What antifungal treatment is recommended for a patient with tinea pedis?

Antifungal Treatment for Tinea Pedis

For interdigital tinea pedis, topical terbinafine 1% cream applied twice daily for 1 week is the first-line treatment, offering superior efficacy to 4 weeks of other topical antifungals. 1, 2

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 compared to fungistatic alternatives 1, 3, 4:

• For interdigital tinea pedis (between toes): Apply twice daily for 1 week 1, 2
• For plantar tinea pedis (bottom or sides of foot): Apply twice daily for 2 weeks 2
• Achieves mycological cure rates of 93.5% at 4 weeks and effective treatment rates of 89.7%, significantly superior to clotrimazole (73.1% and 73.1% respectively) 3

Alternative topical options when terbinafine is unavailable or contraindicated 1:

• Ciclopirox olamine 0.77% cream/gel: Achieves approximately 60% clinical and mycological cure at end of treatment, increasing to 85% two weeks post-treatment 1
• Clotrimazole 1% cream: Applied twice daily for 4 weeks, though less effective than terbinafine; widely available over-the-counter 1, 3

Single-dose terbinafine 1% film-forming solution is an alternative for patients where compliance is a concern, achieving 63% effective treatment and 72% mycological cure at 6 weeks with a single application 5

Oral Therapy for Severe or Resistant Cases

Reserve oral antifungals for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients 1:

First-line oral therapy:

• Terbinafine 250 mg once daily for 1-2 weeks: Most effective oral option with fungicidal action and >70% oral absorption unaffected by food 1
• For extensive tinea pedis, extend treatment to 2 weeks 1

Alternative oral regimens 1:

• Itraconazole: 100 mg daily for 2 weeks, or pulse dosing at 200-400 mg daily for 1 week per month (slightly higher relapse rate than terbinafine) 1
• Fluconazole 150 mg once weekly: Less effective than terbinafine or 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; consider only when other drugs unavailable 1

Special Population Considerations

For diabetic patients: Terbinafine is preferred over itraconazole due to lower risk of drug interactions and hypoglycemia 1

For athletes: Require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered appropriately 1

For pediatric patients: Terbinafine is recommended, though specific dosing should be weight-based 1

Prevention Strategies to Prevent Recurrence

Environmental and hygiene measures are critical to prevent reinfection 1:

• Apply foot powder after bathing (reduces tinea pedis rates from 8.5% to 2.1%) 1
• Change socks daily and wear cotton, absorbent socks 1
• Thoroughly dry between toes after showering 1
• Wear protective footwear in public bathing facilities, gyms, and hotel rooms 1
• Discard old, moldy footwear or seal with naphthalene mothballs in plastic bag for minimum 3 days 1
• Apply antifungal powders (miconazole, clotrimazole, tolnaftate) inside shoes or spray terbinafine solution periodically 1

Critical Pitfalls to Avoid

Treat all infected family members simultaneously to prevent reinfection 1

Address contaminated footwear as a source of reinfection, as shoes can harbor large numbers of infective fungal elements 1

Cover active foot lesions with socks before wearing underwear to prevent spread to the groin area 1

Examine entire skin surface (hands, groin, body folds) when diagnosing tinea pedis, as dermatophyte infections commonly occur at multiple body sites simultaneously in 25% of cases 1