What is the recommended treatment for tinea pedis?

Treatment for Tinea Pedis

For tinea pedis (athlete's foot), topical terbinafine 1% cream applied twice daily for 1-2 weeks is the most effective first-line treatment, offering superior cure rates compared to longer courses of other antifungals. 1, 2, 3

First-Line Treatment Options

Topical Treatments

• Terbinafine 1% cream/solution:

  • Interdigital (between toes): Apply twice daily for 1 week 2, 3
  • On bottom or sides of foot: Apply twice daily for 2 weeks 2
  • Advantages: Fungicidal action, shorter treatment duration, higher cure rates (89-95%) 3, 4

• Ciclopirox olamine 0.77% cream/gel:

  • Apply twice daily for 4 weeks
  • Clinical and mycological cure rates of ~60% at end of treatment, 85% two weeks post-treatment 1

Oral Treatment (for severe or resistant cases)

• Oral terbinafine:
  • 250 mg once daily for 1 week
  • Similar efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 1, 5
  • Well-tolerated in adults and children, though rare side effects include isolated neutropenia and liver issues in those with preexisting liver disease 1

Treatment Algorithm

1. Mild to moderate tinea pedis (most cases):

   • Start with topical terbinafine 1% cream twice daily
   • Treat for 1 week if interdigital only
   • Treat for 2 weeks if involving bottom/sides of feet

2. If no improvement after 2 weeks or severe/extensive disease:

   • Consider oral terbinafine 250 mg daily for 1 week

3. For patients with contraindications to terbinafine:

   • Alternative topical options:
     • Ciclopirox olamine 0.77% cream/gel twice daily for 4 weeks
     • Clotrimazole 1% cream twice daily for 4 weeks (less effective than terbinafine) 3

Prevention Measures

• Dry feet thoroughly after bathing, especially between toes 1
• Use foot powder after bathing (shown to reduce T. pedis rates from 8.5% to 2.1%) 1
• Change socks daily 1
• Periodically clean athletic footwear 1
• Wear well-fitting, ventilated shoes 2

Special Considerations

• Risk factors: Swimming, running (especially marathon runners), warm/humid environments, male gender, obesity, and diabetes 1
• Common causative organisms: Trichophyton rubrum and Trichophyton mentagrophytes 1
• Treatment failure: Consider poor compliance, reinfection, or resistant organisms

Clinical Pearls

• Terbinafine's fungicidal (rather than fungistatic) action explains its superior efficacy with shorter treatment courses 6, 7
• One-week terbinafine treatment has been shown to be more effective than four weeks of clotrimazole in multiple studies 3, 4
• Patients should continue treatment for the full recommended duration even if symptoms improve quickly
• For patients with concurrent tinea cruris (jock itch), cover foot lesions with socks before wearing underwear to prevent spread 1