Treatment of Fungal Infection of the Feet
For interdigital tinea pedis (between the toes), apply topical terbinafine 1% cream twice daily for 1 week, which is superior to longer courses of other antifungals and achieves mycological cure rates exceeding 90%. 1, 2
Topical Therapy (First-Line for Most Cases)
Preferred Topical Agent
- Terbinafine 1% cream applied twice daily for 1 week is the most effective topical treatment, achieving 93.5% mycological cure rates and 89.7% effective treatment rates 2
- This regimen is significantly superior to clotrimazole 1% cream applied twice daily for 4 weeks (73.1% mycological cure, 58.7% effective treatment at 4 weeks) 2
- The fungicidal action of terbinafine allows for this dramatically shortened treatment duration compared to fungistatic azoles 3, 4
Alternative Topical Agents
- Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves approximately 60% clinical and mycological cure at end of treatment, increasing to 85% two weeks after treatment 1
- Clotrimazole 1% cream is less effective than terbinafine but widely available over-the-counter for mild cases 1
Oral Therapy (For Severe or Resistant Disease)
Reserve oral therapy for severe disease, failed topical therapy, concomitant nail involvement (onychomycosis), or immunocompromised patients. 1
Oral Treatment Options
- Terbinafine 250 mg once daily for 1 week provides similar efficacy to 4 weeks of topical clotrimazole with faster clinical resolution 1
- For moccasin-type tinea pedis (dry, hyperkeratotic plantar involvement), use terbinafine 250 mg daily for 2 weeks, which achieves 86% mycological cure 5
- Itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1
- Griseofulvin is no longer recommended as first-line due to lower efficacy, longer treatment duration (4-8 weeks), and greater drug interactions 6, 7
- When terbinafine is compared to griseofulvin, terbinafine is more than twice as effective (RR 2.26,95% CI 1.49-3.44) 8
Critical Prevention Measures to Prevent Recurrence
Failure to address contaminated footwear and treat all infected family members simultaneously will result in reinfection. 6, 1
Footwear Decontamination
- Discard old, moldy footwear when possible 6
- If discarding is not feasible, place naphthalene mothballs in shoes, seal in plastic bag for minimum 3 days, then air out 6
- Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) inside shoes periodically 6
- Spray terbinafine solution into shoes on periodic basis 6
Daily Hygiene Practices
- Thoroughly dry between toes after showering 1, 9
- Change socks daily and wear cotton, absorbent socks 6
- Clean athletic footwear periodically 1, 9
- Apply foot powder after bathing (reduces tinea pedis rates from 8.5% to 2.1%) 1
- Cover active foot lesions with socks before wearing underwear to prevent spread to groin 1, 9
Household Management
- Treat all infected family members simultaneously to prevent reinfection 6, 1
- Avoid sharing toenail clippers with family members 6
- Wear protective footwear in gyms, changing rooms, hotel rooms, and public bathing facilities where T. rubrum is commonly found 6
Common Pitfalls to Avoid
- Do not stop treatment based on clinical improvement alone—continue until mycological cure is confirmed, as clinical response does not guarantee eradication of fungal elements 9
- Do not neglect concomitant nail infections—onychomycosis serves as a reservoir for reinfection and requires separate, prolonged treatment 6
- Do not use topical therapy alone for moccasin-type tinea pedis—this hyperkeratotic plantar variant typically requires oral therapy 5
- Do not forget that yeasts and bacteria may coexist with dermatophytes in some forms of tinea pedis, and antifungal therapy will not eradicate these organisms 7