Evidence-based topical treatments for tinea cruris and tinea corporis: a summary of a Cochrane systematic review

Bioinformatics-Driven mRNA-Based Vaccine Design for Controlling Tinea Cruris Induced by Trichophyton rubrum

Tinea cruris, a dermatophyte fungal infection predominantly caused by Trichophyton rubrum and Epidermophyton floccosum, primarily affects the groin, pubic region, and adjacent thigh. Its recurrence is frequent, attributable to repeated fungal infections in susceptible individuals, especially those with onychomycosis or tinea pedis, which act as reservoirs for dermatophytes. Given the persistent nature of tinea cruris, vaccination emerges as a promising strategy for fungal infection management, offering targeted, durable protection against various fungal species. Vaccines stimulate both humoral and cell-mediated immunity and are administered prophylactically to prevent infections while minimizing the risk of antifungal resistance development. Developing fungal vaccines is challenging due to the thick fungal cell wall, similarities between fungal and human cells, antigenic variation, and evolutionary resemblance to animals, complicating non-toxic target identification and T-cell response variability. No prior research has shown an mRNA vaccine for T. rubrum. Hence, this study proposes a novel mRNA-based vaccine for tinea cruris, potentially offering long-term immunity and reducing reliance on antifungal medications. This study explores the complete proteome of T. rubrum, identifying potential protein candidates for vaccine development through reverse vaccinology. Immunogenic epitopes from these candidates were mapped and integrated into multitope vaccines and reverse translated to construct mRNA vaccines. Then, the mRNA was translated and computationally assessed for physicochemical, chemical, and immunological attributes. Notably, 1,3-beta-glucanosyltransferase, CFEM domain-containing protein, cell wall galactomannoprotein, and LysM domain-containing protein emerged as promising vaccine targets. Antigenic, immunogenic, non-toxic, and non-allergenic cytotoxic T lymphocyte, helper T lymphocyte, and B lymphocyte epitopes were selected and linked with appropriate linkers and Toll-like receptor (TLR) agonist adjuvants to formulate vaccine candidates targeting T. rubrum. The protein-based vaccines underwent reverse translation to construct the mRNA vaccines, which, after inoculation, were translated again by host ribosomes to work as potential components for triggering the immune response. After that, molecular docking, normal mode analysis, and molecular dynamic simulation confirmed strong binding affinities and stable complexes between vaccines and TLR receptors. Furthermore, immune simulations of vaccines with and without adjuvant demonstrated activation of immune responses, evidenced by elevated levels of IgG1, IgG2, IgM antibodies, cytokines, and interleukins. There was no significant change in antibody production between vaccines with and without adjuvants, but adjuvants are crucial for activating the innate immune response via TLRs. Although mRNA vaccines hold promise against fungal infections, further research is essential to assess their safety and efficacy. Experimental validation is crucial for evaluating their immunogenicity, effectiveness, and safety.

Trichophyton indotineae, an Emerging Drug-Resistant Dermatophyte: A Review of the Treatment Options

Background: Dermatophytosis is a prevalent superficial infection caused by filamentous fungi, primarily affecting the skin and/or its appendages. In recent years, there has been a notable increase in mycotic strains resistant to standard antifungal therapies, including Trichophyton indotineae, a dermatophyte of the Trichophyton mentagrophytes complex. This review aims to provide a comprehensive overview of the treatment options for T. indotineae, elucidating their effectiveness in managing this challenging mycotic infection. Methods: For this review, a search was conducted in the PubMed, Scopus, Web of Science, Embase, and Google Scholar databases, encompassing all published data until March 2024. English-language articles detailing therapy outcomes for patients confirmed to be affected by T. indotineae, identified through molecular analysis, were included. Results: Itraconazole was shown to be a good therapeutic choice, particularly when administered at a dosage of 200 mg/day for 1-12 weeks. Voriconazole was also demonstrated to be effective, while terbinafine exhibited a reduced response rate. Griseofulvin and fluconazole, on the other hand, were found to be ineffective. Although topical treatments were mostly ineffective when used alone, they showed promising results when used in combination with systemic therapy. Mutational status was associated with different profiles of treatment response, suggesting the need for a more tailored approach. Conclusions: When managing T. indotineae infections, it is necessary to optimize therapy to mitigate resistances and relapse. Combining in vitro antifungal susceptibility testing with mutational analysis could be a promising strategy in refining treatment selection.

Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance

Dermatophytoses are fungal infections of the skin, hair, and nails that affect approximately 25% of the global population. Occlusive clothing, living in a hot humid environment, poor hygiene, proximity to animals, and crowded living conditions are important risk factors. Dermatophyte infections are named for the anatomic area they infect, and include tinea corporis, cruris, capitis, barbae, faciei, pedis, and manuum. Tinea incognito describes steroid-modified tinea. In some patients, especially those who are immunosuppressed or who have a history of corticosteroid use, dermatophyte infections may spread to involve extensive skin areas, and, in rare cases, may extend to the dermis and hair follicle. Over the past decade, dermatophytoses cases not responding to standard of care therapy have been increasingly reported. These cases are especially prevalent in the Indian subcontinent, and Trichophyton indotineae has been identified as the causative species, generating concern regarding resistance to available antifungal therapies. Antifungal-resistant dermatophyte infections have been recently recognized in the United States. Antifungal resistance is now a global health concern. When feasible, mycological confirmation before starting treatment is considered best practice. To curb antifungal-resistant infections, it is necessary for physicians to maintain a high index of suspicion for resistant dermatophyte infections coupled with antifungal stewardship efforts. Furthermore, by forging partnerships with federal agencies, state and local public health agencies, professional societies, and academic institutions, dermatologists can lead efforts to prevent the spread of antifungal-resistant dermatophytes.

The rapid emergence of antifungal-resistant human-pathogenic fungi

During recent decades, the emergence of pathogenic fungi has posed an increasing public health threat, particularly given the limited number of antifungal drugs available to treat invasive infections. In this Review, we discuss the global emergence and spread of three emerging antifungal-resistant fungi: Candida auris, driven by global health-care transmission and possibly facilitated by climate change; azole-resistant Aspergillus fumigatus, driven by the selection facilitated by azole fungicide use in agricultural and other settings; and Trichophyton indotineae, driven by the under-regulated use of over-the-counter high-potency corticosteroid-containing antifungal creams. The diversity of the fungi themselves and the drivers of their emergence make it clear that we cannot predict what might emerge next. Therefore, vigilance is critical to monitoring fungal emergence, as well as the rise in overall antifungal resistance.

Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review

Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.

Molecular exploration of hidden pleiotropic activities of azoles on dermatophytes in human tinea corporis infection

Dermatophyte infections are widespread worldwide and are the most prevalent cause of fungal infection of the skin, hair, and nails. Tinea corporis is most commonly caused by dermatophytes belonging to three genera: Trichophyton , Microsporum , and Epidermophyton. The disease may be acquired through person-to-person transmission, typically by direct communication with an infected individual. Since dermatophytes causing tinea corporis infection are restricted to superficial keratinized tissue, topical treatments are most effective in patients with naïve tinea corporis unless the disease is widespread. Dermatophyte adherence to a keratinized structure is an essential step in dermatophytosis pathogenesis, whereby proteolytic enzyme activity is converted into a particular keratolytic activity that encourages the dermatophyte to use keratin as the sole source of carbon. Despite increasing dermatophytosis worldwide, particularly in the tropics, this research has often been neglected, appears to predominate globally, and presents practitioners with a therapeutic challenge. However, experts supported the use of allylamines in the pleiotropic molecular exploration of azoles, including reactive oxygen species (ROS) inducer, anti-inflammatory, antibacterial, and wide-spectrum antimycotic effects. Therefore, the current review aims to update and reform this essential subject and illustrate the recent advancement of the hidden pleiotropic activity of azoles at the molecular level on dermatophytes in human tinea corporis infection.

Pathogenesis, Immunology and Management of Dermatophytosis

Dermatophytic infections of the skin and appendages are a common occurrence. The pathogenesis involves complex interplay of agent (dermatophytes), host (inherent host defense and host immune response) and the environment. Infection management has become an important public health issue, due to increased incidence of recurrent, recalcitrant or extensive infections. Recent years have seen a significant rise in incidence of chronic infections which have been difficult to treat. In this review, we review the literature on management of dermatophytoses and bridge the gap in therapeutic recommendations.

Trends in the epidemiology of dermatophytosis in the Middle East and North Africa region

Dermatophytosis corresponds to a broad series of infections, mostly superficial, caused by a group of keratinophilic and keratinolytic filamentous fungi called dermatophytes. These mycoses are currently considered to be a major public health concern worldwide, particularly in developing countries such as those in the Middle East and North Africa (MENA) region. Here we compiled and discussed existing epidemiologic data on these infections in the MENA region. Most of the available studies were based on conventional diagnostic strategies and were published before the last taxonomic revision of dermatophytes. This has led to misidentifications, which might have resulted in the underestimation of the real burden of these infections in the MENA countries. Our analysis of the available literature highlights an urgent need for further studies based on reliable diagnostic tools and standard susceptibility testing methods for dermatophytosis, which represents a major challenge for these countries. This is crucial for guiding appropriate interventions and activating antifungal stewardship programs in the future.

The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options

One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

Development, optimization and characterization of nanoemulsion loaded with clove oil-naftifine antifungal for the management of tinea

Tinea is a common superficial infection caused by keratinophylic fungi called dermatophytes. The objective of the current investigation was to develop and optimize a self-nanoemulsion drug delivery system (SENDDs) using clove oil loaded with naftifine (NF). Clove oil possesses good anti-inflammatory and antifungal properties that can support naftifine action. Box–Behnken designs were used to prepare plain and naftifine loaded SENDDs. The plain SENDDs were evaluated for their globule size. The medicated formulations (NF-CO-SENDDs) were characterized by measuring their globular size, ex vivo % NF permeated, level of interleukin-31 in rats, and antifungal activity. The optimum clove oil level was found to be 10–17%, while NF-CO-SENDDs formulations displayed globular sizes ranging from 119 to 310 nm. The statistical design confirmed the synergistic effect of clove oil and NF in the treatment of fungal infections, confirming that the anti-inflammatory effect of clove oil can counteract the side effects of NF. The optimized formulation composed of 14% clove oil, 12.5 mg Naftifine, and prepared with an Smix ratio equaling 3:1, exhibited good antifungal and anti-inflammatory activity, achieving up to 2-, 3-, 5.75-, and 2.74-fold increases in the amount of permeated NF, steady-state flux, permeability, and diffusion coefficients, respectively, compared with a commercial product. Moreover, the optimum formulation revealed an adequate zeta potential value of 28.31 ± 1.37 mV and showed reasonable stability with no or mild signs of skin sensitivity. Therefore, the designed nanoemulsions containing a combination of clove oil and naftifine could be considered promising delivery systems for the treatment of tinea.

A review of recent research on antifungal agents against dermatophyte biofilms

Dermatophytoses are inflammatory cutaneous mycoses caused by dermatophyte fungi of the genera Trichophyton, Microsporum, and Epidermophyton that affect both immunocompetent and immunocompromised individuals. With therapeutic failure, dermatophytoses can become chronic and recurrent. This is partly due to their ability to develop biofilms, microbial communities involved in a polymeric matrix attached to biotic or abiotic surfaces, contributing to fungal resistance. This review presents evidence accumulated in recent years on antidermatophyte biofilm activity. The following databases were used: Web of Science, Medline/PubMed (via the National Library of Medicine), Embase, and Scopus. Original articles published between 2011 and 2020, emphasizing the antifungal activity of conventional and new drugs against dermatophyte biofilms were eligible. A total of 11 articles met the inclusion criteria and were reviewed - the studies used in vitro and ex vivo (fragments of nails and hair) experimental models. The articles focused on reports of antibiofilm activity for conventional antifungals, natural drugs, and new therapeutic tools. The strains reported on were T. mentagrophytes, T. rubrum, T. tonsurans, M. canis, and M. gypseum. Between the studies, the wide variability of experimental conditions in vitro and ex vivo was observed. The data suggest the need for methodological standardization (at some minimum). This review systematically presents current studies involving agents that present antibiofilm activity against dermatophytes; and an overview of the ideal in vitro and ex vivo experimental conditions to guarantee biofilm formation that may assist future research.

LAY ABSTRACT

This review presents the current studies on the antibiofilm activities of drugs against dermatophytes and ideal experimental conditions, which might guarantee in vitro and ex vivo biofilm formation. It can be useful to examine the efficacy of new antimicrobial drugs against dermatophytes.

Updates on Genital Dermatophytosis

Dermatophytes are a group of keratinophilic fungi, which normally cause superficial infection of skin, hair and nails. Based on ecology, they are classified into three groups: anthropophilic, zoophilic and geophilic. Superficial dermatophytic infection of the genital region is called genital dermatophytosis, tinea genitalis or pubo-genital dermatophytosis. In this review, we would like to discuss briefly, the various clinical presentations of genital dermatophytosis, current changes in the taxonomy and nomenclature, introduction of new diagnostic techniques and briefly describe some common dermatophytes and their sources. Also, there are serious concerns associated with the recent development of antifungal resistance among the dermatophytes. We are also facing the scenario of hard-to-treat dermatophytosis.

Limited effectiveness of four oral antifungal drugs (fluconazole, griseofulvin, itraconazole and terbinafine) in the current epidemic of altered dermatophytosis in India: results of a randomized pragmatic trial

BACKGROUND

Dermatophytic infections have undergone unprecedented changes in India in the recent past. Clinical trials to find out the effectiveness of the four main oral antifungal drugs are lacking.

OBJECTIVES

We tested the effectiveness of oral fluconazole, griseofulvin, itraconazole and terbinafine in chronic and chronic relapsing tinea corporis, tinea cruris and tinea faciei in an investigator-initiated, randomized, pragmatic trial.

METHODS

Two hundred patients with microscopy-confirmed tinea were allocated to four groups (50 patients in each group): fluconazole 5 mg kg^-1 per day, griseofulvin 10 mg kg^-1 per day, itraconazole 5 mg kg^-1 per day and terbinafine 7·5 mg kg^-1 per day. Allocation was performed by concealed block randomization and the patients were treated for 8 weeks or until cure. Effectiveness was calculated based on intention-to-treat analysis. The trial was registered with the Clinical Trials Registry India (CTRI/2017/04/008281).

RESULTS

At 4 weeks, all drugs were similarly ineffective, with cure rates being 8% or less (P = 0·42). At 8 weeks, the numbers of patients cured were as follows: fluconazole 21 (42%), griseofulvin seven (14%), itraconazole 33 (66%) and terbinafine 14 (28%) (P < 0·001). Itraconazole was superior to fluconazole, griseofulvin and terbinafine (adjusted P ≤ 0·048). Relapse rates after 4 and 8 weeks of cure with the four treatments were not different (P ≥ 0·42). Numbers needed to treat (vs. griseofulvin), calculated on the basis of cure rates at 8 weeks, were as follows: fluconazole 4, itraconazole 2 and terbinafine 8.

CONCLUSIONS

The results show limited effectiveness of all four antifungal drugs. In view of cure rates and the number needed to treat, itraconazole is the most effective drug, followed by fluconazole (daily), terbinafine and then griseofulvin, in chronic and chronic relapsing dermatophytosis in India. What is already known about this topic? Oral antifungal drugs are considered to have a high cure rate in tinea corporis, tinea cruris and tinea faciei. Unprecedented changes have been noticed in the last few years in India in the morphology, course and treatment responsiveness of tinea; however, data about the effectiveness of oral antifungals are lacking. What does this study add? Our results show limited effectiveness of four oral antifungal drugs (fluconazole, griseofulvin, itraconazole and terbinafine) in the current epidemic of altered dermatophytosis in India. Among the four drugs tested, oral itraconazole is the most effective. Linked Comment: Elewski. Br J Dermatol 2020; 183:798-799.

The clinical significance of fungi in atopic dermatitis

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases and is caused by multiple factors including genetic factors, skin barrier defects, host immune responses, allergen sensitivity, environmental effects, and infections. Commonly, bacterial and viral infections are present in the eczematous lesions of AD patients and clearly aggravate the symptoms. However, studies of fungal infections in AD are limited in spite of the fact that there are reports showing that Malassezia, Candida, and some dermatophytes can affect the symptoms of AD. Moreover, certain fungal infections are sometimes overlooked and need to be considered particularly in AD patients with treatment failure as clinical features of those fungal infections could mimic eczematous lesions in AD. Here, we review the epidemiology, pathogenesis, clinical manifestations, and overlooked features of fungal infections associated with the symptoms of AD including the diagnosis and effectiveness of fungal treatments in AD patients.

New Developments in Bacterial, Viral, and Fungal Cutaneous Infections

PURPOSE OF REVIEW

This review highlights clinically relevant updates to common and significant bacterial, viral, and fungal cutaneous infection within the past 5 years. Recent developments are presented so that the clinician may provide evidence-based, high-quality patient care.

RECENT FINDINGS

New resistance patterns in cutaneous pathogens have recently emerged as a result of inappropriate antimicrobial use. Several new FDA-approved antimicrobials have been approved to treat such infections, including multi-drug resistant pathogens. Several organizational guidelines for cutaneous infection management have been updated with new recommendations for screening, diagnostic, and treatment strategies.

SUMMARY

Clinicians should be aware of the most recent evidence and guidelines for the management of cutaneous infections in order to reduce the emergence of antimicrobial resistance and most effectively treat their patients.

Diagnosis and Management of Cutaneous Tinea Infections

GENERAL PURPOSE

To provide information about the epidemiology, clinical features, and management of cutaneous tinea infections.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, you should be better able to:1. Summarize the epidemiology related to cutaneous tinea infections.2. Describe the clinical features of cutaneous tinea infections.3. Identify features related to the diagnosis and management of cutaneous tinea infections.

ABSTRACT

Dermatophyte or tinea infection refers to a group of superficial fungal infections of the hair, skin, and nails. Tinea infections are most commonly caused by fungi of the genus Trichophyton, Microsporum, or Epidermophyton. Cutaneous manifestations of tinea infections are seen worldwide and classified based on the affected body site. The diagnosis of these conditions is complicated by morphologic variations in presentation and overlap with other common infectious and noninfectious entities. As a result, diagnosis and appropriate management of these conditions are essential to avoid patient morbidity. This case-based review summarizes the epidemiology, relevant clinical features, microbiology, and management considerations for commonly encountered tinea infections.

Mycotic and Bacterial Infections

This article reviews the salient clinical features, evaluation, and treatment of mycotic and bacterial infections of the perianal and contiguous zones of the human body.

Dermatologic Problems Commonly Seen by the Allergist/Immunologist

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India)

Background

Dermatophytosis management has become an important public health issue, with a large void in research in the area of disease pathophysiology and management. Current treatment recommendations appear to lose their relevance in the current clinical scenario. The objective of the current consensus was to provide an experience-driven approach regarding the diagnosis and management of tinea corporis, cruris and pedis.

Methods

Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi process consisting of two workshops and five rounds of questionnaires, elaborating definitions, diagnosis and management. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. More than 75% of concordance in response was set to reach the consensus.

Result

KOH mount microscopy was recommended as a point of care testing. Fungal culture was recommended in chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve tinea cruris and corporis (localised) cases, while a combination of systemic and topical antifungals was recommended for naïve and recalcitrant tinea pedis, extensive lesions of corporis and recalcitrant cases of cruris and corporis. Because of the anti-inflammatory, antibacterial and broad spectrum activity, topical azoles should be preferred. Terbinafine and itraconazole should be the preferred systemic drugs. Minimum duration of treatment should be 2–4 weeks in naïve cases and > 4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical practice of tinea management was strongly discouraged.

Conclusion

This consensus guideline will help to standardise care, provide guidance on the management, and assist in clinical decision-making for healthcare professionals.

Infectious Diseases Associated With Organized Sports and Outbreak Control

Participation in organized sports has a variety of health benefits but also has the potential to expose the athlete to a variety of infectious diseases, some of which may produce outbreaks. Major risk factors for infection include skin-to-skin contact with athletes who have active skin infections, environmental exposures and physical trauma, and sharing of equipment and contact with contaminated fomites. Close contact that is intrinsic to team sports and psychosocial factors associated with adolescence are additional risks. Minimizing risk requires leadership by the organized sports community (including the athlete's primary care provider) and depends on outlining key hygiene behaviors, recognition, diagnosis, and treatment of common sports-related infections, and the implementation of preventive interventions.

Treatment of Dermatophytosis in Elderly, Children, and Pregnant Women

Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually straightforward, treatment of dermatophytosis becomes notably challenging in certain population groups - pregnant women, children, and elderly. Treatment with topical azoles/allylamines alone is effective in limited cutaneous disease in all three groups. Terbinafine is the preferred oral agent in elderly population for treatment of extensive cutaneous disease and onychomycosis due to its lack of cardiac complications and lower propensity for drug interactions. If required, additional physical/mechanical modalities can be employed for symptomatic onychomycosis. Data for systemic therapy in children mainly pertains to the treatment of tinea capitis. At present, very little data exists regarding the safety of systemic antifungals in pregnancy and there is an effort to restrict treatment to topical therapies because of their negligible systemic absorption.

New Antifungal Agents and New Formulations Against Dermatophytes

A variety of oral and topical antifungal agents are available for the treatment of superficial fungal infections caused by dermatophytes. This review builds on the antifungal therapy update published in this journal for the first special issue on Dermatophytosis (Gupta and Cooper 2008;166:353-67). Since 2008, there have not been additions to the oral antifungal armamentarium, with terbinafine, itraconazole, and fluconazole still in widespread use, albeit for generally more severe or recalcitrant infections. Griseofulvin is used in the treatment of tinea capitis. Oral ketoconazole has fallen out of favor in many jurisdictions due to risks of hepatotoxicity. Topical antifungals, applied once or twice daily, are the primary treatment for tinea pedis, tinea corporis/tinea cruris, and mild cases of tinea unguium. Newer topical antifungal agents introduced include the azoles, efinaconazole, luliconazole, and sertaconazole, and the oxaborole, tavaborole. Research is focused on developing formulations of existing topical antifungals that utilize novel delivery systems in order to enhance treatment efficacy and compliance.

Publication bias in dermatology systematic reviews and meta-analyses

Systematic reviews and meta-analyses in dermatology provide high-level evidence for clinicians and policy makers that influence clinical decision making and treatment guidelines. One methodological problem with systematic reviews is the under representation of unpublished studies. This problem is due in part to publication bias. Omission of statistically non-significant data from meta-analyses may result in overestimation of treatment effect sizes which may lead to clinical consequences. Our goal was to assess whether systematic reviewers in dermatology evaluate and report publication bias. Further, we wanted to conduct our own evaluation of publication bias on meta-analyses that failed to do so. Our study considered systematic reviews and meta-analyses from ten dermatology journals from 2006 to 2016. A PubMed search was conducted, and all full-text articles that met our inclusion criteria were retrieved and coded by the primary author. 293 articles were included in our analysis. Additionally, we formally evaluated publication bias in meta-analyses that failed to do so using trim and fill and cumulative meta-analysis by precision methods. Publication bias was mentioned in 107 articles (36.5%) and was formally evaluated in 64 articles (21.8%). Visual inspection of a funnel plot was the most common method of evaluating publication bias. Publication bias was present in 45 articles (15.3%), not present in 57 articles (19.5%) and not determined in 191 articles (65.2%). Using the trim and fill method, 7 meta-analyses (33.33%) showed evidence of publication bias. Although the trim and fill method only found evidence of publication bias in 7 meta-analyses, the cumulative meta-analysis by precision method found evidence of publication bias in 15 meta-analyses (71.4%). Many of the reviews in our study did not mention or evaluate publication bias. Further, of the 42 articles that stated following PRISMA reporting guidelines, 19 (45.2%) evaluated for publication bias. In comparison to other studies, we found that systematic reviews in dermatology were less likely to evaluate for publication bias. Evaluating and reporting the likelihood of publication bias should be standard practice in systematic reviews when appropriate.