What is the recommended treatment for a patient with Tinea pedis (athlete's foot)?

Treatment of Tinea Pedis

For interdigital tinea pedis, apply topical terbinafine 1% cream twice daily for 1 week, which provides superior efficacy compared to 4 weeks of other topical antifungals and is the recommended first-line treatment. 1, 2, 3

First-Line Topical Treatment

Terbinafine 1% cream is the gold standard topical therapy:

• Apply twice daily for 1 week for interdigital tinea pedis (between the toes) 1, 2, 3
• For infections on the bottom or sides of the foot, extend treatment to 2 weeks of twice-daily application 3
• Achieves 93.5% mycological cure rate and 89.7% effective treatment rate, significantly superior to clotrimazole's 73.1% and 58.7% respectively 4
• The fungicidal action of terbinafine allows for these shorter treatment durations compared to fungistatic azoles 5, 6

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% two weeks post-treatment 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 2
• Failed topical therapy 2
• Concomitant onychomycosis 2
• Immunocompromised patients 2

Oral terbinafine is the preferred systemic agent:

• 250 mg once daily for 1 week for standard cases 1, 2
• Extend to 2 weeks for extensive disease 2
• Provides faster clinical resolution than topical clotrimazole despite similar mycological cure rates 1
• Has fungicidal action allowing shorter treatment duration 2

Alternative oral options:

• Itraconazole 100 mg daily for 2 weeks has similar efficacy to terbinafine but may have slightly higher relapse rates 1, 2
• Fluconazole is less effective than both terbinafine and itraconazole but may be useful when other agents are contraindicated due to fewer drug interactions 2

Critical Prevention Measures to Prevent Recurrence

Environmental and hygiene interventions are essential:

• Apply foot powder after bathing, which reduces tinea pedis rates from 8.5% to 2.1% 1, 2
• Thoroughly dry between toes after showering 1, 2
• Change socks daily, preferably cotton absorbent socks 2
• Clean athletic footwear periodically or discard old moldy footwear 2
• Apply antifungal powders (miconazole, clotrimazole, tolnaftate) inside shoes or spray terbinafine solution periodically 2
• Wear protective footwear in public bathing facilities, gyms, and hotel rooms 2

Prevent spread to other body sites:

• Cover active foot lesions with socks before wearing underwear to prevent spread to groin area 1, 2
• Treat all infected family members simultaneously to prevent reinfection 2
• Avoid sharing toenail clippers and keep nails short 2

Special Populations and Considerations

High-risk groups requiring particular attention:

• Swimmers and marathon runners (up to 22% infection rate) 1
• Patients with obesity and diabetes are at increased risk 1, 7
• For diabetic patients, prefer terbinafine over itraconazole due to lower risk of drug interactions and hypoglycemia 2

Athletes returning to sports:

• Require minimum 72 hours of antifungal therapy before return to contact sports 2
• Cover lesions with gas-permeable dressing followed by underwrap and stretch tape 2
• Exclude from swimming pools until treatment initiated 2

Common Pitfalls to Avoid

Failing to address these factors leads to treatment failure:

• Not treating all infected family members simultaneously results in reinfection 2
• Neglecting contaminated footwear as a source of reinfection causes recurrence 2
• Not examining for concomitant infections at other body sites (hands, groin, body folds) misses 25% of cases with multiple site involvement 2

Monitoring for adverse events with oral terbinafine:

• Watch for occasional isolated neutropenia 1
• Monitor for rare liver failure, particularly in patients with preexisting liver disease 1, 7