What is the treatment for Tinea pedis (athlete's foot)?

Treatment of Tinea Pedis

For uncomplicated tinea pedis, use topical terbinafine 1% cream applied twice daily for 1 week as first-line therapy, which achieves superior cure rates compared to longer courses of other topical antifungals. 1, 2

First-Line Topical Treatment

Terbinafine 1% cream is the preferred topical agent due to its fungicidal action against the causative organisms (T. rubrum and T. mentagrophytes), allowing for shorter treatment duration with superior efficacy. 1, 2

• Apply terbinafine 1% cream twice daily for 1 week - this achieves 93.5% mycological cure rates and 89.7% effective treatment rates, significantly superior to 4 weeks of clotrimazole therapy (73.1% and 58.7% respectively). 1, 3
• Single-dose terbinafine 1% film-forming solution is an alternative that achieves 63% effective treatment and 72% mycological cure at 6 weeks, with similar relapse rates to the 1-week cream regimen. 4
• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks is an effective alternative, achieving 60% cure at end of treatment and 85% cure two weeks post-treatment, superior to clotrimazole. 1, 2

Alternative Topical Options

• Clotrimazole 1% cream applied twice daily for 4 weeks is widely available over-the-counter but less effective than terbinafine, with only 73.1% mycological cure rates. 1, 3
• Butenafine applied twice daily for 2 weeks is an over-the-counter option approved only for adults. 1

Oral Therapy for Severe or Resistant Cases

Reserve oral antifungals for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients. 2

• Oral terbinafine 250 mg once daily for 1 week provides similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution; extend to 2 weeks for extensive disease. 1, 2
• Oral itraconazole 100 mg daily for 2 weeks has similar efficacy to oral terbinafine but may have slightly higher relapse rates. 1, 2
• Fluconazole 150 mg once weekly is less effective than terbinafine or itraconazole but may be useful when other agents are contraindicated due to fewer drug interactions. 2
• Griseofulvin requires 4-8 weeks of treatment and is not recommended as first-line therapy due to lower efficacy (57% cure rate) and longer duration. 5, 6

Special Population Considerations

• For diabetic patients, prefer terbinafine over itraconazole due to lower risk of drug interactions and hypoglycemia; up to one-third of diabetics have onychomycosis, which significantly predicts foot ulcer development. 2
• Athletes require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered by gas-permeable dressing, underwrap, and stretch tape; exclude from swimming pools and discourage barefoot walking in locker rooms until treatment initiated. 2
• Monitor for rare but serious adverse events with oral terbinafine, including isolated neutropenia and rare liver failure, particularly in patients with preexisting liver disease. 1, 5

Prevention Strategies

• Apply foot powder after bathing - reduces tinea pedis rates from 8.5% to 2.1%, primarily by reducing T. mentagrophytes from 5.3% to 0.5%. 1, 2
• Thoroughly dry between toes after showering, change socks daily, and periodically clean athletic footwear to prevent recurrence. 1, 2
• Cover active foot lesions with socks before wearing underwear to prevent spread to the groin area (tinea cruris). 1, 2
• Treat all infected family members simultaneously to prevent reinfection. 2
• Address contaminated footwear as a source of reinfection to prevent recurrence. 2

Common Pitfalls to Avoid

• Do not stop treatment based on clinical improvement alone - the definitive endpoint should be mycological cure, not just clinical response; consider follow-up with repeat mycology sampling at the end of treatment. 5
• Examine the entire skin surface when diagnosing tinea pedis, particularly hands, groin, and body folds, as dermatophytes spread to distant sites and concomitant infections occur in 25% of cases. 2
• Risk factors include swimming, running, warm humid environments, male gender, obesity, and diabetes - address these when counseling patients. 1, 2, 5