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

Treatment of Tinea Pedis (Athlete's Foot)

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

First-Line Topical Treatment

• Terbinafine 1% cream twice daily for 1 week is the gold standard topical treatment, achieving 93.5% mycological cure rates and 89.7% effective treatment rates, significantly outperforming 4 weeks of clotrimazole (73.1% and 73.1% respectively) 1, 3
• The superior efficacy stems from terbinafine's fungicidal action against dermatophytes, allowing dramatically shorter treatment duration compared to fungistatic agents like azoles 1, 4
• A single-dose terbinafine 1% film-forming solution is now available, achieving 63% effective treatment rates with just one application, offering excellent compliance for patients who struggle with multi-day regimens 5

Alternative Topical Options

• Ciclopirox olamine 0.77% cream/gel achieves approximately 60% clinical and mycological cure at end of treatment, rising to 85% two weeks post-treatment, making it superior to clotrimazole but still less effective than terbinafine 1, 2
• Clotrimazole 1% cream remains widely available over-the-counter but requires twice-daily application for 4 weeks and demonstrates inferior efficacy (16% cure rate two weeks after treatment versus 85% for ciclopirox) 1, 2

Oral Therapy for Severe or Resistant Disease

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

First-Line Oral Agent

• Oral terbinafine 250 mg once daily for 1-2 weeks is the most effective systemic treatment, with over 70% oral absorption unaffected by food, fungicidal action, and faster clinical resolution than topical alternatives 1, 2
• For extensive tinea pedis, extend terbinafine to 2 weeks at 250 mg daily 1
• Terbinafine has lower minimum inhibitory concentrations against dermatophytes compared to azoles, translating to superior clinical efficacy 1

Alternative Oral Agents

• Itraconazole offers flexible dosing: 100 mg daily for 2 weeks, pulse dosing at 200-400 mg daily for 1 week per month, or 400 mg daily for 1 week 1
• Itraconazole has similar mycological efficacy to terbinafine but slightly higher relapse rates and is preferred for non-dermatophyte mold infections 1, 2
• Fluconazole 150 mg once weekly (pulse dosing) is less effective than both terbinafine and itraconazole but may be useful when other agents are contraindicated due to fewer cytochrome P450 interactions 1
• Griseofulvin is not recommended as first-line therapy due to lower efficacy and longer treatment duration (4-8 weeks per FDA labeling), but may be considered when other drugs are unavailable or contraindicated 1, 6

Special Population Considerations

Diabetic Patients

• Prefer terbinafine over itraconazole in diabetics due to lower risk of drug interactions and hypoglycemia 1
• Up to one-third of diabetics have onychomycosis, which significantly predicts foot ulcer development, warranting aggressive treatment of any foot dermatophyte infection 1

Athletes

• Require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered by gas-permeable dressing, underwrap, and stretch tape 1
• Exclude from swimming pools and discourage barefoot walking in locker rooms until treatment initiated 1

Prevention Strategies

• Applying foot powder after bathing reduces tinea pedis rates from 8.5% to 2.1% 1
• Thoroughly dry between toes after showering, change socks daily, and clean athletic footwear periodically 1, 2
• Cover active foot lesions with socks before wearing underwear to prevent spread to the groin area (tinea cruris) 1

Critical Pitfalls to Avoid

• Failing to treat all infected family members simultaneously results in reinfection 1
• Neglecting contaminated footwear as a reinfection source leads to recurrence—address this proactively 1
• Examine the entire skin surface (hands, groin, body folds) when diagnosing tinea pedis, as dermatophytes spread to multiple body sites in 25% of cases 1
• Concomitant use of topical agents is usually required with oral therapy, particularly for tinea pedis, and griseofulvin will not eradicate associated bacterial or yeast infections that may coexist 6