What is the recommended treatment for Tinea pedis (athlete's foot)?

Treatment of Tinea Pedis (Athlete's Foot)

Topical terbinafine 1% cream applied twice daily for 1 week is the most effective first-line treatment for tinea pedis, achieving superior cure rates compared to longer courses of other antifungal agents. 1, 2

First-Line Treatment Options

• For interdigital tinea pedis (between the toes), apply terbinafine 1% cream twice daily for 1 week 1, 2
• For tinea pedis on the bottom or sides of the foot, apply terbinafine 1% cream twice daily for 2 weeks 2
• Terbinafine offers a fungicidal mode of action, resulting in higher cure rates and shorter treatment duration compared to fungistatic alternatives 3
• Clinical studies show terbinafine 1% cream applied twice daily for 1 week is significantly more effective than clotrimazole 1% cream applied twice daily for 4 weeks (89.7% vs 58.7% effective treatment rate) 4

Alternative Topical Options

• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves approximately 60% clinical and mycological cure at end of treatment, and 85% two weeks after treatment 5, 1
• Clotrimazole 1% cream applied twice daily for 4 weeks is less effective than terbinafine but is widely available over-the-counter 1, 4

Oral Therapy for Severe or Resistant Cases

• Oral terbinafine 250mg once daily for 1 week has similar efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 5, 1
• Oral terbinafine is well-tolerated in children, though potential adverse events include occasional isolated neutropenia and rare liver failure (typically in people with preexisting liver disease) 5
• Oral itraconazole 100mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have a slightly higher relapse rate 5, 1
• Oral therapy should be reserved for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients 1, 6

Prevention Measures

• Apply foot powder after bathing to reduce tinea pedis rates 5, 1
• Thoroughly dry between toes after showering 5, 1
• Change socks daily and periodically clean athletic footwear 5, 1
• Wear well-fitting, ventilated shoes 2
• To prevent spread to the groin area (tinea cruris), cover active foot lesions with socks before wearing underwear 5, 1

Clinical Considerations

• Risk factors include swimming, running (especially marathon running), warm humid environments, male gender, obesity, and diabetes 5, 1
• Causative organisms are predominantly Trichophyton rubrum and Trichophyton mentagrophytes 5, 6
• Diagnosis should be confirmed with potassium hydroxide (KOH) wet-mount examination of skin scrapings from the active border of the lesion 7, 6
• Treatment should continue for at least one week after clinical clearing of infection 7
• Failing to treat all infected family members simultaneously can result in reinfection 1
• Neglecting to address contaminated footwear as a source of reinfection can lead to recurrence 1

Treatment Algorithm

1. Mild to moderate tinea pedis:

   • First-line: Terbinafine 1% cream twice daily (1 week for interdigital, 2 weeks for plantar)
   • Alternative: Ciclopirox olamine 0.77% cream twice daily for 4 weeks

2. Severe, extensive, or resistant cases:

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

3. For all patients:

   • Implement prevention measures
   • Continue treatment until at least 1 week after clinical clearing
   • Address all potential sources of reinfection