What are the next steps for treating tinea pedis that is not responsive to Lamisil (terbinafine)?

Management of Tinea Pedis Not Responsive to Terbinafine (Lamisil)

For tinea pedis not responsive to terbinafine, switch to itraconazole 100 mg daily for 2 weeks as the next therapeutic option, as it offers broader antimicrobial coverage against resistant dermatophytes and potential non-dermatophyte molds. 1, 2

Assessment of Treatment Failure

Before changing therapy, consider these potential reasons for treatment failure:

• Inadequate treatment duration: Ensure the full recommended course was completed
• Environmental factors: Contaminated footwear may cause reinfection
• Concomitant infections: Check for tinea cruris or other fungal infections
• Misdiagnosis: Confirm diagnosis with KOH preparation or fungal culture
• Non-dermatophyte infection: Consider possibility of Candida or mold infection

Next-Step Treatment Algorithm

1. Topical Antifungal Options

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

  • Achieves ~60% clinical and mycological cure at end of treatment
  • Increases to 85% cure two weeks post-treatment 1
  • Effective against broader spectrum of fungi including resistant strains

• Miconazole cream applied twice daily for 4 weeks 3

  • Pay special attention to spaces between toes
  • FDA-approved for tinea pedis with established efficacy

2. Oral Antifungal Options (for resistant or extensive cases)

• First choice: Itraconazole 100 mg daily for 2 weeks 1, 2

  • Broader spectrum than terbinafine
  • Active against resistant dermatophytes and some non-dermatophyte molds
  • Consider monitoring liver function for treatment durations longer than 1 month

• Alternative: Fluconazole 150-300 mg weekly for 2-4 weeks 2

  • Option for patients who cannot tolerate itraconazole
  • Less effective than itraconazole but better tolerated in some patients

3. Combination Therapy

• Consider combined topical and oral therapy 4
  • Apply ciclopirox cream twice daily + oral itraconazole
  • Provides antimicrobial synergy and improved fungicidal activity
  • Increases cure rates and helps suppress resistant mutants

Adjunctive Measures (Essential for Preventing Recurrence)

• Footwear management:

  • Wear well-fitting, ventilated shoes
  • Change shoes and socks at least once daily
  • Consider discarding heavily contaminated footwear or decontaminating with naphthalene mothballs in a sealed plastic bag for 3 days 2

• Hygiene measures:

  • Thoroughly dry between toes after bathing
  • Apply antifungal powders to shoes and feet
  • Wear cotton, absorbent socks and change daily

• Family treatment:

  • Examine and treat all infected family members simultaneously to prevent reinfection 2

Special Considerations

• Diabetic patients require more aggressive treatment and careful monitoring due to higher risk of complications and secondary bacterial infections 1

• Athletes may benefit from preventive measures including regular application of antifungal powders to shoes and feet 1

• Immunocompromised patients may require longer treatment courses and closer monitoring for treatment response

By following this structured approach, most cases of resistant tinea pedis can be effectively managed, reducing the risk of complications and recurrence.