What is the treatment for tinea pedis?

Treatment of Tinea Pedis

For tinea pedis, topical terbinafine 1% cream applied once daily for 1-2 weeks is the first-line treatment due to its superior efficacy and shorter treatment duration compared to other topical agents. 1

First-Line Treatment Options

Topical Treatments (for localized infection)

• Terbinafine 1% cream: Apply once daily for 1-2 weeks

  • Achieves mycological cure rates of 84.2% compared to 23.3% for placebo 1
  • Significantly superior to 4-week course of clotrimazole with higher cure rates (93.5% vs 73.1%) 2
  • Fungicidal action allows for shorter treatment duration 3

• Alternative topical options:

  • Ciclopirox olamine 0.77% cream/gel: Apply twice daily for 4 weeks (clinical and mycological cure rates ~85% two weeks after treatment) 1
  • Clotrimazole 1% cream: Apply twice daily for 2-4 weeks 1
  • Miconazole 2% cream: Apply twice daily for 2-4 weeks 1
  • Butenafine: Apply as directed 1

Second-Line/Severe Infection Treatment

Oral Antifungal Therapy (for severe, extensive, or resistant cases)

Indicated for:

• Hyperkeratotic tinea pedis unresponsive to topical therapy 4
• Failed topical treatment 5
• Extensive infection 5
• Immunocompromised patients 5
• Concomitant onychomycosis 5

Oral options:

1. Terbinafine: 250 mg once daily for 1 week 1

   • Similar efficacy to 4 weeks of clotrimazole but with faster clinical resolution

2. Itraconazole: 100 mg once daily for 2 weeks 1

   • 87% mycological cure rate after 15 days of treatment

3. Griseofulvin:

   • Adults: 0.5 g daily (can be divided as 125 mg four times daily, 250 mg twice daily, or 500 mg once daily) 6
   • Children (>2 years): 10 mg/kg daily 6
   • Treatment duration for tinea pedis: 4-8 weeks 6

Treatment Algorithm

1. Confirm diagnosis before initiating treatment:

   • Direct microscopic examination with KOH preparation
   • Fungal culture when necessary
   • Identify active border of lesion for sampling 1, 5

2. For localized, uncomplicated tinea pedis:

   • Start with terbinafine 1% cream once daily for 1-2 weeks 1, 3

3. For severe or extensive tinea pedis:

   • Consider oral terbinafine 250 mg daily for 1 week 1
   • Or itraconazole 100 mg daily for 2 weeks 1

4. For hyperkeratotic (moccasin-type) tinea pedis:

   • Consider combination of topical and oral antifungals 4

5. For interdigital tinea pedis with erosion/contact dermatitis:

   • Start with combination of topical corticosteroid and oral antifungal
   • Switch to topical antifungal after complications resolve 4

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
• Apply antifungal powders containing miconazole or clotrimazole to shoes and between toes 1
• Avoid sharing towels and personal items 1
• Consider examining and treating all household members 1

Important Clinical Pearls

• Continue treatment for at least one week after clinical resolution 1, 7
• Treatment endpoint should be mycological cure, not just clinical improvement 1
• Clinical improvement typically expected within 1-2 weeks 1
• Concomitant use of appropriate topical agents is usually required, particularly for tinea pedis 6
• In some forms of tinea pedis, yeasts and bacteria may be involved alongside dermatophytes - griseofulvin will not eradicate these associated infections 6
• Untreated lesions may persist and progress 5
• Combined therapy with topical and oral antifungals may increase cure rates in resistant cases 5

Caution

• Griseofulvin is contraindicated in lupus erythematosus, porphyria, and severe liver disease 1
• Terbinafine can rarely cause serious adverse reactions including Stevens-Johnson syndrome and hepatic toxicity 1
• Oil-based creams may weaken latex condoms and diaphragms 1
• Unnecessary use of OTC preparations can delay proper treatment 1
• Avoid combination antifungal/steroid agents for long-term use due to potential for atrophy and other steroid-associated complications 7