What is the recommended treatment for athlete's foot?

Treatment of Athlete's Foot (Tinea Pedis)

For athlete's foot, apply topical terbinafine 1% cream twice daily for 1 week for interdigital (between-the-toes) infections, or twice daily for 2 weeks for infections on the bottom or sides of the foot. 1, 2

First-Line Topical Treatment

Terbinafine 1% cream is the most effective topical treatment, recommended by the American Academy of Pediatrics as superior to other antifungal agents due to its shorter treatment duration and higher efficacy. 1

Application Instructions:

• For interdigital tinea pedis (between toes): Apply twice daily (morning and night) for 1 week 1, 2
• For plantar tinea pedis (bottom or sides of foot): Apply twice daily for 2 weeks 2
• Wash affected skin with soap and water and dry completely before applying 2
• Wash hands after each use 2

Alternative Topical Options:

• Ciclopirox olamine 0.77% cream/gel: Apply twice daily for 4 weeks, achieving approximately 60% cure at end of treatment and 85% two weeks post-treatment 3, 1
• Clotrimazole 1% cream: Less effective than terbinafine but widely available over-the-counter; requires longer treatment duration 1
• Naftifine ointment: Apply twice daily for 4 weeks 3

Oral Therapy for Severe or Resistant Cases

Reserve oral antifungals for severe disease, failed topical therapy, concomitant nail infection (onychomycosis), or immunocompromised patients. 1

Oral Treatment Options:

• Terbinafine 250 mg once daily for 1-2 weeks: First-line oral therapy with fungicidal action, superior efficacy against dermatophytes, and faster clinical resolution than topical treatments 1
• Itraconazole 100 mg daily for 2 weeks: Similar mycological efficacy to oral terbinafine but may have slightly higher relapse rate 1
• Fluconazole: Less effective than terbinafine or itraconazole; consider only when other agents are contraindicated or not tolerated 1

Essential Prevention Measures

Prevention is critical to avoid recurrence, as contaminated footwear and untreated family members commonly cause reinfection. 1

Daily Hygiene:

• Thoroughly dry between toes after showering 3, 1
• Change socks daily 3, 1
• Apply foot powder after bathing (reduces infection rates from 8.5% to 2.1%) 1

Footwear Management:

• Wear well-fitting, ventilated shoes 2
• Clean athletic footwear periodically 1
• Wear rubber-soled flip-flops or sandals in communal showers 3
• Avoid barefoot walking in locker rooms and public areas 3

Preventing Spread:

• Put on socks before underwear to prevent spread to groin area (tinea cruris) 3, 1
• Avoid skin-to-skin contact with infected individuals 1
• Do not share towels, shoes, or personal items 3, 1
• Treat all infected family members simultaneously to prevent reinfection 1

Special Populations and Considerations

Athletes:

• Require minimum 72 hours of antifungal therapy before return to contact sports 1
• Cover lesions with gas-permeable dressing followed by underwrap and stretch tape 1
• Exclude from swimming pools until treatment initiated 1

Diabetic Patients:

• Prefer terbinafine over itraconazole due to lower risk of drug interactions and hypoglycemia 1
• Up to one-third of diabetics have onychomycosis, which significantly predicts foot ulcer development 1
• Regular foot inspection is essential 3

Risk Factors to Address:

• Swimming, running, warm humid environments 1
• Male gender, obesity, diabetes 1
• Occlusive footwear and excessive sweating 3

Common Pitfalls to Avoid

• Stopping treatment too early: Complete the full course even if symptoms improve 1
• Ignoring contaminated footwear: Failure to address shoes as a source of reinfection leads to recurrence 1
• Not treating concomitant infections: Examine hands, groin, and body folds for secondary infection sites, as dermatophytes spread to multiple body locations in 25% of cases 1
• Treating uninfected ulcers with antibiotics: Do not use systemic or topical antibiotics for clinically uninfected foot ulcers 3

Follow-Up

The definitive endpoint for adequate treatment should be mycological cure, not just clinical response. 1 Consider repeat mycology sampling at the end of the standard treatment period if symptoms persist or recur. 1