What cream is recommended for the treatment of foot mycosis (fungal infection)?

Treatment of Foot Mycosis (Tinea Pedis)

For foot mycosis (athlete's foot), terbinafine 1% cream applied twice daily for 1-2 weeks is the most effective topical treatment, with superior mycological cure rates compared to other antifungal creams. 1, 2

First-Line Topical Treatment Options

Terbinafine 1% Cream

• Application regimen: Apply twice daily (morning and night)
  • For infection between the toes only: Use for 1 week
  • For infection on bottom or sides of foot: Use for 2 weeks 2
• Efficacy:
  • Achieves mycological cure rates >80% 3
  • Significantly superior to clotrimazole (93.5% vs 73.1% mycological cure at 4 weeks) 4
  • Maintains effectiveness after treatment ends due to its fungicidal mechanism 5

Ciclopirox Olamine 0.77% Cream/Gel

• Application regimen: Apply twice daily for 4 weeks
• Efficacy:
  • ~60% clinical and mycological cure at end of treatment
  • 85% cure rate two weeks after treatment (vs. 16% for vehicle) 1, 6

Alternative Topical Treatments

Clotrimazole 1% Cream

• Application regimen: Apply twice daily for 4 weeks
• Efficacy: Less effective than terbinafine (73.1% vs 93.5% mycological cure) 4

Butenafine

• Application regimen: Apply twice daily for 2 weeks
• Note: Only approved for adults 1

Systemic Treatment (for Severe or Resistant Cases)

If topical treatment fails or for extensive/severe infections, consider oral therapy:

Terbinafine (Oral)

• Dosage: 250 mg daily
• Duration: 2-6 weeks depending on severity
• Efficacy: Superior to griseofulvin and comparable or superior to itraconazole 7
• Considerations:
  • First-line systemic treatment due to higher efficacy and lower relapse rates 1
  • Well-tolerated with minimal drug interactions 3

Itraconazole (Oral)

• Dosage: 200 mg daily or 400 mg daily as pulse therapy
• Duration: 1-2 weeks
• Efficacy: Effective but with higher relapse rates than terbinafine 1

Special Considerations

For Diabetic Patients

• Terbinafine is preferred over itraconazole due to lower risk of drug interactions and hypoglycemia 1
• Topical treatments may be appropriate for mild-to-moderate infections when risk of drug interaction is high

For Immunosuppressed Patients

• Terbinafine is preferred due to lower risk of interactions with antiretrovirals and other medications 1

For Prevention of Recurrence

• Thoroughly dry feet, especially between toes, after bathing
• Use foot powder after bathing (reduces rates of T. pedis from 8.5% to 2.1%) 1
• Change socks daily and clean athletic footwear periodically
• For those with recurrent infections, cover foot lesions with socks before wearing underwear to prevent spread to groin area 1

Treatment Algorithm

1. Confirm diagnosis through clinical examination (scaling, fissuring between toes or on soles)
2. Assess severity:
   • Mild to moderate (limited to skin, no nail involvement): Use topical terbinafine 1% cream
   • Severe, extensive, or resistant to topical therapy: Consider oral terbinafine
3. Monitor response after completion of treatment course
4. Implement preventive measures to avoid recurrence

Common Pitfalls to Avoid

• Inadequate treatment duration leading to recurrence
• Failure to treat all affected areas, including spaces between toes
• Neglecting preventive measures after successful treatment
• Not considering underlying conditions (diabetes, immunosuppression) that may affect treatment choice

Terbinafine's superior efficacy is due to its fungicidal (rather than fungistatic) mechanism of action, which explains why it continues to work even after treatment has ended and why shorter treatment durations are effective 5, 8.