Intended for healthcare professionals


Treatment of toenail onychomycosis

BMJ 1999; 319 doi: (Published 30 October 1999) Cite this as: BMJ 1999;319:1196

Will paper's key message soon appear in promotional material for drug?

  1. Fred Kavalier, general practitioner (
  1. Kentish Town Health Centre, London NW5 2BX
  2. Mill Stream Surgery, Benson, Oxfordshire OX10 6RL
  3. Bacon Road Medical Practice, Norwich NR2 3QX
  4. University of Leeds, Leeds LS2 9JTY
  5. BMJ, London WC1H 9JR

    EDITOR—Evans and Sigurgeirsson show that one form of treatment for toenail onychomycosis (continuous terbinafine) is significantly better than another (intermittent itraconazole).1 But I find it disturbing that the journal has given such prominence (the first paper in the journal and the first item in This Week in the BMJ) to a comparative drug trial of two well established drugs that was financed entirely by the manufacturer of one of the drugs.

    The introduction to the paper cites a prevalence of onychomycosis of 2-4%, yet the study population consisted of patients with severe onychomycosis (on average a 10 year history with six toenails affected; this fact is tucked away in the last paragraph). No evidence is presented to show the relevance of the study to a wider population of patients with mild or moderate onychomycosis.

    The optimistic key message (repeated in This Week in the BMJ) that “fungal nail disease is curable” is correct only in the sense that about half of the patients who took terbinafine showed a complete cure at 72 weeks. This accords with Epstein's recent review of the success of oral treatment of onychomycosis.2 Would it not have been equally true (although more pessimistic, and certainly less promotional) to say “fungal nail disease is incurable”?

    The paper states: “As with the mycological cure rates the clinical cure rates for the continuous terbinafine groups continued to increase after treatment through to week 72. This was not the case for the intermittent itraconazole groups.” The graphs on p 1034, however, tell a different story. They show that the cure rates for both forms of treatment continued to increase substantially after treatment stopped.

    I was particularly disturbed to see that the authors acknowledged the “constant help and guidance throughout this project” of an employee of Novartis Pharmaceuticals Corporation. …

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