What is a suitable topical medication for tinea pedis in a patient taking terbinafine (oral antifungal)?

Topical Treatment for Tinea Pedis in Patients Taking Oral Terbinafine

Ciclopirox olamine 0.77% cream or gel applied twice daily for 4 weeks is the recommended topical medication for tinea pedis in patients already taking oral terbinafine, as it provides superior clinical and mycological cure rates compared to other topical agents. 1

First-Line Topical Treatment Options

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

  • Provides superior efficacy against common tinea pedis pathogens (T. rubrum, T. mentagrophytes, E. floccosum) 1
  • Achieves approximately 60% clinical and mycological cure at end of treatment and 85% cure two weeks after treatment completion 1
  • Particularly beneficial when patient is already on oral terbinafine to provide a different mechanism of action 1

• Econazole nitrate cream: FDA-approved for topical treatment of tinea pedis caused by common dermatophytes 2

  • Can be used as an alternative when ciclopirox is not available

Alternative Topical Options

• Clotrimazole 1% cream: Apply twice daily for 4 weeks 1

  • Less effective than ciclopirox but still a viable option 1
  • May be used if ciclopirox is not tolerated or unavailable 1

• Butenafine: Apply twice daily for 2 weeks 1

  • A benzylamine derivative of clotrimazole
  • Only approved for adults 1

Treatment Considerations for Patients on Oral Terbinafine

When selecting a topical agent for a patient already taking oral terbinafine, consider:

• Different mechanism of action: Using a topical agent with a different mechanism than terbinafine (an allylamine) may provide complementary antifungal coverage 3

  • Ciclopirox (hydroxypyridone) works through a different mechanism than terbinafine 1
  • Azoles (econazole, clotrimazole) also work through different mechanisms 2, 4

• Treatment duration: Shorter courses may improve compliance

  • While oral terbinafine offers once-daily dosing and faster clinical resolution than topical treatments alone, combining with an effective topical agent may enhance outcomes 1

Efficacy Comparisons

• Studies comparing terbinafine 1% cream (not oral) to clotrimazole 1% cream show that terbinafine achieves higher mycological cure rates (93.5% vs 73.1%) when used topically 4
• Terbinafine 1% solution used for 1 week is at least as effective as clotrimazole 1% solution used for 4 weeks in treating tinea pedis 5, 6
• However, since the patient is already taking oral terbinafine, a different class of topical agent is preferred 3

Prevention Measures to Recommend

• Careful and thorough drying between toes after showers 1
• Daily changes of socks 1
• Periodic cleaning of athletic footwear 1
• Use of foot powder after bathing, which has been associated with decline in tinea pedis rates 1

Common Pitfalls and Caveats

• Avoid using topical terbinafine: Since the patient is already taking oral terbinafine, using the same agent topically provides no additional benefit and may increase risk of adverse effects 3
• Monitor for adverse reactions: Local skin reactions are common with topical antifungals (4-5% incidence) but are typically mild to moderate 5
• Complete the full course: Even if symptoms improve quickly, complete the full recommended course to prevent recurrence 7
• Consider underlying risk factors: Obesity and diabetes are additional risk factors for tinea pedis and may affect treatment response 1