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

Treatment of Tinea Pedis

First-Line Topical Treatment

Topical terbinafine 1% cream applied twice daily for 1 week is the most effective first-line treatment for interdigital tinea pedis, achieving superior mycological cure rates (93.5%) compared to 4 weeks of clotrimazole (73.1%). 1, 2

Topical Terbinafine Regimens

• For interdigital tinea pedis (between the toes): Apply terbinafine 1% cream twice daily for 1 week 1, 3, 4
• For plantar tinea pedis (bottom or sides of foot): Apply terbinafine 1% cream twice daily for 2 weeks 3
• Terbinafine's fungicidal mechanism allows for these shorter treatment durations compared to fungistatic azoles 4, 5
• A single-dose terbinafine 1% film-forming solution achieves 63% effective treatment at 6 weeks with only one application, offering a highly convenient alternative 6

Alternative Topical Agents

• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves 60% cure at end of treatment and 85% cure two weeks post-treatment 1, 7
• Clotrimazole 1% cream applied twice daily for 4 weeks is less effective than terbinafine but widely available over-the-counter 1, 2

Oral Therapy for Severe or Resistant Cases

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

Oral Terbinafine (First-Line Systemic)

• Terbinafine 250 mg once daily for 1-2 weeks provides similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution 1, 7
• Terbinafine has fungicidal action with >70% oral absorption unaffected by food intake 1
• Preferred for diabetic patients due to lower risk of drug interactions and hypoglycemia 1
• Monitor for rare but serious adverse events including neutropenia and liver failure, particularly in patients with preexisting conditions 7

Alternative Oral Agents

• Itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1, 7
• Pulse dosing of itraconazole 200-400 mg per day for 1 week per month is an alternative regimen 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 (30-40% cure rates) and longer treatment duration 8, 1

Prevention Strategies

Comprehensive prevention measures are essential to reduce recurrence rates from 8.5% to 2.1%. 1

Personal Hygiene Measures

• Apply foot powder after bathing 1, 7
• Thoroughly dry between toes after showering 1, 7
• Change socks daily and wear cotton, absorbent socks 1
• Keep nails as short as possible 1
• Cover active foot lesions with socks before wearing underwear to prevent spread to groin area 1, 7

Footwear Management

• Clean athletic footwear periodically 1, 7
• Wear protective footwear in public bathing facilities, gyms, and hotel rooms 1
• Discard old, moldy footwear when possible, or place naphthalene mothballs in shoes and seal in plastic bag for minimum 3 days 1
• Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) inside shoes, or spray terbinafine solution into shoes periodically 1

Household and Environmental Control

• Treat all infected family members simultaneously to prevent reinfection 1, 7
• Avoid sharing toenail clippers with family members 1
• Address contaminated footwear as a source of reinfection 1

Special Populations and Considerations

Athletes

• Require minimum 72 hours of topical or systemic 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 and discourage barefoot walking in locker rooms until treatment initiated 1

Risk Factors

• Swimming, running, warm humid environments 1, 7
• Male gender, obesity, and diabetes 1, 7
• Up to one-third of diabetics have onychomycosis, which significantly predicts foot ulcer development 1

Common Pitfalls to Avoid

• Failing to examine for concomitant infections: Dermatophyte infections commonly occur at multiple body sites simultaneously, with 25% of pediatric onychomycosis cases having concomitant dermatophytosis at other locations 1
• Inadequate treatment duration: Ensure patients complete the full course even if symptoms improve earlier 4, 2
• Neglecting environmental sources: Shoes can contain large numbers of infective fungal elements causing reinfection 1
• Not treating family members: Simultaneous treatment of all infected household members is essential 1, 7