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

Treatment of Tinea Pedis

First-Line Treatment: Topical Terbinafine

For interdigital tinea pedis, apply topical terbinafine 1% cream twice daily for 1 week, which is the most effective first-line treatment and superior to longer courses of other antifungal agents. 1, 2

Topical Terbinafine Dosing by Location

• Between the toes (interdigital): Apply twice daily for 1 week 1, 2
• Bottom or sides of the foot (moccasin-type): Apply twice daily for 2 weeks 2
• Terbinafine's fungicidal action allows for these shorter treatment durations compared to fungistatic agents like azoles 3

Alternative Topical Agents

• Ciclopirox olamine 0.77% cream/gel: Achieves approximately 60% clinical and mycological cure at end of treatment, increasing to 85% two weeks after treatment 1
• Clotrimazole 1% cream: Less effective than terbinafine but widely available over-the-counter; requires twice daily application for 4 weeks 1, 3
• Other options include ketoconazole, tolnaftate, and amorolfine for 1-6 weeks 4

Oral Therapy for Severe or Resistant Cases

Reserve oral antifungal therapy for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients. 1, 4

Oral Treatment Options (in order of preference)

• Terbinafine 250 mg once daily for 1-2 weeks: First-line systemic treatment with over 70% oral absorption unaffected by food, fungicidal action, and higher efficacy against dermatophytes than itraconazole 1
• Itraconazole: Alternative dosing includes 100 mg daily for 2 weeks, or pulse dosing at 200-400 mg per day for 1 week per month, though it has slightly lower efficacy and potentially higher relapse rates than terbinafine 1
• Fluconazole 150 mg once weekly: Less effective than both terbinafine and itraconazole but useful when other agents are contraindicated due to fewer drug interactions 1
• Griseofulvin: Not recommended as first-line due to lower efficacy and longer treatment duration 1

Special Population Considerations

• 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

Prevention Strategies to Reduce Recurrence

Implement comprehensive prevention measures as tinea pedis has high recurrence rates due to environmental contamination and reinfection. 5, 1

Patient Education and Hygiene

• Apply foot powder after bathing, which can reduce tinea pedis rates from 8.5% to 2.1% 1
• Thoroughly dry between toes after showering 1
• Change socks daily and wear cotton, absorbent socks 5
• Clean athletic footwear periodically 1
• Always wear protective footwear in public bathing facilities, gyms, and hotel rooms 5

Footwear Management

• Discard old, moldy footwear when possible 5
• If discarding is not feasible, place naphthalene mothballs in shoes and seal in plastic bag for minimum 3 days to eliminate fungal elements 5
• Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate inside shoes 5
• Alternatively, spray terbinafine solution into shoes periodically 5

Preventing Spread

• Cover active foot lesions with socks before wearing underwear to prevent spread to groin area 1
• Treat all infected family members simultaneously to prevent reinfection 5, 1
• Avoid sharing toenail clippers with family members 5
• Keep nails as short as possible 5

Common Pitfalls to Avoid

• Inadequate treatment duration: Continue treatment for at least one week after clinical clearing of infection 6
• Ignoring concomitant onychomycosis: Up to one-third of diabetics have onychomycosis, which significantly predicts foot ulcer development and requires concurrent treatment 1
• Failing to address environmental sources: Shoes can contain large numbers of infective fungal elements that cause reinfection 5
• Not examining other body sites: Dermatophyte infections commonly occur at multiple body sites simultaneously, with concomitant infections confirmed in 25% of cases 1