Treatment for Fungal Infection Between the Toes with Cracking Skin
For fungal infection causing cracking skin between the toes (interdigital tinea pedis), start with topical allylamine antifungals (terbinafine or butenafine) applied once or twice daily for 2-4 weeks, as these achieve cure rates of approximately 70-80% and are superior to azole antifungals. 1
First-Line Topical Treatment Approach
Topical allylamines are the preferred initial therapy for skin fungal infections between the toes based on their superior efficacy compared to other topical agents 1:
- Terbinafine cream applied once or twice daily for 2-4 weeks achieves treatment failure rates of only 33% (meaning 67% cure rate) 1
- Butenafine shows similar efficacy with treatment failure rate of 33% 1
- These agents outperform azole antifungals, with meta-analysis showing allylamines reduce treatment failure by 37% compared to azoles (RR 0.63) 1
Alternative topical options if allylamines are unavailable or not tolerated 1:
- Azole antifungals (clotrimazole, miconazole) - treatment failure rate of 30% 1
- Ciclopiroxolamine - treatment failure rate of 27% 1
- Tolnaftate - treatment failure rate of 19% 1
When to Escalate to Oral Therapy
Consider oral antifungals if 2, 3:
- Topical treatment fails after 4 weeks
- Infection is severe or extensive
- Infection is chronic or recurring
- Patient has concurrent nail involvement
Oral treatment options for skin infections 2:
- Terbinafine 250 mg daily for 1-2 weeks - most effective for dermatophyte infections 2
- Itraconazole 100 mg daily for 2 weeks OR 200 mg daily for 7 days 2
- Fluconazole 150 mg once weekly as pulse dosing 2
Critical Management Points
Before starting treatment 4:
- Confirm fungal infection with microscopy and culture when possible, as clinical diagnosis alone leads to frequent treatment failure 4
- The cracking skin between toes is typically interdigital tinea pedis caused by dermatophytes, most commonly Trichophyton rubrum 5
Adjunctive measures to prevent recurrence 6:
- Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) to feet and inside shoes 6
- Wear cotton, absorbent socks 6
- Use protective footwear in public bathing facilities and gyms 6
- Treat all infected family members simultaneously 6
- Consider discarding old footwear or treating shoes with antifungal spray 6
Common Pitfalls to Avoid
- Do not use topical therapy designed for nail infections (amorolfine lacquer, ciclopirox lacquer) for skin infections between toes - these are formulated specifically for nail penetration and are not appropriate for skin infections 6
- Do not assume treatment failure means resistant infection - poor compliance and reinfection from contaminated footwear are more common causes 6
- Do not use terbinafine orally for yeast infections - it has poor activity against Candida species; use fluconazole or itraconazole instead 6, 5