What is the best medication for tinea pedis (athlete's foot)?

Best Medication for Athlete's Foot

Terbinafine is the most effective medication for athlete's foot (tinea pedis), with topical 1% cream applied twice daily for 1 week between the toes or 2 weeks on the bottom/sides of the foot being the first-line treatment option. 1, 2

Treatment Options Based on Clinical Presentation

Interdigital Tinea Pedis (Between the Toes)

• First-line: Terbinafine 1% cream twice daily for 1 week 1, 2
  • Offers superior mycological cure rates (72-89%) compared to placebo 3, 4
  • Faster clinical resolution than azole alternatives 1
  • FDA-approved for children 12 years and older 2

Plantar/Moccasin Type (Bottom or Sides of Foot)

• First-line: Terbinafine 1% cream twice daily for 2 weeks 2
• For severe or extensive cases: Consider oral terbinafine 250 mg daily for 1 week 1

Why Terbinafine Is Superior

1. Mechanism of Action: Fungicidal (kills fungi) rather than fungistatic (inhibits growth), leading to faster resolution and lower relapse rates 5

2. Efficacy:

   • Higher mycological cure rates (78-89%) compared to placebo and other antifungals 3
   • Faster clinical resolution than clotrimazole and other azoles 1
   • Lower relapse rates compared to itraconazole 1

3. Convenience:

   • Shorter treatment duration (1-2 weeks) compared to azoles (4 weeks) 1, 5
   • Once-daily dosing option for oral therapy 1
   • Film-forming solution available for single-dose application with 63% effective treatment rate 4

Alternative Options

• Ciclopirox olamine 0.77% cream/gel: Applied twice daily for 4 weeks

  • 60% clinical and mycological cure rates 1
  • Good option for patients who cannot tolerate terbinafine

• Azoles (e.g., clotrimazole 1%): Applied twice daily for 4 weeks

  • Less effective and requires longer treatment duration than terbinafine 1, 6

• Oral options for severe or resistant cases:

  • Terbinafine 250 mg daily for 1 week 1
  • Itraconazole 100 mg daily for 2 weeks or 200 mg daily for 1 week 1, 6

Important Considerations and Pitfalls

• Safety concerns with oral terbinafine: Monitor for rare but serious adverse effects:

  • Isolated neutropenia
  • Liver failure (particularly in patients with pre-existing liver disease) 1

• Prevention strategies to reduce recurrence:

  • Apply foot powder after bathing (reduces infection rates from 8.5% to 2.1%) 1
  • Thoroughly dry between toes after showering
  • Change socks daily
  • Clean athletic footwear periodically 1
  • Wear well-fitting, ventilated shoes 2

• Risk factors to address:

  • Obesity and diabetes increase susceptibility 1
  • Male gender (higher prevalence) 6
  • Communal environments (swimming pools, locker rooms) 6

• Diagnostic pitfalls: Clinical diagnosis alone has low accuracy; consider KOH examination of skin scrapings for confirmation in resistant cases 6

Special Populations

• Children under 12: Consult a doctor before using topical terbinafine 2
• Immunocompromised patients: May require oral therapy 6
• Patients with concomitant onychomycosis: Consider oral therapy 6

By following this treatment algorithm and addressing preventive measures, most cases of athlete's foot can be effectively treated with minimal risk of recurrence.