Asymptomatic Light-Colored Peeling Skin on Bilateral Feet
This presentation is most consistent with tinea pedis (athlete's foot), specifically the squamous hyperkeratotic or "moccasin" type, which characteristically presents with light-colored scaling and peeling skin on the soles and margins of the feet without symptoms. 1, 2
Clinical Assessment
The key diagnostic features to evaluate include:
- Distribution pattern: Squamous hyperkeratotic tinea pedis typically affects the soles, heels, and lateral margins of the feet bilaterally, appearing as fine scaling or peeling with lighter-colored skin 2
- Interdigital spaces: Examine carefully for fissuring, scaling, or maceration between toes, which serves as a portal for secondary bacterial infection and indicates active fungal infection 1, 3
- Presence of inflammation: The absence of erythema, warmth, tenderness, or pain distinguishes this from cellulitis or other inflammatory conditions 1
- Nail involvement: Check for dystrophic toenails, which commonly coexist with chronic tinea pedis 1
Diagnostic Confirmation
Obtain a KOH preparation or fungal culture from skin scrapings of the affected areas to confirm dermatophyte infection before initiating treatment. 4, 2 This is particularly important because the squamous hyperkeratotic form can be caused by Trichophyton rubrum or T. mentagrophytes 1, 2.
Treatment Approach
For Limited Disease (Margins Only)
Apply topical terbinafine 1% cream twice daily for 2 weeks to the bottom and sides of the feet, as this is superior to other topical agents for dermatophyte infections. 1, 5 The FDA-approved regimen specifically indicates twice-daily application for 2 weeks when treating the soles or sides of the foot 5.
For Extensive Involvement
The squamous hyperkeratotic form requires simultaneous topical and systemic antifungal therapy due to the thickness of the stratum corneum limiting topical penetration. 2 Oral terbinafine 250 mg once daily for 2 weeks provides similar mycological efficacy to longer courses of other agents with faster clinical resolution 1.
Adjunctive Measures
- Apply urea 10% cream three times daily to reduce hyperkeratosis and improve penetration of antifungal agents 1
- Ensure complete drying of feet after bathing, particularly between toes 1, 4
- Change socks daily and wear well-ventilated shoes 5
- Consider foot powder after bathing to maintain dryness and prevent recurrence 1
Alternative Diagnoses to Consider
While tinea pedis is most likely, other conditions can present similarly:
- Acral peeling skin syndrome: A rare autosomal recessive condition causing painless peeling limited to hands and feet, but this is congenital and lifelong 6, 7
- Pernio-like lesions: Can cause peeling of feet but typically follow other symptoms and resolve within 14 days 8
- Hyperkeratosis from mechanical stress: Common in epidermolysis bullosa but would have additional clinical features 1
Critical Pitfalls to Avoid
- Do not ignore interdigital spaces during examination, as untreated toe web infection serves as a reservoir for recurrence and can lead to secondary bacterial cellulitis 1, 3
- Do not rely solely on topical therapy for extensive squamous hyperkeratotic disease, as the thick stratum corneum prevents adequate drug penetration 2
- Do not assume all peeling skin is fungal—obtain confirmatory testing, especially if treatment fails 4, 2
- Address predisposing factors such as occlusive footwear, excessive moisture, and poor foot hygiene to prevent recurrence 1, 3
Prevention of Recurrence
Treat any underlying predisposing factors including proper foot hygiene, management of hyperhidrosis, and addressing any venous insufficiency or lymphedema. 1, 3 For patients with recurrent tinea pedis despite adequate treatment, consider prophylactic foot powder use, which has been shown to reduce recurrence rates from 8.5% to 2.1% over time 1.