What is the appropriate management of tinea pedis in an adult Gulf War veteran?

Management of Tinea Pedis in Gulf War Veterans

Treat tinea pedis in Gulf War veterans with topical terbinafine 1% cream applied twice daily for 1 week for interdigital disease, or twice daily for 2 weeks for plantar involvement, as this provides the most effective first-line therapy. 1, 2

Clinical Context for Gulf War Veterans

Gulf War veterans do not have unique infectious disease risks that would alter standard tinea pedis management. 3 The only documented chronic infectious complication from Gulf War deployment was viscerotropic leishmaniasis in 12 veterans, with no new cases in the past 8 years. 3 While Gulf War veterans report more symptomatic ill-health overall, skin disease prevalence (47.7% in disabled Gulf veterans vs 42.8% in disabled non-Gulf veterans) does not differ significantly from other military populations. 4 The only notable dermatologic finding was a two-fold increase in seborrhoeic dermatitis, not tinea pedis. 4

First-Line Topical Treatment

Topical terbinafine 1% cream is the preferred initial therapy:

• Apply twice daily for 1 week for interdigital tinea pedis 1, 2
• Apply twice daily for 2 weeks for plantar or lateral foot involvement 1, 2
• Terbinafine is more effective than longer courses of other antifungal agents 1
• Wash affected skin with soap and water and dry completely before applying 2

Alternative topical agents if terbinafine is unavailable:

• Ciclopirox olamine 0.77% cream/gel achieves approximately 60% clinical and mycological cure at end of treatment, and 85% two weeks after treatment 1
• Ciclopirox offers advantages for dermatophytosis complex (with bacterial superinfection) due to antibacterial and anti-inflammatory activity 5
• Clotrimazole 1% cream is less effective than terbinafine but widely available over-the-counter 1

Oral Therapy for Severe or Resistant Cases

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

• Oral terbinafine 250 mg once daily for 1-2 weeks is first-line systemic therapy, with over 70% oral absorption unaffected by food intake 1, 6
• Oral itraconazole 100 mg daily for 2 weeks is an alternative, with similar mycological efficacy but potentially higher relapse rates 1, 6
• Pulse dosing of itraconazole 200-400 mg per day for 1 week per month can be used for extensive disease 1, 6
• Itraconazole should be taken with food and acidic pH for optimal absorption 6
• Fluconazole 150 mg once weekly is less effective than both terbinafine and itraconazole but may be useful when other agents are contraindicated 1, 6

Critical Prevention Measures for Military Populations

Military personnel have particularly high tinea pedis prevalence (60.1% clinical prevalence in Israeli soldiers), making prevention essential: 7

• Apply foot powder after bathing to reduce recurrence rates from 8.5% to 2.1% 1, 6
• Change socks daily and wear cotton, absorbent socks 1
• Wear well-fitting, ventilated shoes and change shoes and socks at least once daily 2
• Wear protective footwear in public bathing facilities, gyms, and locker rooms 1
• Thoroughly dry between toes after showering 1
• Clean athletic footwear periodically 1, 6

Environmental Decontamination

Address contaminated footwear to prevent reinfection: 1, 6

• Discard old, moldy footwear when possible 1
• Place naphthalene mothballs in shoes and seal in a plastic bag for minimum 3 days 1
• Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate inside shoes 1
• Spray terbinafine solution into shoes periodically 1

Common Pitfalls to Avoid

Examine for concomitant onychomycosis, which requires longer treatment and serves as a reservoir for reinfection. 6 Nail infection is present in up to one-third of diabetic patients and significantly predicts foot ulcer development. 1

Check for dermatophyte infection at other body sites, present in 25% of cases. 6 Cover active foot lesions with socks before wearing underwear to prevent spread to groin. 1

Treat all infected family members simultaneously to prevent reinfection. 1, 6

Before declaring treatment failure, obtain fungal cultures to verify diagnosis and consider discontinuing antifungals for a few days to optimize specimen collection. 6 Poor compliance, inadequate drug penetration, bacterial superinfection, or reinfection from nails/footwear are more common causes of apparent treatment failure than drug resistance. 6