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Three Part Question

In [patients with tinea pedis] is [topical terbinafine better than miconazole] at [resolving symptoms and fungal infection]?

Clinical Scenario

It's the end of a particularly eye-rending nightshift. You're looking forward to bed but are called to minor injuries where one of the ENP's friends' feet are on display with either leprosy or athlete's foot, you can't decide. He tells you he's tried over-the-counter (OTC) daktarin (miconazole 2%). When asked for advice, instead of inwardly screaming and recommending a trip to see his GP or pharmacist, you admit you don't know, recommend OTC terbinafine and shuffle off to a warm and comfy bed (mmmm, bed!). For some reason you can't sleep that night and eventually get up at 2 am (perhaps it's that itch between your own toes) to find the answer to the question.

Search Strategy

Using the Ovid SP search engine, through the JRUL, accessing Medline, EMBASE and British Nursing Index. The Cochrane library was searched.
The Ovid search strategy was {tinea pedis.mp OR athlete's foot.mp} AND {miconazole.mp OR daktarin.mp} AND {terbinafine.mp OR lamisil.mp} LIMIT TO Human OR Humans AND english language.

Search Outcome

The Ovid search returned 94 results of which 4 were relevant to the three-part question.
The Cochrane database of systematic reviews contains one review published in the Cochrane Library 2009, issue 2. This contains an up-to-date review of the above papers and more and is discussed below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Crawford F, Hollis S 2009 UK	Adults with tinea pedis.	Meta-analysis of published RCTs. Has section relevant to three-part question. Looks at all allylamines (including terbinafine) and azoles (including miconazole).	2/52 allylamines versus azoles	Short term (2/52) - favours allylamines but not statistically significant	Nil identified
				RR of treatment failure at 2 weeks 0.86 (95% CI 0.70 to 1.06)
				Medium term (6/52) - statistically significant relative reduction in treatment failure of 66%(RR 0.34, 95%CI 0.22 to 0.52) favouring allylamines.
				Long term (12/52) - statistically significant relative reduction in treatment failure of 72% (RR 0.28, 95% CI 0.14 to 0.58) favouring allylamines.
			1/52 allylamines versus azoles 4/52	Medium term - no statistically significant difference in treatment failure (RR 0.75, 95% CI 0.33 to 1.72).
			4-6/52 allylamines versus azoles	Medium term - relative reduction in treatment failure of 37%favouring allylamines (RR 0.63, 95%CI 0.42 to 0.94)

Comment(s)

Tinea pedis (athlete's foot) is a common problem in the population, affecting up to 17% of individuals at any one time. Over the counter remedies are cheap, effective and an appropriate first line therapy. As treatment failure is common and patient attendance not always appropriate, individuals may present to the ED. The meta-analysis suggests that both allylamines and azoles are effective with allylamines (which cost slightly more) being more effective and therefore an appropriate second line therapy.

Clinical Bottom Line

Patients with athlete's foot shouldn't present to the Emergency Department, however if they do, or you should suffer from tinea pedis, then terbinafine is a better option than miconazole.

References

1. Crawford F, Hollis S Topical treatments for fungal infections of the skin and nails of the foot The Cochrane Library 2009