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Family Practice THE JOURNAL OF FAMILY ONLINE EXCLUsIVE PRACTICE J.A.H. Eekhof, MD, PhD, Minor derm ailments: A. Knuistingh Neven, MD, PhD, S.P. Gransjean, medical student, and How good is the evidence W.J.J. Assendelft, MD, PhD Leiden University Medical for common treatments? Center, Leiden, The Netherlands Not very. This systematic review reveals that only a few [email protected] therapies have high-level research to support them Practice recommendations o you use silver sulfadiazine for • Oral flucloxacillin is less effective than partial-thickness burns? If you local antibiotics for impetigo in limited ® DowdenDdo, you Health may be surprised Media to learn disease (level of evidence [LOE] 1a). that the evidence for its use in this situ- • Topical metronidazole and azelaic acid ation is conflicting. This was just one of are effective for rosaceaCopyright (LOE 1a).For personalthe findings ofuse our systematiconly review of • Betadine is effective for minor the methodologic quality and statistical infections following partial and clinical relevance of current therapies thickness burns (LOE 1b). for minor dermatologic ailments. • Terbinafine is effective against fungal Given that minor ailments, frequently IN THiS ARTiCLE infections of the nail (LOE 1a). dermatologic, account for 40% to 70% z Summary of • Miconazole is effective against of all consultations in family medicine,2,3 oral thrush (LOE 1a). guidelines based on better research are studies needed. This need is underscored by the Page E8 Level of evidence (LOE) increasing delegation of minor treatments 1a: Systematic reviews (with homogeneity) of randomized controlled trials (RCTs). to staff nurses, nurse practitioners, and 1a-: Systematic review of randomized trials displaying physician assistants, who should undergo worrisome heterogeneity. 1b: Individual RCT (with a narrow confidence interval). comprehensive training, preferably based 1b-: Individual RCT (with a wide confidence interval). on valid guidelines.4.5 Moreover, consul- 1c: All or none RCTs. 2a: Systematic reviews (with homogeneity) of cohort studies. tations for prevalent minor ailments of- 2a-: Systematic reviews of cohort studies displaying worrisome ten lead to prescriptions for medications, heterogeneity. thereby generating considerable costs.6,7 2b: Individual cohort study or low-quality RCTs (<80% follow- up). 2b-: Individual cohort study or low-quality RCTs (<80% follow- up/wide confidence interval). 2c: “Outcomes” research; ecological studies. z Methods 3a: Systematic review (with homogeneity) of case-control studies. The starting point for this review was 3a-: Systematic review of case-control studies with worrisome the textbook, Minor Ailments in Prima- heterogeneity. 6 3b: Individual case-control study. ry Care: An Evidence-Based Approach, 4: Case series (and poor-quality cohort and case-control which describes 119 minor ailments, studies). selected mainly on the basis of disease 5: Expert opinion without explicit critical appraisal, or based on physiology, bench research, or “first principles.” prevalence. We selected all dermatologic Source: Essential Evidence Plus. Levels of evidence.1 ailments (International Classification of www.jfponline.com VOL 58, NO 9 / SEPTEMBER 2009 E1 For mass reproduction, content licensing and permissions contact Dowden Health Media. THE JOURNAL OF FAMILY PRACTICE Primary Care-code ‘S’) (N=42) (TABLE).5 ailments, where possible, into bacte- We searched the online data- rial infection, fungal infection, itch, and bases PubMed, Cochrane Controlled pain. Trials Register, and Clinical Evidence for We classified the efficacy of thera- articles relating to the treatment of these pies as yes, likely (if the result was not conditions. For each ailment, we used convincingly effective or based on small various search terms for indication and studies, or if the study objective was un- treatment.8 (See note at end of Methods clear), or no. Treatments with no trials section.) We excluded alternative (nonal- to support them are so identified. As to lopathic) and most preventive therapies whether the evidence was convincing, we because they are unusual in the daily indicated yes, no, or conflicting. practice of family medicine. Post hoc analysis. For trials with a We searched only for trials in which wide confidence interval and for thera- treatments were compared with placebo pies described as not clearly effective, we or a reasonable, accepted usual therapy. performed a post hoc power analysis to The search followed a hierarchy of evi- explore if the trial was underpowered.10 dence:8 systematic reviews (SRs), then We compared the number of subjects in randomized controlled trials (RCTs), the study (n1) with the number we calcu- then other research articles (nonrandom- lated as necessary for the study to have ized clinical trials, case series). When we sufficient power (n2). For all studies, we found a relevant SR published in 2004 or used standardized values (α=0.05 and later, we did not search for a lower level b=0.20). If n1≥n2 we considered the study of evidence (LOE). Instead, we restricted design accurate, and if n1< n2 we conclud- our subsequent search to RCTs published ed that the power was insufficient for the after the publication date of the SR.8 Two study to be able to answer its objectives. of the authors (SPG and JAHE) selected articles independently, based on article Further details on the following title and abstract. Disagreements in se- information are available from the FAST TRACK lection were discussed and consensus corresponding author: was reached. If an article contained rel- For limited • terms used in searching online evant first-line therapy, we also used the databases impetigo, local “related articles” option in PubMed to • post hoc power analysis antibiotic check for more sources. (See note at end • a summary of treatment ratio- of Methods section.) treatment is nales, therapies and their effec- To evaluate the methodologic qual- more effective tiveness, country where the re- ity of SRs and trials, we ranked articles search was undertaken, number than oral according to the method of infoPOEMs.8 of authors, and year of article (See key on page E1.) Two experienced flucloxacillin. publication for each dermato- researchers (JAHE and AKN) scored all logic ailment. articles independently. Consensus was reached in cases of disagreement.9 We deemed evidence convincing if the study z Results showed the intervention was effective and We collected 71 articles published in the if the LOE of the study was high (levels medical literature between January 1981 1a, 1b, or 2a). and July 2007.11-81 On average, we found Evaluating breadth of treatment ap- 2 articles per minor dermatologic ail- plication. To explore whether a treat- ment, with a range of 0 to 7. For 7 com- ment for a certain minor ailment could mon ailments, we found no studies on be applied to other ailments with similar therapies; for 13 ailments we found just symptoms and thus increase the strength 1 trial each. of the treatment’s rationale, we clustered For 20 of the 42 ailments, we found E2 VOL 58, NO 9 / SEPTEMBER 2009 THE JoURNAL oF FAMILY PRACtICE Minor derm ailments: Evidence for common treatments t a SR of treatments (10 Cochrane reviews, Results varied. With partial thick- 5 Clinical Evidence, and 5 from other ness burns, evidence was conflicting on sources). Most articles describing RCTs the effectiveness and the harms of silver presented results with wide confidence sulfadiazine and several types of gauzes. intervals (LOEs 1b- and 2b-), mainly due For boils, we could find no trial about to small sample sizes. Eleven RCTs (14%) therapy. For both warts and mollusca had high dropout rates (LOE 2b or 2b-). contagiosa, Cochrane reviews were in- Seventy-four percent of all the trials conclusive on therapies commonly used were conducted in Europe and North in general practice. Evidence was also in- America. The United States (24%) and conclusive for treatments for paronychia, United Kingdom (25%) were the lar- polymorphic light eruption, and dog and gest contributors. Studies of Asian and cat bites. South American populations (eg, Indian, Nepalese, Iraqi, Brazilian) tended to fo- cus on problems more prevalent in these z Clustering by treatment countries, such as lice and scabies. rationale For 26 of the 42 ailments, evidence Bacterial infections. We found trials on was unclear (no studies or studies with antibiotic therapy for 5 of the 12 mi- inconclusive evidence). Very few of the nor dermatologic ailments caused by therapies commonly used for minor or followed by bacterial infection. For dermatologic ailments are supported by the other 7, no trials were available. We high-level research evidence. Even some found evidence for the effectiveness of SRs included only methodologically poor treatment in 3 of the 11 indications (im- RCTs, which indicates that more research petigo, erythrasma, and rosacea). For is needed. the treatment of impetigo (in cases of A look at outcomes. The TABLE sum- limited disease), oral flucloxacillin is less marizes the effectiveness of therapies effective than local antibiotic treatment usually applied to minor dermatologic (LOE 1a). Betadine for minor infections ailments in daily practice. The columns after partial thickness burns is effective FAST TRACK present, in turn: (LOE 1b)or all other dermatological mi- Two systematic • the minor ailment, nor ailments in the bacterial infections • the treatments usually applied in category, the effectiveness of antibiotic reviews concluded daily practice, therapy was unclear. that oral • the number of studies found for Fungal infections. For 8 of the 9 ail- terbinafine these treatments, ments in which a fungal infection (yeast, is effective for • the condition at which treatment fungals, dermatophytes) was one of the was aimed, main reasons for therapy, we found trials fungal nail • whether the targeted condition on antimycotic treatment. There were 2 infections. belongs to 1 of the 4 categories SRs of oral therapy for fungal nail infec- of main symptoms, tions, both concluding that terbinafine • whether the study/studies is an effective antifungal therapy for the reported a positive effect for the condition.
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