Topical antifungal treatments for tinea cruris and tinea corporis

425 Pages·2014·4.32 MB·English

Topical antifungal treatments for tinea cruris and tinea
corporis (Review)
El-Gohary M, van Zuuren EJ, FedorowiczZ, Burgess H, DoneyL, StuartB, MooreM, Little P
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2014,Issue8
http://www.thecochranelibrary.com
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review)
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 50
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Analysis1.1.Comparison1Clotrimazole1%creamversusplacebocreamtwicedaily,Outcome1Mycologicalcure. 385
Analysis2.1.Comparison2Terbinafine1%cream/gelonceortwicedailyversusplacebocream/gelonceortwicedaily,
Outcome1Mycologicalcure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
Analysis2.2.Comparison2Terbinafine1%cream/gelonceortwicedailyversusplacebocream/gelonceortwicedaily,
Outcome2Clinicalcure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Analysis2.3.Comparison2Terbinafine1%cream/gelonceortwicedailyversusplacebocream/gelonceortwicedaily,
Outcome3Clinicalcure(lowriskofattritionbias). . . . . . . . . . . . . . . . . . . . . . 388
Analysis2.4.Comparison2Terbinafine1%cream/gelonceortwicedailyversusplacebocream/gelonceortwicedaily,
Outcome4Adverseeffects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Analysis2.5.Comparison2Terbinafine1%cream/gelonceortwicedailyversusplacebocream/gelonceortwicedaily,
Outcome5Participant-judgedcure. . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Analysis3.1.Comparison3Naftifine1%creamonceortwicedailyversusplacebocreamonceortwicedaily,Outcome1
Mycologicalcure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Analysis3.2.Comparison3Naftifine1%creamonceortwicedailyversusplacebocreamonceortwicedaily,Outcome2
Mycologicalcure(lowriskofattritionbias). . . . . . . . . . . . . . . . . . . . . . . . 392
Analysis3.3.Comparison3Naftifine1%creamonceortwicedailyversusplacebocreamonceortwicedaily,Outcome3
Adverseeffects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Analysis4.1.Comparison4Azolesversusallylamines,Outcome1Mycologicalcure. . . . . . . . . . . . 394
Analysis4.2.Comparison4Azolesversusallylamines,Outcome2Clinicalcure. . . . . . . . . . . . . . 395
Analysis4.3.Comparison4Azolesversusallylamines,Outcome3Mycologicalcure(lowriskofattritionbias). . . 396
Analysis4.4.Comparison4Azolesversusallylamines,Outcome4Clinicalcure(lowriskofattritionbias). . . . . 397
Analysis4.5.Comparison4Azolesversusallylamines,Outcome5Adverseeffects. . . . . . . . . . . . . 398
Analysis5.1.Comparison5Azoleversusmoderate-potentcorticosteroid/azolecombination, Outcome1Mycological
cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Analysis5.2.Comparison5Azoleversusmoderate-potentcorticosteroid/azolecombination,Outcome2Mycologicalcure
(lowriskofattritionbias). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Analysis5.3.Comparison5Azoleversusmoderate-potentcorticosteroid/azolecombination,Outcome3Clinicalcure. 401
Analysis5.4.Comparison5Azoleversusmoderate-potentcorticosteroid/azolecombination,Outcome4Clinicalcure(at
endoftreatment). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
Analysis5.5.Comparison5Azoleversusmoderate-potentcorticosteroid/azolecombination,Outcome5Adverseeffects. 403
Analysis6.1.Comparison6Azolesversusbenzylamines,Outcome1Mycologicalcure. . . . . . . . . . . . 404
Analysis6.2.Comparison6Azolesversusbenzylamines,Outcome2Adverseeffects. . . . . . . . . . . . 405
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review) i
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 422
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review) ii
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Topical antifungal treatments for tinea cruris and tinea
corporis
MagdyEl-Gohary1,EstherJvanZuuren2,ZbysFedorowicz3,HanaBurgess1,LizDoney4,BethStuart1,MichaelMoore1,PaulLittle1
1PrimaryCareandPopulationSciences,FacultyofMedicine,AldermoorHealthCentre,UniversityofSouthampton,Southampton,UK.
2DepartmentofDermatology,LeidenUniversityMedicalCenter,Leiden,Netherlands.3BahrainBranch,TheCochraneCollaboration,
Awali,Bahrain.4CentreofEvidenceBasedDermatology,CochraneSkinGroup,TheUniversityofNottingham,Nottingham,UK
Contactaddress:MagdyEl-Gohary,PrimaryCareandPopulationSciences,FacultyofMedicine,AldermoorHealthCentre,University
ofSouthampton,AldermoorClose,Southampton,SO165ST,[email protected].
Editorialgroup:CochraneSkinGroup.
Publicationstatusanddate:New,publishedinIssue8,2014.
Reviewcontentassessedasup-to-date: 16August2013.
Citation: El-Gohary M, van Zuuren EJ, Fedorowicz Z, Burgess H, Doney L, Stuart B, Moore M, Little P. Topical antifungal
treatments for tinea cruris and tinea corporis. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD009992. DOI:
10.1002/14651858.CD009992.pub2.
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Tineainfectionsarefungalinfectionsoftheskincausedbydermatophytes.Itisestimatedthat10%to20%oftheworldpopulationis
affectedbyfungalskininfections.Sitesofinfectionvaryaccordingtogeographicallocation,theorganisminvolved,andenvironmental
andculturaldifferences.Bothtineacorporis,alsoreferredtoas’ringworm’andtineacrurisor’jockitch’areconditionsfrequentlyseen
byprimarycaredoctorsanddermatologists.Thediagnosiscanbemadeonclinicalappearanceandcanbeconfirmedbymicroscopy
orculture.Awiderangeoftopicalantifungaldrugsareusedtotreatthesesuperficialdermatomycoses,butitisunclearwhicharethe
mosteffective.
Objectives
Toassesstheeffectsoftopicalantifungaltreatmentsintineacrurisandtineacorporis.
Searchmethods
We searchedthe following databases up to 13th August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The
CochraneLibrary(2013,Issue7),MEDLINE(from1946),EMBASE(from1974),andLILACS(from1982).Wealsosearchedfive
trialsregisters,andcheckedthereferencelistsofincludedandexcludedstudiesforfurtherreferencestorelevantrandomisedcontrolled
trials.WehandsearchedthejournalMycosesfrom1957to1990.
Selectioncriteria
Randomisedcontrolledtrialsinpeoplewithprovendermatophyteinfectionofthebody(tineacorporis)orgroin(tineacruris).
Datacollectionandanalysis
Tworeviewauthorsindependentlycarriedoutstudyselection,dataextraction,assessmentofriskofbias,andanalyses.
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review) 1
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Ofthe364recordsidentified,129studieswith18,086participantsmettheinclusioncriteria.Halfofthestudieswerejudgedathigh
riskofbiaswiththeremainderjudgedatunclearrisk.Awiderangeofdifferentcomparisonswereevaluatedacrossthe129studies,92
intotal,withazolesaccountingforthemajorityoftheinterventions.Treatmentdurationvariedfromoneweektotwomonths,butin
moststudiesthiswastwotofourweeks.Thelengthoffollow-upvariedfromoneweektosixmonths.Sixty-threestudiescontained
nousableorretrievabledatamainlyduetothelackofseparatedatafordifferenttineainfections.Mycologicalandclinicalcurewere
assessedinthemajorityofstudies,alongwithadverseeffects.Lessthanhalfofthestudiesassesseddiseaserelapse,andhardlyanyof
themassesseddurationuntilclinicalcure,orparticipant-judgedcure.Thequalityofthebodyofevidencewasratedaslowtoverylow
forthedifferentoutcomes.
Dataforseveraloutcomesfortwoindividualtreatmentswerepooled.Acrossfivestudies,significantlyhigherclinicalcurerateswere
seeninparticipantstreatedwithterbinafinecomparedtoplacebo(riskratio(RR)4.51,95%confidenceinterval(CI)3.10to6.56,
numberneededtotreat(NNT)3,95%CI2to4).Thequalityofevidenceforthisoutcomewasratedaslow.Dataformycological
cureforterbinafinecouldnotbepooledduetosubstantialheterogeneity.
Mycologicalcureratesfavourednaftifine1%comparedtoplaceboacrossthreestudies(RR2.38,95%CI1.80to3.14,NNT3,95%
CI2to4)withthequalityofevidenceratedaslow.Inonestudy,naftifine1%wasmoreeffectivethanplaceboinachievingclinical
cure(RR2.42,95%CI1.41to4.16,NNT3,95%CI2to5)withthequalityofevidenceratedaslow.
Acrosstwostudies,mycologicalcureratesfavouredclotrimazole1%comparedtoplacebo(RR2.87,95%CI2.28to3.62,NNT2,
95%CI2to3).
Data for several outcomes were pooled for three comparisons between different classes of treatment. There was no difference in
mycologicalcurebetweenazolesandbenzylamines(RR1.01,95%CI0.94to1.07).Thequalityoftheevidencewasratedaslowfor
thiscomparison.Substantialheterogeneityprecludedthepoolingofdataformycologicalandclinicalcurewhencomparingazolesand
allylamines.Azoleswereslightlylesseffectiveinachievingclinicalcurecomparedtoazoleandsteroidcombinationcreamsimmediately
attheendoftreatment(RR0.67,95%CI0.53to0.84,NNT6,95%CI5to13),buttherewasnodifferenceinmycologicalcure
rate(RR0.99,95%CI0.93to1.05).Thequalityofevidenceforthesetwooutcomeswasratedaslowformycologicalcureandvery
lowforclinicalcure.
Allofthetreatmentsthatwereexaminedappearedtobeeffective,butmostcomparisonswereevaluatedinsinglestudies.Therewas
noevidenceforadifferenceincureratesbetweentineacrurisandtineacorporis.Adverseeffectswereminimal-mainlyirritationand
burning;resultsweregenerallyimprecisebetweenactiveinterventionsandplacebo,andbetweendifferentclassesoftreatment.
Authors’conclusions
Thepooleddatasuggestthattheindividualtreatmentsterbinafineandnaftifineareeffective.Adverseeffectsweregenerallymildand
reportedinfrequently.Asubstantial numberofthestudiesweremorethan20yearsoldandofunclearorhighriskofbias;thereis
however,someevidencethatothertopicalantifungaltreatmentsalsoprovidesimilarclinicalandmycologicalcurerates,particularly
azolesalthoughmostwereevaluatedinsinglestudies.ThereisinsufficientevidencetodetermineifWhitfield’sointment,awidelyused
agentiseffective.
Althoughcombinationsoftopicalsteroidsandantifungalsarenotcurrentlyrecommendedinanyclinicalguidelines,relevantstudies
includedinthisreviewreportedhigherclinicalcurerateswithsimilarmycologicalcureratesattheendoftreatment,butthequality
ofevidencefortheseoutcomeswasratedverylowduetoimprecision,indirectnessandriskofbias.Therewasinsufficientevidenceto
confidentlyassessrelapseratesintheindividualorcombinationtreatments.
Althoughtherewaslittledifferencebetweendifferentclassesoftreatmentinachievingcure,someinterventionsmaybemoreappealing
astheyrequirefewerapplicationsandashorterduration oftreatment.Further,highquality,adequatelypoweredtrialsfocusing on
patient-centredoutcomes,suchaspatientsatisfactionwithtreatmentshouldbeconsidered.
PLAIN LANGUAGE SUMMARY
Treatmentsappliedtotheskinforfungalinfectionsofthegroinandbody
Background
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review) 2
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Upto 20% of the world’s population is affectedby fungal skin infections of the groin (’jock’ itch, or tinea cruris) or of the body
(ringworm,ortineacorporis),whichgenerallyappearasredanditchyareasontheskin.Manytopical(directlyappliedtotheskin)
treatmentsareavailable.
Reviewquestion
Whichtopicaltreatmentsworkbestfor’jock’itchandringworm?
Studycharacteristics
Weincluded129studiespublisheduptoAugust2013whichexamined18,086people.Participantsincludedmenandwomenofany
age,althoughmostwerebetween18to70yearsold.Therewasconsiderablevariationinthereportingqualityofthestudies.Aquarter
werepartiallyfundedbypharmaceuticalcompanies,anditwasunclearwhatimpactthismayhavehadonreportingoftheresults.
Moststudiesappearedtobeconductedwithindermatologyoutpatientclinics.Arangeoftreatmentswereevaluated,mostlyinsingle
studies.Mosttreatmentswereappliedonceortwicedailyforbetweentwoandfourweeks.Mycologicalcure(disappearanceoffungal
infection);andclinicalcure(absenceofsymptomssuchasrednessanditchiness);wereassessedinthemajorityofstudies,alongwith
sideeffects.Lessthanhalfofthestudiesassesseddiseaserecurrenceandhardlyanyassessedthetimetoachieveclinicalcure,orwhether
studyparticipantsconsideredtheyhadbeencured.
Keyresults
Almostalltreatmentswereeffectiveatachievingbothmycologicalandclinicalcure,comparedwithplacebo.
Wecombineddataforseveraloutcomesintwoindividualtreatments:terbinafineagainstplaceboandnaftifineagainstplacebo.Both
wereshowntobeeffectivetreatments.
Wecombineddataondifferentgroupsoftreatments.Therewasnodifferenceinrateofmycologicalcurebetweenazolesandbenzy-
lamines.Combinationsofantifungaltreatmentwithatopicalcorticosteroidachievedhigherclinicalcurerates,probablybecausethe
skinrednessdisappearssoonerduetotheeffectofthecorticosteroid.Therewasnoevidenceofanydifferenceinthespeedofresolution
offungalinfectionwiththesecombinationtreatments.
Qualityoftheevidence
Theoverallqualityoftheevidenceforthedifferentoutcomeswasratedaslowtoverylow.Thereiscurrentlyinsufficientevidenceto
beabletodecideifoneparticulartreatmentisbetterthananyoftheothers.Allthetreatmentsweevaluatedreportedlowratesofmild
sideeffects.
Thisreviewhighlightstheneedforbetterqualitystudiesontreatmentsforfungalskininfections.Despitethelimitationsofourmain
findings,itappearsthatmostactivetreatmentsareeffectiveandfurtherresearchshouldconcentrateoncomparingactivetreatments,
ratherthancomparisonswithaplacebo.Topicaltreatmentsthatneedtobeusedonlyonceadayoverashortperiodoftimemaybe
moreappealinginpractice.Someofthetreatmentsexaminedinourreviewmaynotbereadilyavailablein-lowincomecountries.
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review) 3
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CopyTopic SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
right©2014alantifungal Terbinafine1%cream/gelcomparedwithplacebocream/gelfortineacrurisandtineacorporis
Thtre
ea Patientorpopulation:patientswithtineacrurisandtineacorporis
Ctm
ochraents SInetettrinvegns:tiohons:pteitrablinaanfdinperi1m%arcyrecaamre/gcelilnics
nefor Comparison:placebocream/gel
Cotin
llaea
boratiocruris Outcomes Illustrativecomparativerisks*(95%CI) R(9e5la%tivCeI)effect N(sotuodfiePsa)rticipants Q(GuRaAlitDyEo)ftheevidence Comments
n.Pand
ublishtinea Assumedrisk Correspondingrisk
edco Placebocream/gel Terbinafine 1% cream/
brp
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Johris
n(R
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ileyiew Negative KOH (7studies) low1,2 heterogeneity, data not
&)
microscopy,orculture,or pooled
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o
n both. Treatment duration
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,
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td
.
Clinicalcure Studypopulation RR4.51 273 ⊕⊕(cid:13)(cid:13)
Resolution of clinical (3.1to6.56) (5studies) low3,4,5
signs and symptoms. 165per1000 746per1000
Treatment duration 1-2 (513to1000)
weeks
Follow-up:2-4weeks Moderate
133per1000 600per1000
(412to872)
Adverseeffects Studypopulation RR0.43 469 ⊕(cid:13)(cid:13)(cid:13) Contact dermatitis type
Reportedbyinvestigators (0.2to0.92) (7studies) verylow1,6 symptoms, no systemic
’and’or’or’participants adverseeffectsreported
Follow-up:0-8weeks
4
CT
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right©2014alantifungal 97per1000 4(129pteor8190)00
Thetrea Moderate
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ochraents 29per1000 12per1000
nefor (6to27)
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llaboration.Peacrurisand RmpErveyeildcvaeioponlsuocesgelioycraoclrfueircnceufldeirncrieptcinoaacrnlteicoiin-r Seecomment Seecomment Notestimable 1(368studies) ⊕low⊕7(cid:13),8(cid:13) OlsnoeonwsnlyseemdBweueandrntiemsoauefcljecanure1rilan9atp9ees8ietahasel---r
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edco Follow-up:1-8weeks
brp
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Johris Participant-judgedcure Studypopulation RR4.46 253 ⊕⊕(cid:13)(cid:13)
nW(Re Judgement of treatment (3.16to6.31) (2studies) low9,10,11
v
ileyiew as’good’or’verygood’ 198per1000 885per1000
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Notassessed Seecomment Seecomment
Moderate
*Thebasisfor theassumedrisk(e.g.themediancontrol groupriskacross studies) isprovidedinfootnotes. Thecorresponding risk(andits95%confidence interval) isbasedonthe
assumedriskinthecomparisongroupandtherelativeeffectoftheintervention(andits95%CI).
CI:Confidenceinterval;RR:Riskratio;
5
CT
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right©2014alantifungal GHMRiogAdhDeqrEuaatWeliotqyruk:ainFlugitryGt:hreForuurrptehsgeerraardreceshseiaosrfcvehevriiysdeulinnkcleieklyeltyothoacvheaanngeimopuorrctaonntfiidmepnaccetionnthoeuresctoimnfaidteenocfeefinfetcht.eestimateofeffectandmaychangetheestimate.
Thetrea Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
Cochranetmentsfor 1VRearyndloowmqsueaqluiteyn:cWeegaerneervaetrioynu,naclelortcaaintioanbocuotntcheeaelmsteimntaaten.d blindingat unclear risk of bias across studies, with 2studies (Lebwohl
Cotin 2001andMillikan1990)judgedoverallathighriskofbias.Inbothofthesestudies,therewasahighdrop-outrate(20%to25%)in
llaea alreadyunderpoweredstudies
boratiocruris 23SThurbesetasntutiadlieusn(eLxepblawinoehdl2h0et0e1ro;gMeinlleikitayn1990andZaias1993)judgedathighriskofbiasoverall
n.Pand 4Smallsamplesize,optimalinformationsizewouldbe2790participants
ublishtinea 56CAlIthinoculugdhetshethreeitshraeslahrogledefoffreacptp(RreRci4a.b5le1,biennaelflits(tu0d.7ie5s)RanRd>ne4a.r0ly0)n,otheeffreecatr(e1t.h0r)e,avtesrytolovwalinduitmy,bseereorfisekveonftsb,ialsowsamplesize(optimal
ec
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brp informationsizewouldbe4238participants)
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Johris 7 Millikan 1990 judged at high risk of bias overall - high drop-out rate in an underpowered study; sequence generation, allocation
n(R concealmentandblindingjudgedatunclearriskofbiasinremainingstudies
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iley&view) 89LBoliwndninugmfboerrboofthevsetundtsie,ssajumdpgleedsiazteuinsclloewarerritshkanofobpitaims,aalnindfoZramiaasti1o9n9s3izjeudgedoverallathighriskofbias-detailsontotalnumberof
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s, 10Numberofevents<300andoptimalinformationsizewouldbe2210participants
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td 11Althoughthereisalargeeffect(RR>2),therearethreatstovalidity,seeriskofbias
.
6
BACKGROUND at the need to keep scratching. These conditions are frequently
seenby primary care doctors and dermatologists. The infection
canbetransmittedfromonepersontoanothermainlyviadirect
Descriptionofthecondition skin-to-skincontact,althoughthesheddingofinfecteddeadskin
cellsonclothing, bedding, andtowelsprovidesothersourcesof
Tinea infections are fungal infections of the skin, and they are
transmission.Lesscommonly,infectionfromanimalsandsoilwith
amongst the most common skin conditions worldwide (Gupta
zoophilicandgeophilicdermatophytes,respectively,canoccur(
2003).Theseinfectionscanoftenbesevereandrecurrent(Gupta
Noble 1998). Although people from all socioeconomic groups
2004).Theyarecausedbydermatophytes,agroupofclosely-re-
canbeaffected,theconditiontendstobeseeninthosewithlow
latedfungithatconsistofthegeneraEpidermophyton,Microspo-
socioeconomic status. Crowdedlivingconditions, poorlevelsof
rum, and Trichophyton (Weitzman 1995). The infection is seen
hygiene,andcloseproximitytoanimalscanaidthetransmission
throughouttheworld,andevidencesupportsagreaterprevalence
ofinfection(Havlickova2008).Inaddition,thosesufferingwith
inwarmerandmorehumidconditions(Aly1994).Itisestimated
particularcomorbidities,e.g.diabetesmellitus,areatanincreased
that10% to20% of theworldpopulation isaffectedbyfungal
riskofinfection,particularlychronicinfection(Balci2008).Tinea
skin infections (including other forms of tinea, e.g. tinea pedis,
infections,asmentionedhere,areunabletoaffectdeeperorgans;
alsoknownasathlete’sfoot)(Drake1996).Anatomicalpatterns
therefore,internalfungalinfectionofimmunocompromisedhosts
ofinfectionvaryaccordingtogeographicallocation,theorganism
(peoplewithanaffectedimmunesystem)isonlyveryrarelycaused
involved,andenvironmentalandculturaldifferences(Havlickova
bydermatophytes(Jain2010).
2008). For instance, wearing occlusive clothing, particularly in
Thediagnosisinpracticeisusuallybasedonclinicalappearance,
tropicalclimates,isassociatedwithahigherfrequencyofinfection
althoughscrapings canbetakenandanalysedusingmicroscopy
(Macura1993).Avarietyofotherfactorsareatplayindetermin-
orWood’s lampexamination (Andrews2008).Culturingof the
ingifinfectionwilltakehold,e.g.theageandsexoftheaffected
organismcanalsobeperformed,althoughthisisalengthypro-
individual or ’host’,immune status, andgenetic factors(Brasch
cess,butitmaybeimportantindeterminingthespeciescausing
2010).
infectionandthusthelikelysource.Occasionally,theconditionis
Thedermatophytescanbesubdividedintothreegroups-anthro-
misdiagnosedbypatientsandhealthcareprofessionals,andtreat-
pophilic(confinedtohumans),zoophilic(animals),andgeophilic
mentsforotherskinrashes,particularlysteroids,aregiveninap-
(liveinsoil).Themostcommondermatophytecausingtineacruris
propriately(Wacker2004).Thiscanaltertheappearanceofthe
andtineacorporisworldwideisTrichophytonrubrum,ananthro-
infectionleadingtoaconditionknownas’tineaincognito’,adding
pophilicdermatophyte(Ameen2010;Seebacher2008).
furtherdiagnosticuncertainty.
Tineacorporis,commonlyreferredtoas’ringworm’,canbecaused
byanyofthedermatophytes.Itisasuperficialskininfectionthatis
unabletoaffectdeepertissuesandorgansinpeoplewithnormally-
Descriptionoftheintervention
functioningimmunesystems,or’immunocompetenthosts’(Smijs
2011).Tineacorporisreferstosuchafungalinfectionanywhereon An array of topical (externally applied) treatments exist for this
thebodyapartfromthescalp,beardarea,feet,orhands.Itpresents problem.Asthedermatophytescausingthisinfectionarelimited
clinicallyasawell-demarcatedannularplaque(orraisedarea)with tothesuperficialkeratinisedtissue,topicaltreatmentsarethemost
ascalyandadvancingborder.Lesionsmayshowconcentricrings appropriatetouse,providingtheinfectionisnotwidespread.The
withredplaquesinthecentre;thesemayclearasthelesionspreads, two main groups of antifungal drugs are the azoles and the al-
leavinganareaofcentralhypopigmentation(lossofskincolour) lylamines.Newerdrugstendtobewithinone or otherof these
(Weinstein2002). groups(Gupta2008).Otherantifungaldrugsusedfortineainfec-
Tineacruris,otherwiseknownas’jockitch’,isaninfectioninthe tionsincludethebenzylaminesandhydroxypyridones(Havlickova
groin,perineal,andperianalarea,usuallyaffectingadultmen.It 2008a).Therearedifferentstrengthpreparationsofthesameac-
can presentunilaterallyor bilaterallywith ared, raised, and ac- tive compound and different dosing regimens suggested. There
tive border. Small vesicles, papules, and scaling may be present areotherlesswidely-usedtopicaltreatments,suchasoilofbitter
(Aridogan 2005).Ittypicallysparesthepenisandscrotum,and orange and Eucalyptus pauciflora. Some treatments also contain
this may be helpful in distinguishing it from other rashes in antibacterial and corticosteroid components alongside the anti-
thearea(Hainer2003).Thetypeofdermatophytecausingtinea fungalagent.Inmanycountries,topicalantifungaltreatmentsare
crurisvariesaccordingtogeographicallocation;commonorgan- availabledirectlytothepublicwithouttheneedforamedicalcon-
ismsincludeTrichophtyonrubrumandEpidermophytonfloccosum sultation.
(Bassiri-Jahromi2009;Weitzman1995). Theidealtopicaltreatmentisonethatpossessesahighcurerate,a
Inbothoftheseconditions,theseverityofthelesionsrangesfrom lowrelapserate,hasashortdurationofaction,andcausesminimal
mildtosevere,withitchbeingthepredominantcomplaint.Those adverse effects(Crawford 2007). In addition, it isimportant to
affected can be in some discomfort and are often embarrassed findatreatmentregimenthatissatisfactorytothepersonwiththe
Topicalantifungaltreatmentsfortineacrurisandtineacorporis(Review) 7
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