What are the best treatment options for athlete's foot?

Treatment of Athlete's Foot (Tinea Pedis)

For most cases of athlete's foot, topical terbinafine 1% cream applied twice daily for 1 week (interdigital) or 2 weeks (plantar) is the best first-line treatment, offering superior efficacy and shorter treatment duration compared to other topical agents. 1, 2

First-Line Topical Treatment

Topical terbinafine is the gold standard for uncomplicated tinea pedis:

• Terbinafine 1% cream twice daily for 1 week achieves 66% effective cure rate for interdigital infections and demonstrates 89% combined mycologic and clinical cure at 2-week follow-up 1, 3, 4
• For plantar (moccasin-type) infections affecting the bottom or sides of the foot, extend treatment to 2 weeks of twice-daily application 2
• Terbinafine has fungicidal action, allowing shorter treatment courses than fungistatic agents 1

Alternative topical agents when terbinafine is unavailable or not tolerated:

• Ciclopirox olamine 0.77% cream/gel twice daily for 4 weeks achieves 60% cure at end of treatment and 85% cure two weeks post-treatment 1, 3
• Clotrimazole 1% cream twice daily for 2-4 weeks is less effective than terbinafine but widely available over-the-counter 1, 3

Oral Therapy for Severe or Resistant Cases

Reserve oral antifungals for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients 1, 5

Oral terbinafine is the preferred systemic agent:

• 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, 3
• Terbinafine has superior efficacy against dermatophytes compared to itraconazole, with lower minimum inhibitory concentrations 1
• Over 70% oral absorption unaffected by food intake 1
• Monitor for rare but serious adverse events including neutropenia and liver failure, particularly in patients with preexisting conditions 3

Alternative oral agents:

• Itraconazole 100 mg daily for 2 weeks has similar mycological efficacy to terbinafine but may have slightly higher relapse rates 1, 3
• Flexible dosing options include pulse dosing at 200-400 mg per day for 1 week per month 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 1, 6

Critical Prevention Measures

Environmental and hygiene interventions are essential to prevent recurrence:

• Apply foot powder after bathing to reduce tinea pedis rates from 8.5% to 2.1% 1
• Thoroughly dry between toes after showering and change socks daily 1, 3
• Wear cotton, absorbent socks and well-fitting, ventilated shoes 1, 2
• Clean athletic footwear periodically or discard old, moldy footwear when possible 1
• For contaminated shoes that cannot be discarded, place naphthalene mothballs inside and seal in plastic bag for minimum 3 days 1
• Apply antifungal powders (miconazole, clotrimazole, tolnaftate) inside shoes or spray terbinafine solution periodically 1

Common Pitfalls to Avoid

Failing to address these factors leads to treatment failure and recurrence:

• Treat all infected family members simultaneously to prevent reinfection 1, 3
• Examine for concomitant onychomycosis, which requires longer treatment and serves as a reservoir for reinfection 1
• Cover active foot lesions with socks before wearing underwear to prevent spread to groin area 1, 3
• Avoid sharing toenail clippers with family members and keep nails as short as possible 1
• Wear protective footwear in public bathing facilities, gyms, and hotel rooms 1

Special Population Considerations

For diabetic patients:

• Terbinafine is preferred over itraconazole due to lower risk of drug interactions and hypoglycemia 1
• Up to one-third of diabetics have onychomycosis, which significantly predicts foot ulcer development 1

For athletes:

• Minimum 72 hours of antifungal therapy required 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 requiring heightened vigilance include swimming, running, warm humid environments, male gender, obesity, and diabetes 1, 3