What is the treatment for athlete's foot?

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, which provides superior efficacy compared to other topical antifungals. 1, 2

First-Line Topical Treatment

• Terbinafine 1% cream is the most effective topical agent, applied twice daily for 1 week for interdigital (between-toes) infections, achieving 66-89% cure rates 1, 2, 3
• For infections on the bottom or sides of the foot, extend terbinafine treatment to 2 weeks 2
• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves approximately 60% cure at end of treatment and 85% cure two weeks post-treatment 1, 4
• Clotrimazole 1% cream is less effective than terbinafine but widely available over-the-counter as an alternative option 1

When to Use Oral Therapy

Reserve oral antifungals for severe disease, failed topical therapy, concomitant nail infection (onychomycosis), or immunocompromised patients. 1, 5

Oral Treatment Options (in order of preference):

• Terbinafine 250 mg once daily for 1-2 weeks is the most effective oral treatment, providing faster clinical resolution than topical therapy 1, 5, 4
• Itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1, 5
• Pulse dosing of itraconazole 200-400 mg per day for 1 week per month is an alternative regimen 5
• Fluconazole 150 mg once weekly is less effective than both terbinafine and itraconazole but may be useful when other agents are contraindicated due to fewer drug interactions 1, 5

Essential Adjunctive Measures

These prevention strategies are critical to prevent recurrence and should be implemented alongside antifungal therapy:

• Apply foot powder after bathing, which reduces tinea pedis rates from 8.5% to 2.1% 1, 5
• Thoroughly dry between toes after showering 1, 4
• Change socks daily and clean athletic footwear periodically 1, 5, 4
• Wear well-fitting, ventilated shoes 2
• Cover active foot lesions with socks before wearing underwear to prevent spread to the groin area 1, 4

Critical Pitfalls to Avoid

• Do not treat feet in isolation: Examine for concomitant onychomycosis (nail infection), as this serves as a reservoir for reinfection and is present in up to one-third of diabetic patients 5, 4
• Check for infection at other body sites: Dermatophyte infections occur at multiple sites simultaneously in 25% of cases 1, 5
• Treat all infected family members simultaneously to prevent reinfection 1, 5, 4
• Address contaminated footwear as a source of reinfection 1, 5
• Before assuming treatment failure, consider poor compliance, inadequate drug penetration, bacterial superinfection, or reinfection from nails/footwear rather than drug resistance alone 5

Special Populations

• Diabetic patients: Prefer terbinafine over itraconazole due to lower risk of drug interactions and hypoglycemia 1
• Athletes: Require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered appropriately 1
• Children under 12 years: Consult a physician before treatment 2

When Treatment Fails

• Obtain fungal cultures after discontinuing antifungals for a few days to optimize specimen collection and verify treatment failure 5
• Switch to oral itraconazole if topical terbinafine fails 5
• Monitor liver function tests at baseline and during prolonged oral therapy 5
• Consider culture at end of treatment to confirm mycological clearance, as this is the definitive endpoint rather than clinical response alone 4