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

Treatment of Tinea Pedis

First-Line Topical Therapy

For uncomplicated tinea pedis, use topical terbinafine 1% cream applied twice daily for 1 week, which is superior to longer courses of other topical antifungals and achieves mycological cure rates exceeding 90%. 1, 2

Topical Treatment Options (in order of preference):

• Terbinafine 1% cream twice daily for 1 week is the most effective topical option, achieving 93.5% mycological cure and 89.7% effective treatment rates, significantly superior to 4 weeks of clotrimazole (73.1% and 58.7% respectively) 1, 3

  • The fungicidal action of terbinafine allows for dramatically shorter treatment duration compared to fungistatic azoles 4, 5
  • A single-dose film-forming solution formulation is also available and may improve compliance 5

• Ciclopirox olamine 0.77% cream/gel twice daily for 4 weeks is an alternative broad-spectrum option, achieving approximately 60% cure at end of treatment and 85% cure two weeks post-treatment 1, 2

  • This agent is effective against T. rubrum, T. mentagrophytes, and Epidermophyton floccosum 1

• Clotrimazole 1% cream twice daily for 4 weeks is less effective but widely available over-the-counter 2, 3

  • Requires longer treatment duration (4 weeks) with lower efficacy compared to terbinafine 3

Oral Therapy for Severe or Resistant Cases

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

Oral Treatment Options (in order of preference):

• Oral terbinafine 250 mg once daily for 1-2 weeks is the first-line systemic option 2, 6

  • Provides similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 1
  • Has fungicidal action allowing shorter treatment duration 2
  • Over 70% oral absorption unaffected by food 2
  • Caution: Monitor for rare but serious adverse events including isolated neutropenia and liver failure, particularly in patients with preexisting liver disease 1

• Oral itraconazole 100 mg daily for 2 weeks is an alternative with similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1, 2

  • Pulse dosing options include 200-400 mg per day for 1 week per month 2

• Oral 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 2

• Griseofulvin is NOT recommended as first-line therapy due to lower efficacy (57% cure rate vs 87% with itraconazole) and longer treatment duration (4-8 weeks) 6, 7

Prevention Strategies

Implement these measures to reduce recurrence rates from 8.5% to 2.1%: 1

• Apply foot powder after bathing daily 1, 6
• Thoroughly dry between toes after showering 1, 6
• Change socks daily 1, 6
• Periodically clean athletic footwear 1, 6
• Cover active foot lesions with socks before wearing underwear to prevent spread to groin (tinea cruris) 1, 6

Critical Pitfalls to Avoid

• Failing to treat all infected family members simultaneously results in reinfection 2, 6
• Neglecting contaminated footwear as a source of reinfection leads to recurrence 2, 6
• Stopping treatment based on clinical appearance alone rather than mycological cure increases relapse risk 6
• Not examining other body sites (hands, groin, body folds) misses concomitant infections present in 25% of cases 2

Special Populations

• Athletes require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered by gas-permeable dressing, underwrap, and stretch tape 6
• Diabetic patients should receive terbinafine over itraconazole due to lower risk of drug interactions and hypoglycemia 2
• Patients with obesity and diabetes have increased risk and warrant more aggressive treatment 1, 6

Treatment Duration Summary

• Topical terbinafine: 1 week 1, 2
• Topical azoles (clotrimazole): 4 weeks 8, 3
• Oral terbinafine: 1-2 weeks 2, 6
• Oral itraconazole: 2 weeks 1, 2