What is the recommended medical management for athlete's foot in pediatric patients?

Medical Management of Athlete's Foot in Pediatrics

For pediatric patients with athlete's foot (tinea pedis), topical terbinafine 1% cream applied twice daily for 1 week for interdigital disease (or 2 weeks for plantar involvement) is the first-line treatment, as it provides superior efficacy with the shortest treatment duration. 1, 2, 3

First-Line Topical Treatment

Terbinafine 1% Cream (Preferred)

• Apply twice daily for 1 week for interdigital tinea pedis 1, 2, 3
• Apply twice daily for 2 weeks for plantar/moccasin-type disease 3
• FDA-approved for children 12 years and older 3
• Achieves faster clinical resolution than other topical agents and allows once-daily dosing with shorter treatment duration 1, 2
• Superior mycological cure rates compared to clotrimazole (approximately 78-89% vs. near zero for placebo) 4

Alternative Topical Agents

• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves approximately 60% clinical and mycological cure at end of treatment, increasing to 85% two weeks post-treatment 1, 2, 5
• Clotrimazole 1% cream applied twice daily for 4 weeks is less effective than terbinafine but widely available over-the-counter 1
• Miconazole cream applied twice daily for 4 weeks is another over-the-counter option 6

Oral Therapy for Severe or Resistant Cases

Reserve oral antifungals for extensive disease, failed topical therapy, concomitant nail involvement, or immunocompromised patients. 2, 7

Oral Terbinafine (First-Line Systemic)

• 250 mg once daily for 1-2 weeks (standard adult dosing; weight-based dosing for younger children) 1, 2, 7
• Similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 1
• Well-tolerated in children, though monitor for rare neutropenia and liver toxicity (especially with pre-existing liver disease) 1
• Over 70% oral absorption unaffected by food 2

Alternative Oral Agents

• Itraconazole 100 mg daily for 2 weeks or pulse dosing 200-400 mg daily for 1 week per month 1, 2, 7
• Similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1, 2
• Must be taken with food and acidic pH for optimal absorption 7
• Fluconazole 150 mg once weekly is less effective than both terbinafine and itraconazole but has fewer drug interactions 2
• Griseofulvin is not recommended as first-line due to lower efficacy and longer treatment duration 2, 8

Essential Adjunctive Measures

Prevention strategies are critical to reduce recurrence rates and should be implemented alongside pharmacologic treatment. 1, 2

Hygiene and Footwear Management

• Apply foot powder after bathing (reduces recurrence from 8.5% to 2.1%) 1, 2, 7
• Thoroughly dry between toes after showering 1, 2
• Change socks daily and wear absorbent cotton socks 1, 2
• Clean athletic footwear periodically or discard old moldy shoes 2
• Apply antifungal powders (miconazole, clotrimazole, tolnaftate) inside shoes or spray terbinafine solution periodically 2
• Wear well-fitting, ventilated shoes and avoid tight footwear 3, 6

Preventing Spread and Reinfection

• Cover active foot lesions with socks before wearing underwear to prevent spread to groin (tinea cruris) 1, 2
• Treat all infected family members simultaneously to prevent reinfection 2, 7
• Avoid sharing toenail clippers and keep nails short 2
• Wear protective footwear in communal showers, locker rooms, and public bathing facilities 2

Critical Considerations for Pediatric Athletes

Return 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 and discourage barefoot walking in locker rooms until treatment initiated 2

High-Risk Populations

• Athletes (especially swimmers and marathon runners) have documented infection rates up to 22% 1
• Warm, humid environments and male gender increase risk 1, 2
• Obesity and diabetes are additional risk factors 1

Common Pitfalls to Avoid

• Do not assume treatment failure is drug resistance alone—poor compliance, inadequate drug penetration, bacterial superinfection, or reinfection from nails/footwear are more common causes 7
• Do not treat feet in isolation—examine for concomitant onychomycosis (present in 25% of cases) and other body sites, as nail infection serves as a reservoir for reinfection 2, 7
• Do not neglect environmental sources—shoes contain large numbers of infective fungal elements and cause reinfection if not addressed 2
• Before switching therapy for apparent treatment failure, obtain fungal cultures (consider discontinuing antifungals briefly to optimize specimen collection) 7

Monitoring and Follow-Up

• Monitor liver function tests at baseline and during prolonged oral therapy, especially with itraconazole 7
• Follow up to ensure treatment effectiveness and consider culture at end of treatment to confirm mycological clearance 7
• Continue follow-up for up to 6 months to establish whether infection recurred 8