Pragmatic clinical trial is now needed

EDITOR—The systematic review on topical treatment for fungal infections of the feet and the accompanying editorial by Finlay illustrate the difficulties encountered when the evidence shows that an alternative treatment is both more effective and more expensive.1 2 Finlay (a member of the advisory board of Novartis, which manufactures the more expensive allylamine treatment) believes that we should give our patients the most effective (and most expensive) treatment. Hart et al provide purchasers with a more balanced view by presenting the costs of treating patients with an azole initially followed by an allylamine against the likely costs of treating all patients with allylamines from the start.

I had always been led to believe that topical terbinafine was vastly superior to azoles in tinea pedis, but the systematic review shows that cure rates were 80% and 72% respectively—not a vast difference in absolute terms So there is at least a case for a policy of “try the cheaper one first and …