What is the treatment for painful and smelly toes?

Treatment of Painful and Smelly Toes

For painful and smelly toes suggestive of fungal infection (athlete's foot/tinea pedis), initiate oral terbinafine 250 mg daily for 2 weeks for skin infection, or 12-16 weeks if nails are involved, combined with aggressive hygiene measures and footwear decontamination. 1

Initial Assessment and Diagnosis

Before starting treatment, confirm the diagnosis:

• Obtain skin or nail specimens for microscopy and fungal culture to confirm dermatophyte infection before initiating systemic therapy 1
• Examine between the toes for maceration, scaling, and fissuring (interdigital type) and the soles/heels for dry, scaly skin (moccasin type) 2
• Assess for nail involvement by looking for thickened, discolored, or dystrophic nails, as this requires prolonged treatment 1
• Rule out bacterial superinfection (Pseudomonas causes green/black discoloration; Staphylococcus causes purulent drainage) 3

First-Line Pharmacologic Treatment

For Skin Infection Only (No Nail Involvement)

Oral terbinafine is superior to all alternatives for dermatophyte infections:

• Terbinafine 250 mg once daily for 2 weeks achieves 86% mycological cure rates for moccasin-type tinea pedis 4
• This is significantly more effective than griseofulvin (RR 2.26,95% CI 1.49-3.44) 2
• Terbinafine demonstrates superior efficacy compared to placebo (RR 24.54,95% CI 1.57-384.32) 2

Alternative if terbinafine is contraindicated:

• Itraconazole 200 mg daily for 2-4 weeks (less effective than terbinafine but still superior to placebo) 1, 2
• Fluconazole 150-450 mg weekly for 3-6 months (useful if patient cannot tolerate terbinafine or itraconazole) 1

For Nail Involvement (Onychomycosis)

If nails are affected, treatment duration must be extended:

• Terbinafine 250 mg daily for 12-16 weeks for toenails (6 weeks for fingernails if involved) 1
• Baseline liver function tests and complete blood count are recommended before starting therapy 1
• Monitor liver function in patients with pre-existing hepatic abnormalities or those on prolonged therapy 1
• Expected cure rates: 70-80% for toenails, 80-90% for fingernails 1

Alternative regimen:

• Itraconazole 400 mg daily for 1 week per month (pulse therapy): 3 pulses for toenails, 2 pulses for fingernails 1
• Take with food for optimal absorption 1

Adjunctive Topical Therapy

For localized skin infection or as adjunct to oral therapy:

• Terbinafine 1% cream applied twice daily for 1-2 weeks between the toes or once daily for 2 weeks on soles/sides of foot 5
• Topical therapy alone is inferior to systemic treatment except for very distal or superficial infections 1, 6
• Ciclopirox olamine 0.77% cream/gel twice daily for 4 weeks if fungal infection is confirmed 7

Critical Hygiene and Environmental Measures

These measures are essential to prevent treatment failure and reinfection:

Footwear Management

• Discard all old, moldy footwear if possible 1
• If discarding shoes is not feasible, decontaminate by placing naphthalene mothballs inside shoes, seal in plastic bag for minimum 3 days, then air out 1
• Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) inside shoes daily 1
• Alternatively, spray terbinafine solution into shoes periodically 1
• Change shoes daily and wear well-fitting, ventilated footwear 5, 8

Daily Foot Care

• Wash feet with soap and water, dry completely (especially between toes) before applying treatments 5
• Apply absorbent or antifungal powder to feet and inside shoes 1
• Wear cotton, absorbent socks and change at least once daily 1, 5
• Keep nails trimmed short and straight (not too short to avoid trauma) 1
• Always wear protective footwear in public areas (gyms, pools, hotel rooms, changing rooms) to prevent reinfection 1

Preventing Spread

• Do not share nail clippers, towels, or footwear with family members 1
• Treat all infected family members simultaneously to prevent cross-contamination 1
• Sanitize bathroom surfaces and shower floors regularly 8

Monitoring and Follow-Up

• Assess clinical response at 2-4 weeks for skin infections 4
• For nail infections, follow-up should extend at least 48-72 weeks from treatment initiation to allow complete nail regrowth and identify relapses 1
• If no improvement after 4 weeks of appropriate therapy, re-culture and consider alternative diagnoses or resistant organisms 1

Common Pitfalls to Avoid

Treatment failure often results from:

• Starting treatment without mycological confirmation (may be treating non-fungal conditions) 1
• Inadequate treatment duration, especially for nail infections (requires 12-16 weeks, not 2 weeks) 1
• Failure to address environmental reservoirs in footwear (shoes remain contaminated and cause reinfection) 1, 8
• Not treating all infected household members simultaneously 1
• Presence of dermatophytoma (dense fungal mass under nail) without surgical debridement makes medical therapy ineffective 1
• Confusing secondary bacterial infection (which requires antibiotics) with primary fungal infection 3

Special Considerations

Monitor for adverse effects:

• Terbinafine: headache, taste disturbance, gastrointestinal upset; can aggravate psoriasis or cause lupus-like syndrome 1
• Itraconazole: headache, gastrointestinal upset; contraindicated in heart failure 1
• Both require hepatic monitoring in at-risk patients 1

If bacterial superinfection is present:

• Topical antiseptics (octenidine) or antibiotics (nadifloxacin, gentamicin) for localized infection 3
• Oral ciprofloxacin for Pseudomonas infection 3

1, 7, 5, 3, 4, 2, 6, 8