What is the recommended treatment for athlete's foot?

Treatment of Athlete's Foot

The first-line treatment for athlete's foot (tinea pedis) is topical terbinafine 1% cream applied twice daily for 1 week for interdigital infections, and twice daily for 2 weeks for infections on the bottom or sides of the foot. 1, 2

First-Line Treatment Options

• Topical terbinafine 1% cream is the most effective first-line treatment, with significantly higher cure rates than placebo (89% vs 0% at 2-week follow-up) 1, 3
• Application instructions for terbinafine:
  • For infections between toes: apply twice daily (morning and night) for 1 week 2
  • For infections on bottom or sides of foot: apply twice daily for 2 weeks 2
• Alternative topical options include:
  • Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks (achieves ~60% cure at end of treatment, 85% two weeks after treatment) 4, 1
  • Miconazole or other azole creams applied twice daily for 4 weeks 5, 6

Oral Therapy for Severe or Resistant Cases

• Reserve oral therapy for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients 6, 7
• Oral terbinafine 250 mg once daily for 1 week has similar efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 4, 1
• Oral itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rate 4, 1

Prevention Measures

• Wear well-fitting, ventilated shoes and change shoes and socks at least once daily 2, 5
• Thoroughly dry feet, especially between toes, after showering 6, 8
• Apply foot powder after bathing to reduce tinea pedis rates 1, 8
• Avoid walking barefoot in communal areas like swimming pools, showers, and locker rooms 4
• Cover active foot lesions with socks before wearing underwear to prevent spread to the groin area 6

Special Considerations

• Risk factors include swimming, running, warm humid environments, male gender, obesity, and diabetes 4, 6
• Treat all infected family members simultaneously to prevent reinfection 6
• Address contaminated footwear as a potential source of reinfection 6, 8
• If lesions persist despite appropriate treatment, consider alternative diagnoses or resistant infection 7
• Untreated infections may persist, progress, and spread to other body parts or other people 7, 9

Clinical Presentation and Diagnosis

• Tinea pedis presents as fine scaly or vesiculopustular eruptions, often itchy, commonly affecting spaces between toes 4, 6
• Three main clinical forms: interdigital (most common), hyperkeratotic (moccasin-type), and vesiculobullous (inflammatory) 7
• Diagnosis can be confirmed with KOH wet-mount examination of skin scrapings from the active border of the lesion 7

Treatment Algorithm

1. For uncomplicated interdigital tinea pedis: topical terbinafine 1% cream twice daily for 1 week 1, 2
2. For tinea pedis on bottom or sides of foot: topical terbinafine 1% cream twice daily for 2 weeks 1, 2
3. If no improvement after appropriate topical therapy, consider:
   • Switching to ciclopirox olamine 0.77% cream/gel twice daily for 4 weeks 4, 1
   • Oral terbinafine 250 mg once daily for 1 week for faster resolution 4, 1
4. For severe, extensive, or resistant cases: oral terbinafine 250 mg daily for 1 week or oral itraconazole 100 mg daily for 2 weeks 4, 6