eMedicine Specialties > Dermatology > Fungal Infections
Tinea Pedis: Treatment & Medication
Updated: Nov 13, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Medical therapy is the mainstay of tinea pedis treatment (see Medication).
Surgical Care
Surgical care is usually not required.
Activity
- Infection can occur through contact with infected scales on bath or pool floors, so wearing protective footwear in communal areas may help decrease the likelihood of infection.
- Because infected scales can be present on clothing, frequent laundering is a good idea.
- Occlusive footwear promotes infection by creating warm, humid, macerating environments where dermatophytes thrive. Therefore, patients should try to minimize foot moisture by limiting the use of occlusive footwear and should discard shoes that may be contributing to recurrence of the infection.
- The Medscape Exercise and Sports Medicine Resource Center may be of interest.
Medication
Tinea pedis can be treated with topical or oral antifungals or a combination of both. Topical agents are used for 1-6 weeks, depending on manufacturers' recommendations. A patient with chronic hyperkeratotic (moccasin) tinea pedis should be instructed to apply medication to the bottoms and sides of his or her feet. For interdigital tinea pedis, even though symptoms may not be present, a patient should apply the topical agent to the interdigital areas and to the soles because of the likelihood of plantar-surface infection.
Recurrence of the infection is often due to a patient's discontinuance of medication after symptoms abate. A simple strategy to increase a patient's compliance is to prescribe a large quantity of topical medicine, which may motivate a patient to continue use until the entire tube is empty.
Moccasin-type tinea pedis is often recalcitrant to topical antifungals alone, owing to the thickness of the scale on the plantar surface. The concomitant use of topical urea or other keratolytics with topical antifungals should improve the response to topical agents. In addition, for moccasin tinea pedis caused by Scytalidium species, Whitfield solution, containing benzoic and salicylic acids, can be beneficial. However, patients with extensive chronic hyperkeratotic tinea pedis or inflammatory/vesicular tinea pedis usually require oral therapy, as do patients with concomitant onychomycosis,3 diabetes, peripheral vascular disease, or immunocompromising conditions.
Topical imidazoles
Effective in all forms of tinea pedis but are excellent treatments for interdigital tinea pedis because they are effective against dermatophytes and Candida. Some of these drugs (eg, econazole) also have antibacterial activity.
Clotrimazole 1% (Mycelex, Lotrimin)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell-membrane permeability, causing death of fungal cells. Reevaluate diagnosis if no clinical improvement after 4 wk.
Adult
Gently massage into affected area and surrounding skin areas bid for 2-6 wk
Pediatric
Children: Not established
Adolescents: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external use only; avoid contact with eyes; discontinue if irritation or sensitivity develops
Econazole 1% cream (Spectazole Topical)
Effective in cutaneous infections. May interfere with RNA and protein synthesis and metabolism. Disrupts cell membrane permeability, causing death of fungal cells.
Adult
Apply sparingly over affected areas qd/bid for 4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if sensitivity or irritation develops; for external use only; avoid contact with eyes
Ketoconazole 1% cream (Nizoral)
Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in death of fungal cells.
Adult
Rub gently into affected area bid/qid for 2-4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; fungal meningitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if sensitivity or irritation develops; for external use only; avoid contact with eyes
Miconazole (Monistat)
Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, resulting in fungal cell death. The 2% lotion is preferred in intertriginous areas. If the 2% cream is used, apply sparingly to avoid maceration effects.
Adult
Cream and lotion: Cover affected areas bid for 2-6 wk
Powder: Spray or sprinkle liberally over affected area bid for 2-4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes
Oxiconazole 1% cream (Oxistat)
Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, resulting in death of fungal cells.
Adult
Apply to affected area bid for 4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue if sensitivity or chemical irritation occurs; for external use only; avoid contact with eyes
Sertaconazole nitrate cream (Ertaczo)
Topical imidazole antifungal active against T rubrum, T mentagrophytes, and E floccosum. Indicated for tinea pedis.
Adult
Apply topically bid to clean, dry skin between toes and immediate surrounding healthy skin for 4 wk
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For topical use only; may cause dermatitis, dry skin, burning sensation, pruritus, hyperpigmentation, desquamation, or skin tenderness
Topical pyridones
Broad-spectrum agents with antidermatophytic, antibacterial, and anticandidal activity and are therefore useful in all forms of tinea pedis but especially effective in interdigital tinea pedis.
Ciclopirox 1% cream (Loprox)
Interferes with synthesis of DNA, RNA, and protein by inhibiting transport of essential elements in fungal cells.
Adult
Massage into affected area bid; reevaluate diagnosis if no improvement after 4 wk
Pediatric
<10 years: Not established
>10 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid contact with eyes and other internal routes; discontinue if irritation or sensitivity develops
Topical allylamines
Effective in treating all forms of tinea pedis. In vitro, these agents have demonstrated potent activity against dermatophyte fungi, so they are useful in treating patients with refractory tinea pedis (eg, chronic hyperkeratotic). Terbinafine 1% (Lamisil) has been shown to be effective in some patients with interdigital tinea pedis with only 1 wk of treatment. Patients with chronic hyperkeratotic tinea pedis generally require 4 wk of treatment.
Naftifine 1% cream and gel (Naftin)
Broad-spectrum antifungal agent and synthetic allylamine derivative; may decrease synthesis, which, in turn, inhibits growth of fungal cells.
Adult
Cream: Apply to affected area qd for 4 wk
Gel: Apply to affected areas bid for 4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue if sensitivity or irritation occurs; for external use only; avoid contact with eyes
Terbinafine (Lamisil)
Inhibits squalene epoxidase, which decreases ergosterol synthesis, causing death of fungal cells. Use until symptoms significantly improve. Duration of treatment should be >1 wk but not >4 wk.
Adult
Cream: Apply bid 1-4 wk
Spray: Apply bid (morning and night) for 1 wk
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue if sensitivity or irritation occurs; for external use only; avoid contact with eyes
Topical benzylamines
Sometimes classified as a subset of allylamines. Useful for treating patients with refractory tinea pedis (eg, chronic hyperkeratotic). Have been shown to be effective in some patients with interdigital tinea pedis with only 1 wk of treatment.4
Butenafine 1% cream (Mentax)
Damages fungal cell membranes, arresting growth of fungal cells.
Adult
Apply bid for 1 wk or apply topically to affected area qd for 4 wk
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external use only; discontinue if irritation or sensitivity develops
Oral antimycotics
Should be considered in patients with extensive chronic hyperkeratotic or inflammatory/vesicular tinea pedis. Could also be used for patients with disabling disease, patients in whom topical treatments have failed, patients with diabetes or peripheral vascular disease, and patients with immunocompromising conditions.
Itraconazole (Sporanox)
Fungistatic activity. Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Adult
200 mg PO qd for 1 wk; not to exceed 400 mg/d; increase in 100-mg increments if no improvement (administer >200 mg/d in divided doses)
Pediatric
Not established; suggested dose of 100 mg/d for systemic fungal infections
Antacids may reduce absorption; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (eg, lovastatin, simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce levels (phenytoin metabolism may be altered)
Documented hypersensitivity; coadministration with terfenadine (withdrawn from US market), astemizole (withdrawn from US market), triazolam, simvastatin, cisapride, quinidine, pimozide (withdrawn from US market), and HMG-CoA reductase inhibitors may cause adverse cardiovascular effects (possibly death)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor hepatic function in patients taking itraconazole for >1 mo and in patients who develop any sign of hepatic insufficiency
Terbinafine (Lamisil, Daskil)
Inhibits squalene epoxidase, which decreases ergosterol synthesis, causing death of fungal cells. Use until symptoms significantly improve.
Adult
250 mg PO qd for 1-2 wk
Pediatric
Weight-based dosing
12-20 kg: 62.5 mg/d PO
20-40 kg: 125 mg/d PO
>40 kg: 250 mg/d PO
Treatment duration as in adults
May decrease cyclosporine effects; toxicity may increase with rifampin and cimetidine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform hepatic function tests and CBC counts when taking for >6 wk, if signs of hepatic dysfunction develop, or if immunocompromised; not recommended for patients with preexisting liver disease or renal impairment
Fluconazole (Diflucan)
Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.
Adult
150 mg PO qwk for up to 4 wk
Pediatric
6 mg/kg/d PO for 2-3 wk
Levels may increase with coadministration of hydrochlorothiazide; levels may decrease with long-term coadministration of rifampin; coadministration of fluconazole may decrease phenytoin clearance; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with coadministration of fluconazole; increases in cyclosporine concentrations may occur when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor closely if rash develops and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions (eg, AIDS, malignancy) and while taking multiple concomitant medications; not recommended in breastfeeding
Dermatological agents
May use to supplement antimycotic agents in certain clinical situations.
Aluminum acetate (Otic Domeboro, Burow's Solution)
Drying agent for vesicular tinea pedis. Dissolve aluminum acetate tablets in water to produce a 1:10-40 solution.
Adult
Soak feet bid; apply as a compress for 20-30 min 4-6 times/d until condition resolves
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For external use only
Ammonium lactate lotion (Lac Hydrin)
Used to decrease scaling in patients with hyperkeratotic soles. Contains lactic acid, an alpha hydroxy acid that has keratolytic action and thus facilitates release of comedones. Causes disadhesion of corneocytes. Available in 12% and 5% strengths. Use 12% lotion.
Adult
Apply liberally to all affected areas bid until condition resolves
Pediatric
Apply as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause pain if applied on broken skin; may cause irritation with erythema, burning, and peeling if applied to face in 12% concentration
Urea, topical (Carmol-40, Keralac)
Used to decrease scaling in patients with hyperkeratotic soles. Promotes hydration and removal of excess keratin by dissolving the intracellular matrix. Available in 10-40% concentration.
Adult
Apply to all affected areas bid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
For external use only
More on Tinea Pedis |
| Overview: Tinea Pedis |
| Differential Diagnoses & Workup: Tinea Pedis |
 Treatment & Medication: Tinea Pedis |
| Follow-up: Tinea Pedis |
| References |
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References
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Further Reading
Keywords
athlete's foot, ringworm of the feet, dermatophytosis, dermatophytid, Trichophyton rubrum, T rubrum, Trichophyton mentagrophytes, T mentagrophytes, Epidermophyton floccosum, E floccosum, Scytalidium hyalinum, S hyalinum, Scytalidium dimidiatum, S dimidiatum
