Athlete's foot medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Overview

• There are many conventional medications (over-the-counter and prescription) as well as alternative treatments for fungal skin infections, including athlete's foot.
• Important with any treatment plan is the practice of good hygiene.
• Several placebo controlled studies report that good foot hygiene alone can cure athlete's foot even without medication in 30-40% of the cases.
• However, placebo-controlled trials of allylamines and azoles for athlete’s foot consistently produce much higher percentages of cure than placebo.

Medical Therapy

Conventional Treatments

• Conventional treatment typically involves daily or twice daily application of a topical medication in conjunction with improvement of hygiene.
• Severe or prolonged fungal skin infections may require treatment with oral anti-fungal medication.
• Application of zinc oxide based diaper rash ointment can be helpful.

Pharmacotherapy

Pharmacotherapy for tinea pedis includes topical and systemic therapy.

Topical Medications

Main article: Antifungal drug

• The fungal infection is often treated with topical antifungal agents, which can take the form of a spray, powder, cream, or gel.
• The most common ingredients in over-the-counter products are miconazole nitrate (2% typical concentration in the United States) and tolnaftate (1% typ. in the U.S.).
• Terbinafine, is another over-the-counter drug, but some strains are resistant.
• There exists a large number of prescription antifungal drugs, from several different drug families. These include ketaconazole, clotrimazole, itraconazole,naftifine, nystatin, caspofungin.
• One study showed that allylamines (terbinafine, Amorolfine, naftifine, butenafine) cure slightly more infections than azoles (Miconazole,ketaconazole, clotrimazole, itraconazole, sertaconazole, etc.).
• Undecylenic acid (a castor oil derivative) is a known fungicide that can be used for fungal skin infections such as athlete's foot.
• Whitfield's Ointment (benzoic and salicylic acid) is an older treatment that still sees occasional use.
• Some topical applications such as carbol fuchsin (also known in the U.S. as Castellani's paint), often used for intertrigo, work well but in small selected areas. This red dye, used in this treatment like many other vital stains, is both fungicidal and bacteriocidal; however, because of the staining it is cosmetically undesirable. For many years gentian violet was also used for bacterial and fungal infections between fingers or toes.
• The time line for cure may be long, often 45 days or longer. The recommended course of treatment is to continue to use the topical treatment for four weeks after the symptoms have subsided to ensure that the fungus has been completely eliminated. However, because the itching associated with the infection subsides quickly, patients may not complete the courses of therapy prescribed.
• Anti-itch creams are not recommended as they will alleviate the symptoms but will exacerbate the fungus; this is due to the fact that anti-itch creams typically enhance the moisture content of the skin and encourage fungal growth. For the same reason, some drug manufacturers are using a gel instead of a cream for application of topical drugs (for example, naftin and Lamisil).Novartis, maker of Lamisil, claims that a gel penetrates the skin more quickly than cream.
• If the fungal invader is not a dermatophyte but a yeast, other medications such as fluconazole may be used.
• Typically fluconazole is used for candidal vaginal infections moniliasis but has been shown to be of benefit for those with cutaneous yeast infections as well. The most common of these infections occur in the web spaces (intertriginous) of the toes and at the base of the fingernail or toenail. The hall mark of these infections is a cherry red color surrounding the lesion and a yellow thick pus.
• It is important to note that moccasin type tinea pedis infection may be resistant to topical antifungals because of the accompanying hyperkeratosis. Use of a keratolytic agent in conjunction with a topical antifungal cream improves penetration.

Oral Medications

• Oral treatment with griseofulvin was begun early in the 1950s.
• Because of the tendency to cause liver problems and to provoke aplastic anemia the drugs were used cautiously and sparingly.
• Over time it was found that those problems were due to the size of the crystal in the manufacturing process and microsize and now ultramicrosize crystals are available with few of the original side effects.

• For severe cases, the current preferred oral agent in the UK, is the more effective terbinafine. Other prescription oral antifungals include itraconazole and fluconazole.

Alternative Treatments

Topical Oils

• Symptomatic relief from itching may be achieved after topical application of tea tree oil, probably due to its involvement in the histamine response;
• However, the efficacy of tea tree oil in the treatment of athlete's foot (achieving mycological cure) is questionable.

Onion Extract

• A study of the effect of 3% (v/v) aqueous onion extract was shown to be very effective in laboratory conditions against Trichophyton mentagrophytes and T. rubrum.

Garlic Extract

• Ajoene, a compound found in garlic, is sometimes used to treat athlete's foot.

Rubbing Alcohol, Hydrogen Peroxide and Vinegar

• Direct application of rubbing alcohol and/or hydrogen peroxide after bathing can aid in killing the fungus at the surface level of the skin and will help prevent a secondary (bacterial) infection from occurring.
• In addition, soaking the feet in a bath of 70% rubbing alcohol will help dry the skin out, and likewise kill the invading fungus.
• The alcohol is not, however, effective against spores.
• Vinegar in some cases has killed the fungus and is effective against spores.

Boric Acid

• Boric acid application in the socks is used to prevent athlete's foot when recurrent infections occurs, but is not used to treat it.

Hair Dryer

• Since fungi grow in moist conditions, it is very important to dry the feet well after bathing.
• A hair dryer can be used to aid the drying process, or to dry feet which have become slightly moist in between showers or baths.

Baking Soda

• Rubbing feet with a baking soda paste and/or sprinkling baking soda in shoes is thought to help by changing pH.

Household Bleach (not recommended)

• The use of household bleach as a direct topical application or soak for tinea pedis is not recommended, as it is a well documented irritant (clearly labelled in the United Kingdom as "Harmful" by COSHH).
• It is used diluted as an environmental decontaminatant to prevent the spread of dermatophytes between animals, and from animals to humans.

Epsom Salts

• Some podiatrists recommend soaking the feet in a solution of Epsom salts in warm water.

Antimicrobial Regimen

• 1. Tinea pedis

• 1.1 Athlete's foot

• 1.1.1 Interdigital

• Preferred regimen: Topical cream/ointment Terbinafine OR Miconazole OR Econazole OR Clotrimazole

• 1.1.2 Dry type

• Preferred regimen (1): Terbinafine 250 mg/day PO for 2-4 weeks
• Preferred regimen (2): Itraconazole 400 mg/day PO for 1 week per month (repeated if necessary)
• Preferred regimen (3): Fluconazole 200 mg PO weekly for 4-8 weeks