Treatment of Bromhidrosis (Foot Odor)
For stinky feet caused by bromhidrosis, start with topical antiperspirants containing aluminum chloride, combined with proper foot hygiene, antibacterial agents, and daily sock changes; if this fails, consider topical glycopyrrolate cream or botulinum toxin injections for refractory cases. 1, 2
Initial Conservative Management
The first-line approach focuses on reducing moisture and bacterial colonization:
- Apply topical aluminum chloride antiperspirants to the feet, particularly between the toes and on the soles, as these reduce sweat production that contributes to odor 3, 1
- Use antibacterial agents (soaps or topical antibiotics) to reduce bacterial decomposition of sweat, which is the primary source of malodor 1
- Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate in shoes and on feet if fungal infection (tinea pedis) is present, as this commonly coexists with foot odor 4
Hygiene and Footwear Modifications
These lifestyle measures are essential adjuncts to medical treatment:
- Dry feet thoroughly after bathing, especially between the toes, as moisture promotes bacterial growth 4
- Change to clean cotton socks daily to absorb moisture and reduce bacterial load 4
- Rotate footwear and avoid wearing the same shoes on consecutive days 4
- Discard old, contaminated footwear or decontaminate by placing naphthalene mothballs in shoes sealed in plastic bags for minimum 3 days 4
- Apply absorbent foot powder after bathing, which has been shown to reduce foot infections and associated odor 4
Advanced Medical Therapies for Refractory Cases
When conservative measures fail after 4-6 weeks:
- Topical 2% glycopyrronium bromide cream applied nightly has demonstrated significant improvement in bromhidrosis with minimal side effects in clinical studies 5
- Botulinum toxin A injections into the plantar surface provide consistent benefit by reducing sweat production, though repeated treatments every 4-6 months are required 3, 2
- Iontophoresis (electrical current therapy) can reduce plantar sweating in severe hyperhidrosis contributing to odor 3, 1
Treatment of Underlying Fungal Infection
If tinea pedis is contributing to foot odor:
- Topical terbinafine 1% cream applied once daily for 1 week is highly effective for athlete's foot 4
- Oral terbinafine 250 mg daily for 1-2 weeks for more extensive infections, with faster clinical resolution than topical therapy alone 4
- Ciclopirox olamine 0.77% cream or gel applied twice daily for 4 weeks achieves approximately 60% mycological cure 4
Important Clinical Considerations
Common pitfall: Many patients self-treat with inadequate hygiene measures alone without addressing the underlying hyperhidrosis. The combination of antiperspirants (to reduce sweat) plus antibacterial agents (to reduce bacterial decomposition) is more effective than either alone 1.
Key distinction: Bromhidrosis results from bacterial decomposition of apocrine sweat, not simply from poor hygiene. Histologic studies show that apocrine gland hyperactivity contributes more to bromhidrosis than bacterial factors alone, which is why reducing sweat production is critical 6.
Treatment escalation: Begin with topical antiperspirants and hygiene measures for 4-6 weeks. If inadequate response, add topical glycopyrrolate. Reserve botulinum toxin for severe, refractory cases due to cost and need for repeated injections 2, 5.