What is the recommended treatment for a 93-year-old patient with a mild athlete's foot (tinea pedis) infection?

Treatment for Mild Athlete's Foot in a 93-Year-Old Patient

For a 93-year-old patient with mild athlete's foot infection, topical terbinafine 1% cream applied twice daily for 1 week is the recommended first-line treatment due to its superior efficacy and short treatment duration. 1, 2

Treatment Algorithm

First-Line Therapy

1. Topical terbinafine 1% cream
   • Apply twice daily (morning and night) for 1 week if infection is between the toes
   • Apply twice daily for 2 weeks if infection involves the bottom or sides of the foot 2
   • Terbinafine has demonstrated superior efficacy with mycological cure rates of 93.5% compared to 73.1% for clotrimazole, even with a shorter treatment duration 3

Alternative Options

If terbinafine is not available or not tolerated:

1. Ciclopirox olamine 0.77% cream/gel

   • Apply twice daily for 4 weeks
   • Particularly effective for interdigital tinea pedis with maceration or secondary bacterial involvement 1, 4
   • Clinical and mycological cure rates of approximately 85% two weeks after treatment 1

2. Miconazole or other azole antifungals

   • Apply twice daily for 4 weeks 5
   • Less effective than terbinafine but still a viable option 3

Special Considerations for Elderly Patients

• Prefer topical over oral therapy in this 93-year-old patient to avoid systemic side effects and drug interactions
• Avoid oral terbinafine despite its efficacy, as it carries risks of neutropenia and liver toxicity, which are particularly concerning in the elderly 1
• Monitor for skin irritation as elderly skin is more sensitive and prone to adverse reactions
• Consider assistance with application if the patient has mobility or dexterity issues

Adjunctive Measures

• Keep feet clean and thoroughly dry, especially between toes 1, 6
• Use absorbent cotton socks and change daily 1
• Wear well-ventilated shoes 2
• Apply talcum or antifungal powder after bathing to keep feet dry 1, 6
• Clean footwear periodically 1

Follow-up and Monitoring

• Evaluate response after completing the treatment course
• If no improvement after the initial treatment period, consider:
  • Confirming diagnosis with KOH preparation or culture 7
  • Switching to an alternative topical agent
  • Extending treatment duration
  • Only consider oral therapy if topical treatments fail and the infection is severe 7

Common Pitfalls to Avoid

• Inadequate duration of treatment: Even if symptoms improve quickly, complete the full treatment course to prevent recurrence
• Neglecting foot hygiene: Treatment will be less effective without proper drying and hygiene measures
• Missing secondary bacterial infection: Look for increased inflammation, maceration, and odor which may indicate bacterial superinfection requiring additional treatment 4
• Assuming all foot rashes are fungal: Consider alternative diagnoses if treatment fails (eczema, psoriasis, contact dermatitis)

The evidence strongly supports topical terbinafine as the most effective treatment with the shortest duration, making it particularly suitable for elderly patients where medication adherence may be challenging 3, 8.