Pharmaceutical Sciences Postgraduate Program.
JAMA Dermatol. 2013 Mar;149(3):341-9. doi: 10.1001/jamadermatol.2013.1721.
Considering that most randomized controlled trials compare antifungals with placebo instead of other antifungals, conventional meta-analysis is insufficient to define superiority between the evaluated strategies. To our knowledge, this is the first mixed-treatment comparison meta-analysis on antifungal treatments in the literature and shows all the evidence available at the time of the study.
To evaluate and compare the efficacy of topical antifungals used in dermatophytosis treatment, using mixed-treatment comparisons.
We performed a comprehensive search (up to July 31, 2012) for all entries in MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Literatura Latino Americana e do Caribe em Ciências da Saúde, and International Pharmaceutical Abstracts. Randomized controlled trials that compared topical antifungals with one another or with placebo in dermatophytosis treatment were selected for analysis. Methodologic quality of the trials was assessed using the Jadad scale. We excluded studies that scored less than 3 points. The outcomes evaluated were mycologic cure at the end of treatment and sustained cure. A random-effects Bayesian mixed-treatment comparisons model was applied to combine placebo-controlled and direct topical antifungals comparison trials. RESULTS Pooled data of the 65 trials identified did not show any statistically significant differences among the antifungals concerning the outcome of mycologic cure at the end of treatment. Regarding the sustained cure outcome, butenafine hydrochloride and terbinafine hydrochloride were significantly more efficacious than were clotrimazole, oxiconazole nitrate, and sertaconazole nitrate. Terbinafine also demonstrated statistical superiority when compared with ciclopirox (ciclopiroxolamine), and naftifine hydrochloride showed better response compared with oxiconazole. No inconsistency was detected in the network of evidence for both outcomes, sustaining the validity of the mixed-treatment comparisons results.
With the outcome mycologic cure at the end of treatment, there was no significant difference among the antifungals. Butenafine, naftifine, and terbinafine might be the best strategies for maintaining cured status. Because of the different costs of the antifungals, pharmacoeconomic analysis is required to identify the most efficient strategy for dermatophytosis management.
考虑到大多数随机对照试验比较的是抗真菌药物与安慰剂，而不是其他抗真菌药物，传统的荟萃分析不足以确定评估策略之间的优越性。据我们所知，这是文献中首次关于抗真菌治疗的混合治疗比较荟萃分析，显示了研究时所有可用的证据。
使用混合治疗比较评估和比较治疗皮肤真菌病时局部使用的抗真菌药物的疗效。
我们进行了全面的检索（截至 2012 年 7 月 31 日），包括 MEDLINE、Cochrane 对照试验中心注册库、EMBASE、拉丁美洲和加勒比地区健康科学文献以及国际药学文摘中的所有条目。选择了比较局部抗真菌药物彼此或与安慰剂治疗皮肤真菌病的随机对照试验进行分析。使用 Jadad 量表评估试验的方法学质量。我们排除了评分低于 3 分的研究。评估的结局是治疗结束时的真菌学治愈率和持续治愈率。应用随机效应贝叶斯混合治疗比较模型将安慰剂对照和直接局部抗真菌药物比较试验结合起来。结果：从确定的 65 项试验中汇总的数据显示，在治疗结束时的真菌学治愈率方面，抗真菌药物之间没有任何统计学上的显著差异。关于持续治愈率的结果，盐酸布替萘芬和特比萘芬比克霉唑、硝酸奥昔康唑和硝酸舍他康唑更有效。特比萘芬与环吡酮（环吡酮胺）相比也显示出统计学优势，盐酸萘替芬的反应优于奥昔康唑。两个结局的证据网络中没有检测到不一致性，支持混合治疗比较结果的有效性。
在治疗结束时的真菌学治愈率方面，抗真菌药物之间没有显著差异。布替萘芬、萘替芬和特比萘芬可能是维持治愈状态的最佳策略。由于抗真菌药物的成本不同，需要进行药物经济学分析，以确定治疗皮肤真菌病的最有效策略。
