What is the best treatment for athlete's foot?

Treatment of Athlete's Foot

Topical terbinafine 1% cream applied twice daily for 1-2 weeks is the first-line treatment for athlete's foot due to its superior efficacy and shorter treatment duration compared to other antifungal agents. 1

First-Line Treatment Options

Topical Antifungals

• Terbinafine 1% cream:

  • Apply twice daily (morning and night) 2
  • For infections between toes only: use for 1 week
  • For infections on bottom or sides of foot: use for 2 weeks
  • Achieves 93.5% mycological cure rate after just 1 week 1

• Ciclopirox olamine 0.77% cream/gel:

  • Alternative first-line option
  • Apply for 4 weeks
  • ~60% clinical and mycological cure at end of treatment, increasing to 85% cure two weeks post-treatment 1

• Tolnaftate:

  • Apply thin layer twice daily (morning and night) 3
  • Continue for 4 weeks
  • Less effective than terbinafine but still useful for mild cases

Treatment Algorithm

1. Assess severity and location:

   • Mild to moderate infection between toes → Terbinafine 1% cream for 1 week
   • Infection on bottom or sides of foot → Terbinafine 1% cream for 2 weeks
   • Widespread or severe infection → Consider second-line therapy

2. Monitor response:

   • If no clinical improvement after 4 weeks of appropriate treatment, switch to second-line therapy 1
   • If clinical improvement but positive mycology, continue current therapy for 2-4 more weeks 1

3. Second-line options (for treatment failures or severe cases):

   • Oral itraconazole 100 mg daily for 4 weeks 1
   • Oral terbinafine 250 mg daily (provides faster clinical resolution than topical treatments) 1

Special Considerations

• Diabetic patients:

  • Require more aggressive treatment and careful monitoring
  • Higher risk of complications and secondary bacterial infections 1
  • Lower threshold for oral therapy

• Prevention of recurrence:

  • Keep feet dry, especially between toes
  • Wear well-fitting, ventilated shoes
  • Change socks at least once daily 2
  • Apply antifungal powders to shoes and feet
  • Thorough drying between toes can reduce recurrence rates from 8.5% to 2.1% 1

Common Pitfalls

1. Inadequate treatment duration:

   • Stopping treatment too early once symptoms improve
   • Continue for full recommended course even if symptoms resolve

2. Neglecting environmental factors:

   • Failure to change socks and shoes regularly
   • Not treating all infected family members simultaneously 1

3. Misdiagnosis:

   • Contact dermatitis can mimic athlete's foot 4
   • Consider alternative diagnoses if standard treatment fails

4. Overlooking secondary bacterial infection:

   • Watch for increasing pain, swelling, warmth, or discharge 5
   • May require antibacterial treatment in addition to antifungal therapy

Terbinafine has demonstrated superior efficacy in clinical trials, with one study showing it was significantly more effective than placebo at the end of therapy (78% vs 0%) and at 2-week follow-up (89% vs 0%) 6. This makes it the optimal first choice for treating athlete's foot, with other agents serving as alternatives based on individual response or contraindications.