First-Line Medication for Athlete's Foot

Topical terbinafine 1% cream applied twice daily for 1 week is the first-line treatment for uncomplicated tinea pedis (athlete's foot). 1

Why Terbinafine is Superior

Terbinafine has fungicidal activity against dermatophytes, allowing dramatically shorter treatment courses compared to fungistatic agents like azoles. 1
One week of terbinafine 1% cream twice daily achieves 66-78% effective cure rates, which is superior to 4 weeks of clotrimazole 1% cream. 1, 2
The American Academy of Pediatrics specifically recommends terbinafine 1% cream twice daily for 1 week as more effective than longer courses of other antifungal agents for interdigital tinea pedis. 1

Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves approximately 60% clinical and mycological cure at end of treatment, rising to 85% two weeks after treatment completion. 1
Clotrimazole 1% cream applied twice daily for 4 weeks is less effective than both terbinafine and ciclopirox but remains widely available over-the-counter. 1

Reserve oral antifungals for specific situations only: 1

If oral therapy is needed:

Oral terbinafine 250 mg once daily for 1-2 weeks is the first-line systemic option, with similar mycological efficacy to 4 weeks of topical clotrimazole but faster clinical resolution. 1
Oral itraconazole 100 mg daily for 2 weeks has similar efficacy to oral terbinafine but may have slightly higher relapse rates. 1
Fluconazole is less effective than both terbinafine and itraconazole for dermatophyte infections and should only be used when other agents are contraindicated. 1

Address these factors or treatment will fail: 1

Examine for concomitant onychomycosis (nail infection), which requires 12-16 weeks of oral terbinafine and serves as a reservoir for reinfection. 1
Treat all infected family members simultaneously to prevent reinfection cycles. 1
Decontaminate or discard contaminated footwear, as shoes harbor large numbers of viable fungal spores. 1
- If shoes cannot be discarded, seal with naphthalene mothballs in a plastic bag for minimum 3 days, then air out. 1
- Alternatively, spray terbinafine solution inside shoes periodically. 1

Thoroughly dry between toes after showering to reduce moisture that promotes fungal growth. 1
Apply antifungal foot powder after bathing, which reduces tinea pedis rates from 8.5% to 2.1%. 1
Change to cotton, absorbent socks daily to maintain dry environment. 1
Cover active foot lesions with socks before wearing underwear to prevent spread to groin area. 1

Failing to address contaminated footwear is a major cause of recurrence—shoes can contain large numbers of infective fungal elements. 1
Treating only the index patient without examining household contacts leads to repeated reinfection. 1
Stopping treatment when symptoms improve rather than completing the full course results in incomplete mycological cure. 3
Not examining for nail involvement, which requires extended oral therapy and acts as a persistent source of reinfection. 1

Baseline liver function tests and complete blood count are recommended in adults with history of hepatotoxicity or hematologic abnormalities. 1
Monitor for rare but serious adverse events including isolated neutropenia and hepatic failure, particularly in patients with pre-existing liver disease. 1
Common adverse effects include headache, taste disturbance, and gastrointestinal upset. 1