What is the treatment for tinea pedis?

Treatment for Tinea Pedis

For tinea pedis (athlete's foot), topical terbinafine 1% cream applied once daily for 1 week is the most effective first-line treatment with mycological cure rates of approximately 84% compared to 23% for placebo. 1

First-Line Treatment Options

Topical Antifungals

• Terbinafine 1% cream:

  • Apply once daily for 1-2 weeks
  • Offers faster clinical resolution than other topical agents
  • Approved for children 12 years and older 2
  • Single application formulation has shown effective treatment rates of 66% 3

• Ciclopirox olamine 0.77% cream/gel:

  • Apply twice daily for 4 weeks
  • Achieves both clinical and mycological cure rates of ~60% at end of treatment and 85% two weeks after treatment
  • Superior to 1% clotrimazole cream 2

• Other effective topical options:

  • Clotrimazole 1% cream: Apply twice daily for 2-4 weeks
  • Miconazole 2% cream: Apply twice daily for 2 weeks
  • Butenafine: Apply twice daily for 2 weeks (only approved for adults) 2

Second-Line/Severe Infection Treatment

Oral Antifungals (for extensive or resistant cases)

• Terbinafine (oral):

  • 250 mg once daily for 1 week
  • Similar efficacy to 4 weeks of clotrimazole 1% cream but with faster clinical resolution
  • Well-tolerated in children with rare side effects including occasional isolated neutropenia and rare liver failure (typically in people with preexisting liver disease) 2

• Itraconazole:

  • 100 mg once daily for 2 weeks
  • Similar mycological efficacy to terbinafine but may have slightly higher relapse rate 2

• Griseofulvin:

  • 0.5 g daily for adults (10 mg/kg daily for children)
  • Treatment duration for tinea pedis: 4-8 weeks
  • Continue until the infecting organism is eradicated 4

Treatment Algorithm

1. Confirm diagnosis: Direct microscopic examination with KOH preparation or fungal culture 4

2. Assess severity:

   • Mild to moderate (localized): Use topical therapy
   • Severe, extensive, or resistant: Consider oral therapy

3. For mild to moderate cases:

   • Start with terbinafine 1% cream once daily for 1 week
   • If unavailable, use ciclopirox olamine 0.77% twice daily for 4 weeks

4. For severe or resistant cases:

   • Oral terbinafine 250 mg once daily for 1 week
   • Alternative: oral itraconazole 100 mg daily for 2 weeks

5. Continue treatment until mycological cure is achieved, not just clinical improvement 1

Prevention Measures

• Apply foot powder after bathing (reduces rates from 8.5% to 2.1%) 2
• Thoroughly dry between toes after showering 2
• Change socks daily 2
• Periodically clean athletic footwear 2
• For recurrent infections, consider applying antifungal powders inside shoes 1

Important Clinical Considerations

• Treatment should continue for at least one week after clinical resolution 1, 5
• Concomitant use of topical agents is usually required, particularly in treatment of tinea pedis 4
• In some forms of tinea pedis, yeasts and bacteria may be involved as well as dermatophytes - antifungals will not eradicate associated bacterial or yeast infections 4
• The presence of inflammation may necessitate an agent with anti-inflammatory properties 5
• Clinical improvement typically occurs within 1-2 weeks, but complete mycological cure takes longer 1

Common Pitfalls to Avoid

• Stopping treatment too early based only on clinical improvement rather than mycological cure
• Failing to address hygiene factors that contribute to reinfection
• Not treating family members or close contacts when appropriate
• Using unnecessary or inappropriate OTC preparations that may delay proper treatment 1
• Neglecting to address bacterial co-infections when present

Remember that tinea pedis is most commonly caused by Trichophyton rubrum and Trichophyton interdigitale, and is more prevalent in warm, humid environments, affecting men more than women 2, 6.