For limited impetigo, local antibiotic treatment is more effective than oral flucloxacillin.
Bacterial infections. We found trials on antibiotic therapy for 5 of the 12 minor dermatologic ailments caused by or followed by bacterial infection. For the other 7, no trials were available. We found evidence for the effectiveness of treatment in 3 of the 11 indications (impetigo, erythrasma, and rosacea). For the treatment of impetigo (in cases of limited disease), oral flucloxacillin is less effective than local antibiotic treatment (LOE 1a). Betadine for minor infections after partial thickness burns is effective (LOE 1b)or all other dermatological minor ailments in the bacterial infections category, the effectiveness of antibiotic therapy was unclear.
Fungal infections. For 8 of the 9 ailments in which a fungal infection (yeast, fungals, dermatophytes) was one of the main reasons for therapy, we found trials on antimycotic treatment. There were 2 SRs of oral therapy for fungal nail infections, both concluding that terbinafine is an effective antifungal therapy for the condition. Miconazole is effective for infections with Candida albicans or dermatophytes (LOE 1a).
FAST TRACK
Two systematic reviews concluded that oral terbinafine is effective for fungal nail infections.
Itch. Itch was a main reason for treating 8 ailments. We found some trials for neutral lotion or oral antihistamines. We also found evidence supporting use of local antihistamines for 2 of the 8 minor ailments. For 4 ailments, we found studies with positive results for local application of steroids; we found no studies for oral steroids. We can therefore conclude that local steroids are effective for ailments in which itch is one of the main symptoms.
Pain. For 5 ailments, relief from pain was the main target of treatment. Trials, however, did not focus on generic pain medications but on treatments aimed at specific causal pathways of the ailment (eg, antiviral treatment for the post-herpetic pain of shingles). Therefore, we cannot draw generalizable conclusions on the treatment of pain in minor dermatologic ailments.
Post hoc power analysis
Most of the 10 trials with LOE 1b- (and effectiveness of treatment described as no or likely) needed many more patients to reach a higher LOE. In only 2 trials,55,66 the number of patients was sufficient. Four of the 10 trials were missing information that would have enabled us to judge whether they were underpowered. In 4 other trials, we considered the number of patients needed to prove treatment effectiveness (n2) unrealistic, and, consequently, the therapy as very likely ineffective.
Conclusions
FAST TRACK
Fewer than half of the ailments had convincing evidence to support the effectiveness of usual therapy.
Study design was poor for more than half of the trials identified. And other studies were so small as to lack statistical power. We found convincing evidence (SRs or good RCTs) for the effectiveness of usual therapy for fewer than half of the ailments selected. Had we extended our search to more databases, such as EMBASE and CINAHL, we may have identified more trials. However, it is unlikely we would have arrived at a different conclusion, given that the number of relevant studies was so low in the databases we did search (PubMed, Cochrane library, Clinical Evidence).
We clustered ailments to determine if a treatment aimed at a particular symptom or complication could be applied to all ailments exhibiting that condition. On the basis of the treatment effect found for 4 ailments, we determined that local steroids would most likely effectively relieve itch associated with all minor dermatologic ailments. For other conditions, grouping by rationale for treatment did not yield any extendable applications.
Generally accepted treatments for minor dermatologic ailments are insufficiently supported by research evidence. This limitation contrasts dramatically with the body of evidence supporting therapies in other aspects of family practice, reportedly having sufficient LOEs in the range of 50% to 80% of treatments.82,83 Given that minor ailments are a substantial portion of a family physician’s workload, and that other primary care providers are increasingly treating these ailments, definitive guidelines based on high-quality research are needed. This aspect of medical care deserves more attention from researchers and funding agencies.
Correspondence J.A.H. Eekhof, MD, PhD, Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), PO Box 9600, 2300 RC Leiden, The Netherlands; J.A.H.Eekhof@lumc.nl
