What is the recommended treatment for athlete's foot (tinea pedis)?

Treatment of Athlete's Foot (Tinea Pedis)

For uncomplicated tinea pedis, topical terbinafine 1% cream applied twice daily for 1-2 weeks is the recommended first-line treatment, with a mycological cure rate of 93.5% after just one week of treatment. 1, 2, 3

Treatment Algorithm

First-Line Treatment Options:

1. Topical antifungals:

   • Terbinafine 1% cream: Apply twice daily
     • Between toes only: 1 week
     • On bottom or sides of foot: 2 weeks 2
   • Ciclopirox olamine 0.77% cream/gel: Apply twice daily for 4 weeks (60-85% cure rate) 1
   • Other azoles: Miconazole, clotrimazole - apply as directed for 4 weeks 1

2. For severe or resistant cases:

   • Oral terbinafine: 250 mg once daily for 1 week 1
   • Oral itraconazole: 100 mg daily for 2 weeks 1
   • Oral fluconazole: Alternative for those who cannot tolerate other oral agents 1

Type-Specific Treatment

• Interdigital/between toes: Topical terbinafine twice daily for 1 week 2
• Plantar/moccasin (bottom/sides of foot): Topical terbinafine twice daily for 2 weeks 2
• Vesicular: Topical treatment; consider oral therapy if severe
• Hyperkeratotic: May require longer treatment duration and possibly oral therapy 4

Evidence Strength

Terbinafine has demonstrated superior efficacy compared to other treatments:

• Terbinafine 1% cream for 1 week showed significantly better mycological cure rates (93.5%) than clotrimazole 1% cream for 4 weeks (73.1%) 3
• In a randomized controlled trial, terbinafine was significantly more effective than placebo (89% vs. 0% cure rate) 5

Prevention and Management of Recurrence

• Wear well-fitting, ventilated shoes and change shoes and socks at least once daily 1, 2
• Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate to shoes 1
• Thoroughly dry between toes after bathing 1
• Wear cotton, absorbent socks and change them daily 1
• Clean athletic footwear periodically 1
• Consider discarding heavily contaminated footwear or decontaminating with naphthalene mothballs in a sealed plastic bag for 3 days in severe cases 1

Common Pitfalls to Avoid

• Inadequate treatment duration: Even with fungicidal agents like terbinafine, insufficient treatment time can lead to recurrence 1
• Neglecting environmental factors: Contaminated footwear can cause reinfection 1
• Missing concomitant infections: Check for tinea infections elsewhere on the body 1
• Not treating family members: Consider treating all infected family members simultaneously to prevent reinfection 1
• Monitoring for side effects: When using oral antifungals, be aware of rare hepatotoxicity or neutropenia with terbinafine 1

Special Populations

• Athletes: Higher risk group; emphasize preventive measures including foot powder after bathing, which can reduce infection rates from 8.5% to 2.1% 1, 6
• Diabetics: Almost three times more likely to develop tinea pedis; require regular foot checks and may need more aggressive treatment 1

Terbinafine's superior efficacy, shorter treatment duration, and excellent safety profile make it the optimal choice for most cases of tinea pedis, with oral options reserved for severe or resistant cases.