What is the 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 first-line treatment for tinea pedis due to its high efficacy and convenient dosing regimen. 1, 2

First-Line Topical Treatment Options

• Terbinafine 1% cream should be applied twice daily for 1 week for interdigital tinea pedis (between the toes) and for 2 weeks for plantar tinea pedis (bottom or sides of the foot) 2
• Ciclopirox olamine 0.77% cream/gel is highly effective, achieving approximately 85% mycological cure two weeks after treatment, and is superior to clotrimazole 1% cream 3, 1
• Before applying any topical treatment, wash and thoroughly dry the affected area 2
• Treatment should continue for at least one week after clinical clearing of infection to prevent recurrence 4

Treatment Algorithm Based on Presentation

1. Interdigital (between toes) tinea pedis:

   • First-line: Terbinafine 1% cream twice daily for 1 week 1, 2
   • Alternative: Ciclopirox olamine 0.77% cream twice daily for 4 weeks 3

2. Plantar/moccasin-type (bottom/sides of foot) tinea pedis:

   • First-line: Terbinafine 1% cream twice daily for 2 weeks 2
   • Alternative: Ciclopirox olamine 0.77% cream twice daily for 4 weeks 3

3. Vesiculobullous (inflammatory) tinea pedis:

   • Consider oral therapy due to more severe presentation 5

Oral Therapy for Severe or Resistant Cases

• Oral therapy is indicated for severe disease, failed topical therapy, extensive infection, immunocompromised patients, or concomitant onychomycosis 6, 5
• Oral terbinafine 250 mg once daily for 1 week provides faster clinical resolution than topical treatments with similar efficacy to 4 weeks of clotrimazole 1% cream 3, 1
• Oral itraconazole 100 mg daily for 2 weeks is an alternative but may have a slightly higher relapse rate compared to terbinafine 3, 1

Prevention Measures

• Thoroughly dry between toes after bathing/showering 3
• Apply foot powder after bathing (reduces tinea pedis rates from 8.5% to 2.1%) 3, 1
• Change socks daily and clean athletic footwear periodically 3, 6
• Wear well-fitting, ventilated shoes 2
• To prevent spread to the groin area (tinea cruris), cover active foot lesions with socks before wearing underwear 3

Common Pitfalls and Caveats

• Clinical diagnosis alone is unreliable as tinea pedis has many mimics; confirm diagnosis with potassium hydroxide preparation or culture in uncertain cases 5, 7
• Failing to treat for the full recommended duration can lead to recurrence; treatment should continue for at least one week after clinical clearing 4
• Neglecting to address contaminated footwear as a source of reinfection can lead to recurrence 6
• Risk factors that should prompt more aggressive treatment include diabetes, obesity, and immunocompromised status 3, 1
• Single-dose terbinafine 1% film-forming solution has shown efficacy (63% effective treatment at 6 weeks) but has a 12.5% recurrence rate at 3 months 8

Efficacy Comparison

• Terbinafine cream has demonstrated 89% mycological and clinical cure rates at 2-week follow-up compared to 0% for placebo in chronic tinea pedis 9
• Ciclopirox olamine cream achieves approximately 60% clinical and mycological cure at end of treatment, increasing to 85% two weeks after treatment 3