What are the treatment options for pediatric patients with smelly and itchy feet?

Treatment of Smelly and Itchy Feet in Children

The most likely diagnosis is tinea pedis (athlete's foot), which should be treated with topical terbinafine applied twice daily for 1-2 weeks depending on location, combined with aggressive hygiene measures to eliminate odor-causing bacteria. 1

Diagnostic Approach

The combination of itching and odor in pediatric feet most commonly indicates:

• Tinea pedis (athlete's foot) - fungal infection causing itching, scaling, and fissures, particularly between toes 2, 3
• Bacterial overgrowth - produces the characteristic pungent foot odor in moist environments 4, 5
• Atopic dermatitis - less likely if limited to feet only, but consider if there's a personal or family history of atopy 6, 7

Examine carefully for concomitant tinea capitis (scalp ringworm), and check parents and siblings for tinea pedis and onychomycosis, as these serve as infection reservoirs. 2

First-Line Treatment Algorithm

For Tinea Pedis (Fungal Infection)

Topical terbinafine is the treatment of choice for children 12 years and older:

• Between the toes: Apply twice daily (morning and night) for 1 week 1
• Bottom or sides of foot: Apply twice daily for 2 weeks 1
• Wash affected skin with soap and water and dry completely before applying 1
• For children under 12 years: Consult a physician before use 1

For Odor Control (Bacterial Overgrowth)

Implement aggressive moisture control and hygiene measures:

• Keep feet clean and dry with toenails trimmed 4
• Wear well-fitting, ventilated shoes and change shoes and socks at least once daily 1, 4
• Wear sandals in locker and shower rooms to prevent reinfection 4
• Expose feet to air frequently to enhance evaporation and reduce moisture 4
• Consider shoe and sock sanitization using UV irradiation or ozone application to eliminate fungal reservoirs 8

When Systemic Antifungals Are Needed

If topical treatment fails or nail involvement is present, systemic therapy is indicated. The British Association of Dermatologists provides clear pediatric dosing for onychomycosis:

Terbinafine (Preferred for Dermatophytes)

• Weight <20 kg: 6.25 mg daily 2
• Weight 20-40 kg: 125 mg daily 2
• Weight >40 kg: 250 mg daily 2
• Duration: 6 weeks for fingernails, 12 weeks for toenails 2

Itraconazole (Alternative, Especially for Candida)

• Pulse therapy: 5 mg/kg/day for 1 week each month 2
• Duration: 2 months for fingernails, 3 months for toenails 2
• Clinical cure rates of 94-100% in pediatric studies 2

Systemic treatment is well-tolerated in children and achieves higher cure rates than in adults due to faster nail growth. 2

Alternative Diagnoses to Consider

Atopic Dermatitis

If the presentation includes dry skin, flexural involvement, or facial/cheek involvement in children under 4 years, consider atopic dermatitis:

• Apply emollients liberally at least twice daily 6, 9
• Use mild topical corticosteroids (hydrocortisone) for flares, applied not more than 3-4 times daily 10
• Replace soaps with gentle, dispersible cream cleansers 6, 9

Allergic Contact Dermatitis (Shoe Dermatitis)

Allergic contact dermatitis from footwear is a common cause of foot dermatitis in children (44.2% of cases in one study), with potassium dichromate, cobalt chloride, and nickel being the most frequent allergens. 7

• Consider patch testing if dermatitis persists despite antifungal treatment 7
• Avoid shoes containing common allergens 7

Critical Red Flags Requiring Urgent Evaluation

• Extensive crusting, weeping, or honey-colored discharge - suggests secondary bacterial infection requiring flucloxacillin 2, 6, 9
• Multiple uniform "punched-out" erosions - suggests eczema herpeticum requiring immediate systemic acyclovir 6, 9, 11
• Failure to improve with appropriate first-line management within 1-2 weeks 9, 11

Common Pitfalls to Avoid

• Don't assume young children can't have tinea pedis - while historically considered rare, studies show it does occur in pediatric populations 3
• Don't neglect environmental reservoirs - shoes, socks, and family members can harbor fungi and cause reinfection 2, 8
• Don't use non-sedating antihistamines - they have little to no value for itching in fungal infections or atopic eczema 2, 9
• Don't overlook nail involvement - infection under nails predicts future reinfection and may require systemic therapy 4