 4 August 2014
Organisations: Primary Care & Population Sciences

Identifiers

Local EPrints ID: 368615
URI: http://eprints.soton.ac.uk/id/eprint/368615
ISSN: 1469-493X
PURE UUID: b5dbb9fa-ba21-4eee-9a8e-25a9098d4218
ORCID for Beth Stuart: ORCID iD orcid.org/0000-0001-5432-7437
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509
ORCID for Paul Little: ORCID iD orcid.org/0000-0003-3664-1873

Catalogue record

Date deposited: 06 Sep 2014 13:50
Last modified: 11 Jul 2024 01:44

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Contributors

Author: Magdy El-Gohary
Author: Esther van Zuuren
Author: Zbys Fedorowicz
Author: Hana Burgess
Author: Liz Doney
Author: Beth Stuart ORCID iD
Author: Michael Moore ORCID iD
Author: Paul Little ORCID iD

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