What is the treatment for tinea pedis?

Treatment of Tinea Pedis

For tinea pedis, first-line treatment is topical terbinafine 1% cream applied once daily for 1-2 weeks, which offers faster clinical resolution than other topical agents with mycological cure rates of 84.2% compared to 23.3% for placebo. 1

Treatment Algorithm

First-Line Therapy (Localized Infection)

• Topical antifungals:
  • Terbinafine 1% cream: Apply once daily for 1-2 weeks 1, 2
  • Ciclopirox olamine 0.77% cream/gel: Apply twice daily for 4 weeks (clinical and mycological cure rates ~60% at end of treatment and 85% two weeks after treatment) 1
  • Clotrimazole 1% cream or Miconazole 2% cream: Apply twice daily for 2-4 weeks 1
  • Butenafine or Naftifine 1%: Naftifine shows higher mycological cure rates than placebo (RR 2.38) 1

Second-Line Therapy (Severe/Extensive Disease)

• Oral antifungals:
  • Terbinafine: 250 mg once daily for 1 week (similar efficacy to 4 weeks of clotrimazole but faster resolution) 1
  • Itraconazole: 100 mg once daily for 2 weeks (87% mycological cure rate) 1
  • Griseofulvin: 0.5 g daily (125 mg four times a day, 250 mg twice a day, or 500 mg/day) for 4-8 weeks 3
    • For pediatric patients: 10 mg/kg daily 3

Clinical Presentation Types and Treatment Considerations

1. Interdigital tinea pedis:

   • Most common form
   • Topical antifungals are usually sufficient 4

2. Hyperkeratotic (moccasin-type) tinea pedis:

   • Consider combination of topical and oral antifungals 5, 6
   • Often resistant to topical therapy alone

3. Vesiculobullous (inflammatory) tinea pedis:

   • May benefit from antifungals with anti-inflammatory properties 7
   • In severe cases with bacterial superinfection, consider combination therapy addressing both fungal and bacterial components 6

Diagnostic Confirmation

• KOH preparation of skin scrapings is recommended as point-of-care testing 4
• Fungal culture or PCR may be used for confirmation in resistant cases 1
• Treatment can be initiated while awaiting confirmatory mycology if clinical signs are present 1

Duration of Treatment

• Continue treatment for at least one week after clinical resolution 1, 7
• The endpoint of treatment should be mycological cure, not just clinical improvement 1

Prevention and Hygiene Measures

• Apply foot powder after bathing (reduces infection rates from 8.5% to 2.1%) 1
• Thoroughly dry between toes after showering 1
• Change socks daily 1
• Periodically clean athletic footwear 1
• Consider applying antifungal powders to shoes 1
• Examine and treat all household members for anthropophilic infections 1

Important Considerations

• For interdigital tinea pedis with erosion or contact dermatitis, topical drugs may cause irritant dermatitis; consider starting with oral antifungals 5
• Concomitant use of appropriate topical agents is usually required, particularly in treatment of tinea pedis, as noted in the griseofulvin drug label 3
• In tinea pedis, yeasts and bacteria may be involved as well as dermatophytes; griseofulvin will not eradicate these associated bacterial or yeast infections 3
• Clinical relapse will occur if medication is not continued until the infecting organism is eradicated 3

Pitfalls to Avoid

• Inadequate treatment duration leading to recurrence
• Failure to address predisposing factors (moisture, occlusive footwear)
• Misdiagnosis - the accuracy of clinical diagnosis of tinea pedis is low 4
• Unnecessary or inappropriate use of OTC preparations can delay proper treatment 1
• Oil-based creams may weaken latex condoms and diaphragms 1