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 then the more expensive one after” in an NHS that has limited money to spend. Wider debate is needed about whether the inconvenience associated with such a policy for the 8% of patients who might have been cured if they had been given terbinafine in the first place outweighs the savings. Extrapolated on a national scale, the saving of £155 per cohort of 100 patients could save around £12.5m for the NHS as a whole, even if only a tenth of those with fungal infections of the foot sought medical care—money that arguably could be better spent.

One of the conclusions has to be that a pragmatic clinical trial is now necessary to test the model of azoles first then allylamine for treatment failures versus allylamines throughout. Finlay suggests that patients will simply not comply with four weeks’ treatment whereas they would with one week’s treatment, a hypothesis that is fully testable in a pragmatic trial. Such a trial would also answer the question of whether the 28% or so of people who do not respond to azoles initially will then respond to the allylamine or whether they represent a subset with resistant fungal species that fail to respond to anything.

Those working for the NHS have a duty not to accept automatically the most effective and expensive treatment but to question the evidence of gains and losses for competing strategies. Far from being confused by the evidence, patients and prescribers are now aware of exactly how much extra benefit they may receive from different treatment choices.