| Abstract
| - Abstract. Objective: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. Design: Systematic review. Interventions: Topical treatments for superficial fungal infections. Main outcome measures: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. Results: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cureskin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0.11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidenceof language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), butfour reports in foreign languages showed no difference between the two drugs (1.01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. Conclusions: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails. Key messages. About 15% of the population have fungal infections of the skin or nails of the foot Topical allylamines—available only on prescription—cure slightly more infections of the skin of the foot than topical azoles or undecenoic acid, both of which are available over the counter No significant differences in efficacy between individual allylamines or individual azoles were found Allylamines cost more than over the counter preparations and their few extra cures are expensive, with a marginal cost per cure that is more than five times as high as that of azoles Topical allylamines are therefore best reserved for athlete's foot that does not respond to initial treatment with azoles or undecenoic acid
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