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

Treatment of Athlete's Foot (Tinea Pedis)

For uncomplicated athlete's foot, apply topical terbinafine 1% cream twice daily for 1 week for interdigital infections or 2 weeks for infections on the bottom or sides of the foot—this provides superior efficacy compared to longer courses of other topical agents. 1, 2, 3

Topical Therapy (First-Line Treatment)

Terbinafine 1% cream is the preferred topical agent based on superior efficacy data:

• Apply twice daily for 1 week for interdigital tinea pedis (between the toes) 1, 2, 3
• Apply twice daily for 2 weeks for plantar tinea pedis (bottom or sides of foot) 3
• Achieves 93.5% mycological cure rate and 89.7% effective treatment rate, significantly superior to clotrimazole 4
• Provides faster clinical resolution than other topical agents 1, 2

Alternative topical options if terbinafine is unavailable:

• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves 60% cure at end of treatment and 85% cure two weeks post-treatment, superior to clotrimazole 1, 2
• Clotrimazole 1% cream applied twice daily for 4 weeks is less effective but widely available over-the-counter 1, 2

Oral Therapy (For Severe or Resistant Cases)

Reserve systemic treatment for: severe disease, failed topical therapy, concomitant nail infection, or immunocompromised patients 5

Oral terbinafine 250 mg once daily for 1 week is the most effective systemic option:

• Provides similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 1, 2
• Fungicidal action allows shorter treatment duration 5
• Can be extended to 2 weeks for extensive disease 5
• Monitor for rare but serious adverse events: neutropenia and liver failure, particularly in patients with preexisting liver disease 1, 2

Alternative oral option:

• Itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1, 2

Prevention Strategies

Essential preventive measures to reduce recurrence and transmission:

• Thoroughly dry between toes after showering—moisture accumulation stimulates bacterial overgrowth that worsens infection 1, 2
• Change socks daily and wear well-fitting, ventilated shoes 1, 2, 3
• Apply foot powder after bathing—reduces tinea pedis rates from 8.5% to 2.1% 1, 5
• Clean athletic footwear periodically—contaminated footwear is a source of reinfection 1, 5
• Cover active foot lesions with socks before wearing underwear to prevent spread to groin (tinea cruris) 1, 2

Special Populations and Considerations

Athletes require specific management:

• Minimum 72 hours of antifungal therapy before return to contact sports 5
• Cover lesions with gas-permeable dressing, underwrap, and stretch tape 5
• Exclude from swimming pools and discourage barefoot walking in locker rooms until treatment initiated 5

Diabetic patients warrant special attention:

• Prefer terbinafine over itraconazole due to lower risk of drug interactions and hypoglycemia 5
• Up to one-third of diabetics have concomitant onychomycosis, which significantly predicts foot ulcer development 5

Risk factors to identify:

• Swimming, running, warm humid environments 1, 2, 5
• Male gender, obesity, diabetes 1, 2, 5

Common Pitfalls to Avoid

• Failing to treat all infected family members simultaneously results in reinfection 5
• Neglecting contaminated footwear as a source of reinfection leads to recurrence 5
• Examining only the feet—dermatophytes spread to other body sites (hands, groin, body folds) in 25% of cases; examine the entire skin surface 5
• Stopping treatment based on clinical improvement alone—mycological cure, not just clinical response, is the definitive endpoint 2