Eekhof J.A.h., MD, PhD

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Minor derm ailments: How good is the evidence for common treatments?

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Eekhof J.A.h., MD, PhD

Practice recommendations

Oral flucloxacillin is less effective than local antibiotics for impetigo in limited disease (level of evidence [LOE] 1a).
Topical metronidazole and azelaic acid are effective for rosacea (LOE 1a).
Betadine is effective for minor infections following partial thickness burns (LOE 1b).
Terbinafine is effective against fungal infections of the nail (LOE 1a).
Miconazole is effective against oral thrush (LOE 1a).

Level of evidence (LOE)

1a: Systematic reviews (with homogeneity) of randomized controlled trials (RCTs).
1a-: Systematic review of randomized trials displaying worrisome heterogeneity.
1b: Individual RCT (with a narrow confidence interval).
1b-: Individual RCT (with a wide confidence interval).
1c: All or none RCTs.
2a: Systematic reviews (with homogeneity) of cohort studies.
2a-: Systematic reviews of cohort studies displaying worrisome heterogeneity.
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.
3a: Systematic review (with homogeneity) of case-control studies.
3a-: Systematic review of case-control studies with worrisome heterogeneity.
3b: Individual case-control study.
4: Case series (and poor-quality cohort and case-control studies).
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research, or “first principles.”

Source: Essential Evidence Plus. Levels of evidence.¹

Do you use silver sulfadiazine for partial-thickness burns? If you do, you may be surprised to learn that the evidence for its use in this situation is conflicting. This was just one of the findings of our systematic review of the methodologic quality and statistical and clinical relevance of current therapies for minor dermatologic ailments.

Given that minor ailments, frequently dermatologic, account for 40% to 70% of all consultations in family medicine,^2,3 guidelines based on better research are needed. This need is underscored by the increasing delegation of minor treatments to staff nurses, nurse practitioners, and physician assistants, who should undergo comprehensive training, preferably based on valid guidelines.^4,5 Moreover, consultations for prevalent minor ailments often lead to prescriptions for medications, thereby generating considerable costs.^6,7

Methods

The starting point for this review was the textbook, Minor Ailments in Primary Care: An Evidence-Based Approach,⁶ which describes 119 minor ailments, selected mainly on the basis of disease prevalence. We selected all dermatologic ailments (International Classification of Primary Care-code ‘S’) (N=42) (TABLE).⁵

We searched the online databases PubMed, Cochrane Controlled Trials Register, and Clinical Evidence for articles relating to the treatment of these conditions. For each ailment, we used various search terms for indication and treatment.⁸ (See note at end of Methods section.) We excluded alternative (nonallopathic) and most preventive therapies because they are unusual in the daily practice of family medicine.

We searched only for trials in which treatments were compared with placebo or a reasonable, accepted usual therapy. The search followed a hierarchy of evidence:⁸ systematic reviews (SRs), then randomized controlled trials (RCTs), then other research articles (nonrandomized clinical trials, case series). When we found a relevant SR published in 2004 or later, we did not search for a lower level of evidence (LOE). Instead, we restricted our subsequent search to RCTs published after the publication date of the SR.⁸ Two of the authors (SPG and JAHE) selected articles independently, based on article title and abstract. Disagreements in selection were discussed and consensus was reached. If an article contained relevant first-line therapy, we also used the “related articles” option in PubMed to check for more sources. (See note at end of Methods section.)

To evaluate the methodologic quality of SRs and trials, we ranked articles according to the method of infoPOEMs.⁸ (See key.) Two experienced researchers (JAHE and AKN) scored all articles independently. Consensus was reached in cases of disagreement.⁹ We deemed evidence convincing if the study showed the intervention was effective and if the LOE of the study was high (levels 1a, 1b, or 2a).

Evaluating breadth of treatment application. To explore whether a treatment for a certain minor ailment could be applied to other ailments with similar symptoms and thus increase the strength of the treatment’s rationale, we clustered ailments, where possible, into bacterial infection, fungal infection, itch, and pain.

We classified the efficacy of therapies as yes, likely (if the result was not convincingly effective or based on small studies, or if the study objective was unclear), or no. Treatments with no trials to support them are so identified. As to whether the evidence was convincing, we indicated yes, no, or conflicting.

Post hoc analysis. For trials with a wide confidence interval and for therapies described as not clearly effective, we performed a post hoc power analysis to explore if the trial was underpowered.¹⁰ We compared the number of subjects in the study (n₁) with the number we calculated as necessary for the study to have sufficient power (n₂). For all studies, we used standardized values (α=0.05 and β=0.20). If n₁≥n₂ we considered the study design accurate, and if n₁< n₂ we concluded that the power was insufficient for the study to be able to answer its objectives.

Further details on the following information are available from the corresponding author:

terms used in searching online databases
post hoc power analysis
a summary of treatment rationales, therapies and their effectiveness, country where the research was undertaken, number of authors, and year of article publication for each dermatologic ailment.

Results

We collected 71 articles published in the medical literature between January 1981 and July 2007.^11-81 On average, we found 2 articles per minor dermatologic ailment, with a range of 0 to 7. For 7 common ailments, we found no studies on therapies; for 13 ailments we found just 1 trial each.

For 20 of the 42 ailments, we found a SR of treatments (10 Cochrane reviews, 5 Clinical Evidence, and 5 from other sources). Most articles describing RCTs presented results with wide confidence intervals (LOEs 1b- and 2b-), mainly due to small sample sizes. Eleven RCTs (14%) had high dropout rates (LOE 2b or 2b-).

Seventy-four percent of all the trials were conducted in Europe and North America. The United States (24%) and United Kingdom (25%) were the largest contributors. Studies of Asian and South American populations (eg, Indian, Nepalese, Iraqi, Brazilian) tended to focus on problems more prevalent in these countries, such as lice and scabies.

For 26 of the 42 ailments, evidence was unclear (no studies or studies with inconclusive evidence). Very few of the therapies commonly used for minor dermatologic ailments are supported by high-level research evidence. Even some SRs included only methodologically poor RCTs, which indicates that more research is needed.

A look at outcomes. The TABLE summarizes the effectiveness of therapies usually applied to minor dermatologic ailments in daily practice. The columns present, in turn:

the minor ailment,
the treatments usually applied in daily practice,
the number of studies found for these treatments,
the condition at which treatment was aimed,
whether the targeted condition belongs to 1 of the 4 categories of main symptoms,
whether the study/studies reported a positive effect for the treatment,
whether the evidence for the effectiveness of a particular treatment was (according to the authors) convincing,
whether the overall rating of evidence was convincing,
and whether further studies are needed.

FAST TRACK

Duct tape occlusion for treating warts is ineffective.

Results varied. With partial thickness burns, evidence was conflicting on the effectiveness and the harms of silver sulfadiazine and several types of gauzes. For boils, we could find no trial about therapy. For both warts and mollusca contagiosa, Cochrane reviews were inconclusive on therapies commonly used in general practice. Evidence was also inconclusive for treatments for paronychia, polymorphic light eruption, and dog and cat bites.

TABLE
The treatment of minor dermatologic ailments: What the research tells us
Treatments for which sufficient positive evidence exists are formatted in bold; those for which negative evidence exists are formatted in bold italic.

	*Dermatological minor ailment (N)**	Treatment	Target for treatment	Category of treatment target, according to main symptoms	Was treatment effective?	Was the research convincing?^†	Overall rating of research evidence	Are further studies required?
1.	Partial thickness burns (4)	Oral antibiotics (flucloxacillin)¹¹	Infection (bacterial)	Bacterial infection	No trials	No	Moderate	Yes
		Gauze dressings¹¹	Skin lesion		Likely	Conflicting
		Silver sulfadiazine¹¹	Skin lesion		No	Conflicting
		Betadine¹²	Infection (bacterial)	Bacterial infection	Yes	Yes
		Cooling¹³	Pain	Pain	No	No
		Honey¹⁴	Pain	Pain	No	No
2.	Polymorphic light eruption (4)	Neutral lotion	Itch	Itch	No trials	No	Poor	Yes
		Corticosteroids^15,18	Itch	Itch	Yes	Yes
		Oral antihistamines	Itch	Itch	No trials	No
		Sunscreens^16,17	Preventive		Yes	No
3.	Acute urticaria (2)	Local ointments	Itch/rash	Itch	No trials	No	Moderate	Yes
		Oral antihistamines¹⁹	Itch/rash	Itch	Yes	Yes
		Corticosteroids²⁰	Itch/rash	Itch	Yes	Yes
4.	Insect bites and stings (0)	Doxycycline	Infection (bacterial)	Bacterial infection	No trials	No	None	Yes
		Amoxicillin	Infection (bacterial)	Bacterial infection	No trials	No
		Oral antihistamines	Pain/itch	Itch	No trials	No
5.	Pediculosis (3)	Malathion²¹	Infection		Yes	Yes	Good	No
		Permethrin²²	Infection		Yes	Yes
		Lindane	Infection		No trials	No
		Combing²³	Infection		Yes	Yes
6.	Scabies (3)	Permethrin^25,26	Infection		Yes	Yes	Good	No
		Lindane²⁴	Infection		Yes	Yes
		Benzyl benzoate	Infection		No trials	No
		Malathion	Infection		No trials	No
7.	Dog and cat bites (1)	Oral antibiotics (amoxicillin)²⁷	Infection (bacterial)	Bacterial infection	Yes, for bites to the hands. No, for other bites	No	Moderate	Yes
8.	Abrasions (1)	Paraffin gauze	Skin lesion		No trials	No	Poor	Yes
		Non-adherent absorbent compress	Skin lesion		No trials	No
		Betadine	Skin lesion/infection (bacterial)	Bacterial infection	No trials	No
		Honey²	Skin lesion		Likely	No
9.	Warts (4)	Salicylic acid²⁹	Lump on the skin		Yes	Yes	Moderate	Yes
		Cryotherapy²⁹	Lump on the skin		No	No
		*Duct tape occlusion*^30-32	Lump on the skin		No	Yes, treatment was not effective
		Surgical procedures	Lump on the skin		No trials	No
10.	Molluscum contagiosum (1)	Curettage³³	Lump on the skin		No trials	No	Poor	Yes
		Liquid nitrogen³³	Lump on the skin		No trials	No
		Fusidic acid cream³³	Lump on the skin		No trials	No
		Betadine³³	Lump on the skin		No	No
11.	Furuncles (0)	Hot compress	Pain	Bacterial infection	No trials	No	None	Yes
11.	Furuncles (0)	Antibiotics	Infection (bacterial)	Bacterial infection	No trials	No	None	Yes
12.	Impetigo (1)	Local fusidic acid or mupirocin³⁴	Infection (bacterial)	Bacterial infection	Yes	Yes	Good	No
12.	Impetigo (1)	Oral antibiotics³⁴	Infection (bacterial)	Bacterial infection	Yes	Yes, but less effective than local treatment in limited disease	Good	No
13.	Pityriasis versicolor (2)	Selenium sulphide	Infection	Fungal infection	No trials	No	Moderate	Yes
		Imidazole	Infection	Fungal infection	No trials	No
		Fluconazole³⁵	Infection	Fungal infection	Yes	No
		Itraconazole³⁶	Infection	Fungal infection	Yes	No
14.	Intertrigo (2)	Miconazole^37,38	Infection	Fungal infection	Yes	Yes	Moderate	Yes
14.	Intertrigo (2)	Hydrocortisone³⁷	Infection	Fungal infection	No	No	Moderate	Yes
15.	Erythrasma (1)	Imidazole	Infection (bacterial)	Bacterial infection	No trials	No	Good	No
		Benzoic acid	Infection (bacterial)	Bacterial infection	No trials	No
		Erythromycin³⁹	Infection (bacterial)	Bacterial infection	Yes	Yes
16.	Shingles (6)	Acyclovir⁴⁰	Infection (viral)		Yes	Yes	Moderate/Good	Yes
		Famcyclovir⁴¹	Infection (viral)		Yes	No
		Acyclovir + prednisolone⁴²	Infection (viral)		Yes	No
		*Corticosteroids*^43,44	Inflammation		No	Yes, treatment was not effective
		Amitriptyline⁴⁵	Pain		Likely	No
17.	Pruritus in the elderly (1)	Local emollients	Itch	Itch	No trials	No	Moderate	Yes
		Corticosteroids	Itch	Itch	No trials	No
		Local antihistamines	Itch	Itch	No trials	No
		Oral antihistamines⁴⁶	Itch	Itch	Yes	Yes
18.	Xeroderma (0)	Emollients	Dry skin		No trials	No	None	Yes
19.	Androgenic alopecia (5)	Wig	Hair loss		No trials	No	Moderate	Yes
		Finasteride^49-51	Hair loss		Yes	Yes
		Minoxidil^47,48	Hair loss		Likely	Conflicting
20.	Alopecia areata (5)	Minoxidil^52,53	Hair loss		No	No	Moderate	Yes
		Oral prednisolone⁵⁴	Hair loss		Likely	No
		Desoxymethasone⁵⁵	Hair loss		No	No
		Betamethasone⁵⁶	Hair loss		Likely	No
21.	Dandruff (4)	Zinc pyrithione⁵⁷	Infection (yeast)	Fungal infection	Yes	No	Moderate	Yes
		Ciclopirox^58-60	Infection (yeast)	Fungal infection	Yes	Yes
		Ketoconazole⁶¹	Infection (yeast)	Fungal infection	Yes	Yes
		Selenium sulphide⁶¹	Infection (yeast)	Fungal infection	Yes	Yes
		Corticosteroids⁶¹	Itch	Itch	Yes	Yes
22.	Seborrhoeic eczema (2)	Zinc pyrithione⁵⁷	Infection (yeast)	Fungal infection	Yes	No	Moderate	Yes
		Ketoconazole⁶¹	Infection (yeast)	Fungal infection	Yes	Yes
		Coal tar⁶¹	Infection (yeast)	Fungal infection	Yes	Yes
		Selenium sulphide⁶¹	Infection (yeast)	Fungal infection	Yes	No
		Corticosteroids⁶¹	Itch	Itch	Yes	Yes
23.	Herpes labialis (1)	Sunscreens⁶²	Prevention		Yes	Yes	Good	No
		Oral antivirals⁶²	Infection (viral)		Yes	Yes
		Zinc oxide cream⁶²	Skin lesion		Likely	No
		Topical antivirals	Infection (viral)		No trials	No
		Topical antivirals	Pain		No trials	No
24.	Perioral dermatitis (1)	Clean with water	Prevention		No trials	No	Poor	Yes
		Topical metronidazole⁶³	Infection	Bacterial infection	Likely	No
		Tetracycline	Infection	Bacterial infection	No	No
25.	Oral thrush (1)	Nystatin⁶⁴	Infection	Fungal infection	Less effective than miconazole	No	Good	No
25.	Oral thrush (1)	Miconazole⁶⁴	Infection	Fungal infection	Yes	Yes	Good	No
26.	Salmon patch (0)	No treatment is needed					None	No
27.	Chloasma (3)	Hydroquinone, tretinoin, hydrocortisone combination^65,66	Skin irritation		Yes	No	Moderate	Yes
27.	Chloasma (3)	Hydroquinone ⁶⁷	Skin irritation		Yes	No	Moderate	Yes
28.	Rosacea (2)	Topical metronidazole⁶⁸	Infection	Bacterial infection	Yes	Yes	Moderate	Yes
		Azelaic acid⁶⁸	Infection	Bacterial infection	Yes	Yes
		Zinc-sulphate⁶⁹	Infection	Bacterial infection	Yes	No
		Tetracycline⁶⁸	Infection	Bacterial infection	Yes	No
29.	Umbilical problems in infants (0)	Disinfectant liquid	Infection	Bacterial infection	No trials	-	None	Yes
		Antiseptic dressing	Infection	Bacterial infection	No trials	-
		Silver nitrate	To stop granulations		No trials	-
		Electrocauterization	To stop granulations		No trials	-
30.	Nappy rash (2)	Zinc oxide cream⁷⁰	Skin lesion		Yes	Yes	Moderate	Yes
		Miconazole⁷¹	Infection	Fungal infection	Yes	No
		Hydrocortisone	Itch	Itch	No trials	No
31.	Fish hook in finger (0)	Local extirpation	Skin lesion		No trials	-	None	No
32.	Splinter under nail (0)	Splinter removal	Skin lesion		No trials	-	None	No
33.	Subungual hematoma (1)	Making a hole in the nail⁷²	Discharging hematoma		Likely	No	Moderate	Yes
34.	Brittle nails (0)	Terbinafine (oral)	Infection		No trials	No	None	Yes
34.	Brittle nails (0)	Itraconazole (oral)	Infection		No trials	No	None	Yes
35.	Paronychia (0)	Antibiotics	IInfection (bacterial)	Bacterial infection	No trials	No	Poor	Yes
		Drainage	Discharging pus		No trials	No
		Antifungal cream	Infection	Fungal infection	No trials	No
36.	Fungal infection of the nail (3)	Local treatment (imidazole)⁷³	Infection	Fungal infection	Yes	Yes	Good	No
36.	Fungal infection of the nail (3)	Oral terbinafine^74,75	Infection	Fungal infection	Yes	Yes	Good	No
37.	Calluses on the feet (1)	Removing the excess callus⁷⁶	Removing callosity		Yes	No	None	Yes
37.	Calluses on the feet (1)	Disinfectant ointment	Infection		No trials	No	None	Yes
38.	Ingrown nail (2)	Wedge excision^77,78	Removing infected tissue		Yes	Yes	Good	Yes
38.	Ingrown nail (2)	Chemical ablation^77,78	Destruction nail matrix		Yes	Yes	Good	Yes
39.	Corns (1)	Salicylic acid	Resolution callosity		No trials	No	None	Yes
39.	Corns (1)	Excision⁷⁶	Removing callosity		Yes	No	None	Yes
40.	Athlete’s foot (1)	Imidazole⁷⁹	Infection	Fungal infection	Yes	Yes	Good	No
		Imidazole + hydrocortisone⁷⁹	Infection/itch	Fungal infection /itch	Yes	Yes
		Itraconazole⁷⁹	Infection	Fungal infection	Yes	Yes
41.	Foot blisters (2)	Betadine	Infection	Bacterial infection	No trials	No	Moderate	Yes
41.	Foot blisters (2)	Antiperspirant ^80,81	Reducing incidence of blisters		Yes	Conflicting	Moderate	Yes
42.	Plantar warts (4)	Salicylic acid²⁹	Lump on the skin		Yes	Yes	Moderate/good	Yes
		Cryotherapy ²⁹	Lump on the skin		No	No
		*Duct tape occlusion*^30-32	Lump on the skin		No	Yes, treatment was not effective
		Surgical procedures	Lump on the skin		No trials	No
*N=Number of trials.
^† Convincing evidence taken as level of evidence 1a or 1b.

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Clustering by treatment rationale

FAST TRACK

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; [email protected]

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Eekhof J.A.H. , MD, PhD;
Knuistingh A. Neven, MD, PhD;
Gransjean S.P.
medical student

Assendelft W.J.J. , MD, PhD
Leiden University Medical Center, Leiden, The Netherlands
[email protected]

The authors reported no potential conflict of interest relevant to this article.

Issue

The Journal of Family Practice - 58(9)

Publications

The Journal of Family Practice

MDedge Family Medicine

Topics

Dermatology

Page Number

E1-E11

Read more about Minor derm ailments: How good is the evidence for common treatments?

Sections

Applied Evidence

Author(s)

Eekhof J.A.h., MD, PhD

Author(s)

Eekhof J.A.h., MD, PhD

Author and Disclosure Information

Eekhof J.A.H. , MD, PhD;
Knuistingh A. Neven, MD, PhD;
Gransjean S.P.
medical student

Assendelft W.J.J. , MD, PhD
Leiden University Medical Center, Leiden, The Netherlands
[email protected]

The authors reported no potential conflict of interest relevant to this article.

Author and Disclosure Information

Eekhof J.A.H. , MD, PhD;
Knuistingh A. Neven, MD, PhD;
Gransjean S.P.
medical student

Assendelft W.J.J. , MD, PhD
Leiden University Medical Center, Leiden, The Netherlands
[email protected]

The authors reported no potential conflict of interest relevant to this article.

Article PDF

5809JFP_Article6.pdf

Article PDF

5809JFP_Article6.pdf

Practice recommendations

Oral flucloxacillin is less effective than local antibiotics for impetigo in limited disease (level of evidence [LOE] 1a).
Topical metronidazole and azelaic acid are effective for rosacea (LOE 1a).
Betadine is effective for minor infections following partial thickness burns (LOE 1b).
Terbinafine is effective against fungal infections of the nail (LOE 1a).
Miconazole is effective against oral thrush (LOE 1a).