What is the treatment for tinea pedis?

Treatment of Tinea Pedis

For uncomplicated interdigital tinea pedis, apply topical terbinafine 1% cream twice daily for 1 week, which provides superior efficacy compared to longer courses of other topical agents. 1

First-Line Topical Therapy

Terbinafine 1% cream is the preferred topical agent due to its fungicidal action against dermatophytes, allowing for significantly shorter treatment duration than fungistatic alternatives. 1, 2

• Apply twice daily for 1 week for interdigital tinea pedis, achieving 66% effective cure rates and 93.5% mycological cure rates. 1, 3
• This regimen is significantly more effective than clotrimazole 1% cream applied twice daily for 4 weeks (89.7% vs 73.1% effective treatment at 6 weeks, P=0.002). 3
• The fungicidal mechanism enables shorter therapy compared to azoles, which require 4 weeks of twice-daily application. 2, 4

Alternative topical options when terbinafine is unavailable or contraindicated:

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

Oral Therapy for Severe or Resistant Disease

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

Terbinafine 250 mg once daily for 1-2 weeks is the first-line oral agent:

• Provides similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution. 1, 5
• Has fungicidal action with over 70% oral absorption unaffected by food intake. 1
• Superior efficacy against dermatophytes compared to itraconazole due to lower MIC. 1
• For diabetic patients, terbinafine is preferred over itraconazole due to lower risk of drug interactions and hypoglycemia. 1

Alternative oral agents:

• Itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rates. 1
• Pulse dosing options include 200-400 mg per day for 1 week per month. 1
• Fluconazole is less effective than both terbinafine and itraconazole for dermatophyte infections but may be useful when other agents are contraindicated due to fewer drug interactions. 1
• Griseofulvin is not recommended as first-line therapy due to lower efficacy (57% cure rate vs 87% with itraconazole) and longer treatment duration of 4-8 weeks. 1, 6

Critical Prevention Measures

Implement these strategies to prevent recurrence and reinfection:

• Treat all infected family members simultaneously to prevent reinfection. 1
• Address contaminated footwear as a source of reinfection by cleaning athletic shoes periodically. 1
• Apply foot powder after bathing, which reduces tinea pedis rates from 8.5% to 2.1%. 1
• Thoroughly dry between toes after showering and change socks daily. 1
• Cover active foot lesions with socks before wearing underwear to prevent spread to the groin area. 1

Special Populations and Considerations

For 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

Risk factors to address: swimming, running, warm humid environments, male gender, obesity, and diabetes. 1

Examine the entire skin surface (hands, groin, body folds) when diagnosing tinea pedis, as dermatophyte organisms can spread to distant sites via direct contact, with concomitant infections occurring in 25% of cases. 1

Monitor for rare but serious adverse events with oral terbinafine, including neutropenia and liver failure, particularly in patients with preexisting conditions. 7