Tinea pedis is the most common infection you will come across in podiatry practice affecting around a third of adults, and half of older adults. The condition is easy to treat, provided the patient is on board, using an antifungal cream. On that basis, it makes good business sense to sell the medicines to treat the condition directly to the patients from your clinic. Why pass up business and send them onto the pharmacist? If you do decide to sell antifungals, the question often arises which is the best antifungal cream? What should I stock in the clinic?
In the UK, there are a range of “P” (pharmacy) and “POM” (prescription only medicines) available which are more than capable of treating fungal skin infection. The medicines basically fall into two chemical groups – firstly the allylamines (of which terbinafine is the only one available in the UK) and the imidazoles. Commonly used example imidazoles include miconazole and clotrimazole. So, which is product is the better choice to keep in stock?
The answer comes down to two things – which is the cheapest and which is most effective? If you read the Cochrane review of antifungal drugs for tinea pedis (1), you will find some guidance there. Essentially, imidazoles and terbinafine showed themselves to be more effective than placebo when treating athlete’s foot but terbinafine showed superiority over the azoles as it had a quicker time to cure - the azoles being a bit slower to work. One study showed that at 1-week cure rates with clotrimazole to be just 27%, rising to 70% when the treatment is continued for a month (2). However, when treating tinea pedis, I would always recommend that patients treat themselves for a month anyway, particularly if this has been a chronic infection ongoing. When the azoles and terbinafine go to head-to-head for a month you find that there is no difference between the two drugs in their cure rates.
That being equal then should we not just go on the price? The lowest price product means a happy patient and a happy podiatrist, providing you have an appropriate mark up on the product? Possibly. Let’s take the two leading brand heavyweights – Canesten® and Lamisil®. At retail price, for a 15g tube of each Canesten® costs around £3 upwards, Lamisil is double that around £6 or just over. On the face of it, it’s a straight forward choice – Canesten is cheaper and therefore wins.
Before we put Canesten as your clinic brand, let’s look at the downside. From a patient’s perspective what would they want? Probably something that’s the most convenient and gets the job done quickly. From that perspective, terbinafine is your winner – it’s a once daily application (very convenient) and technically will cure the patient in half the time (two weeks versus four with an imidazole). So, if compliance is an issue Lamisil is your choice. Moreover, Lamisil Once® (a single application film forming solution) is another solution to the problem. The patient only has to apply this once and it should do the trick. The product can be sourced from about £4.25 (4g) and has been shown as effective as Lamisil cream (3).
Is there any way the imidazoles can fight back? Hidden amongst the imidazoles is ketoconazole (only available as Daktarin Intensiv®). Originally, ketoconazole was developed as an oral medication but has since been withdrawn over fears of its safety profile. However, topically it has been shown to be very safe and in one study it has been shown to be effective in the topical treatment of tinea pedis in just two weeks (4). It not going to win on price (around £5 retail) but there is one imidazole on the market in the UK which boasts a once-a-day application, meaning more convenience for the patient. The lesser known imidazole Bifonazole comes in a 20g tube and is about £1 cheaper than Lamisil at around £5. It’s sold as Canesten Once Daily Athletes Foot Cream®. So that may tip balance back in favour of the imidazoles.
However, here’s one last tip – always think generic. Branded products are generally more expensive than their unbranded counterparts. Firstly, clotrimazole 1% is available as a generic cream and very cheap too. It can be bought for about £2.15 for a 15g tube in podiatry wholesale. Put a mark-up on that and you are still much cheaper than the branded Canesten products at their retail price. Just when you thought the battle was won, there is a generic terbinafine cream, almost as cheap at just £2.75 for 15g! Even with the 50% mark up, it still makes financial and patient-friendly sense and should be one to place on your shelves.
Generic Anti-fungal Creams (clotrimazole and terbinafine)
Top Tips
Stock generic terbinafine & clotrimazole creams as they are the cheapest price for the medicines but offer the effectiveness of their branded, more expensive counterparts.
Always ensure you are cheaper by £1 than the local pharmacy on an antifungal product. That way patients have no reason to go down the road after treatment but instead always buy from you.
Buy in bulk. Ask your regular supplier for a bulk discount and the price should drop. For example, when I enquired at C&P Medical, a tube of clotrimazole cream (generic 15g) and they cost £2.15 each. Buy 50 tubes and the price drops to £1.95 a tube.
When buying in bulk, always ask for a good 2-year shelf life, that ensures your investment in the stock stays good and its doesn’t go out of date.
Also, remind patients who have had tinea that it is recurrent, so they will need to use an antifungal prophylactically. I generally recommend for 1 week in every 4 for patients with recurrent infection to use terbinafine cream. Consequently, patients need to buy some from you to keep their own stock at home.
Topical Antifungals use with children, during pregnancy and breast feeding
Terbinafine products are not recommended in the under-16’s as there is insufficient data on their use, whilst the imidazoles are suitable for use in children – except ketoconazole.
For all antifungal products, they are not recommended during pregnancy or lactation, advise should be sought from the patient’s general practitioner before using. This is based purely on a lack of data rather than known issues and interactions.
The table below summarises the topical antifungal cream market in the UK and lists wholesale price and retail price. The prices below are the prices given by one Podiatry wholesaler (C & P Medical) as a rough comparison (prices correct at the time of writing).
Table comparing main anti-fungal creams in the UK
(Prices correct at the time of writing from C&P Medical Limited)
References
1. Hart R, Bell-Syer SEM, Crawford F, Torgerson DJ, Young P, Russell I. Systematic review of topical treatments for fungal infections of the skin and nails of the feet. Brit Med J. 1999;319(7202):79-82.
2. Bergstresser PR, Elewski B, Hanifin J, Lesher J, Savin R, Shupack J, et al. Topical terbinafine and clotrimazole in interdigital tinea pedis: a multicenter comparison of cure and relapse rates with 1- and 4-week treatment regimens. J Am Acad Dermatol. 1993;28(4):648-51.
3. Korting HC, Kiencke P, Nelles S, Rychlik R. Comparable efficacy and safety of various topical formulations of terbinafine in tinea pedis irrespective of the treatment regimen: results of a meta-analysis. American journal of clinical dermatology. 2007;8(6):357-64.
4. Gobbato AAM, Gobbato C, Moreno RA, Antunes NJ, De Nucci G. Dapaconazole versus ketoconazole in the treatment of interdigital tinea pedis. Int J Clin Pharmacol Ther. 2018;56(1):31-3.