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Athlete's Foot

Anne Mallin, RPh, BScPhm, PharmD, CDE

Date of Revision: January 31, 2018
Peer Review Date: April 1, 2016

Pathophysiology

Athlete's foot (tinea pedis) is a superficial fungal infection of the feet.[1] The fungal species most
commonly involved are Trichophyton rubrum, Trichophyton mentagrophytes and Epidermophyton
floccosum.[2][3] Up to 70% of the population will acquire this infection at some point in their lives.[4] It
occurs most commonly in teenage and adult males and is uncommon in children.[1][3] Not all infected
individuals will be aware of or have symptoms of tinea pedis infection.[5]

Tinea pedis is transmitted either directly via contact with an infected person or indirectly through contact
with contaminated surfaces (e.g., swimming pool decks, gym change rooms).[5] The infection can be
spread to other parts of the body, usually the groin or underarms, by autoinoculation (e.g., touching the
infected feet then touching other parts of the body).[6]

Hyperhidrosis may contribute to the presence of tinea pedis. Warm, dark, poorly ventilated, moist
environments between the toes promote fungal growth and may contribute to the presence of this
condition.[7] Wearing shoes, with or without socks or hosiery, can create such environments. Other risk
factors for tinea pedis may include diabetes, immunosuppression, peripheral vascular disease, occluded
skin, poor hygiene, obesity and trauma.[8] Susceptibility to the fungus varies among individuals.[5]

Tinea pedis may progress to ulceration if the infection extends into the dermis. Complications may
include secondary bacterial infections that may be localized or spreading, e.g., cellulitis, lymphangitis.[8]
Patients with diabetes or those who have had saphenous vein grafts for coronary artery bypass are
especially prone to secondary bacterial infections.[1]

Goals of Therapy
Resolve symptoms
Cure infection
Prevent recurrence
Prevent transmission to others

Patient Assessment
Tinea pedis may present in several ways (see Table 1). The most common presentation is chronic
interdigital infection.[9][10][11][12][13]

Table 1: Morphologic Variants of Tinea Pedis

Variant Lesion Typical Location Special Considerations
Morphology

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Variant Lesion Typical Location Special Considerations

Morphology

Chronic Fissures, scaling Most commonly found
interdigital or maceration in on the lateral toe webs,
infection the interdigital usually between the 4th
spaces and 5th or 3rd and 4th
toes. From this area, the
infection often spreads
to the instep or sole of
the foot.
Humidity and warmth worsen
this condition. Therefore,
patients whose feet are prone
to excessive sweating should
be encouraged to treat their
hyperhidrosis along with the
fungal infection.

Moccasin- Chronic, Generally found on both Involvement of the toenails

type papulosquamous feet, it is characterized
infection pattern by a mild inflammation
and diffuse scaling on
the soles of the feet.
Often the toenails are
affected.
perpetuates the infection such
that the toenail infection must
be treated by oral antifungal
therapy for up to 3–4 months or
by surgery.[5]

Vesicular Small vesicles Near the instep and on Often caused by Trichophyton
the midanterior plantar mentagrophytes.
surface. Skin scaling is More prevalent in the summer.
also observed in this
area and on the toe
webs.

Acute Macerated, Sole of the foot. Hyperkeratosis and a pungent

ulcerative denuded, odour are usually present. May
disease weeping lesions be complicated by an
overgrowth of opportunistic,
gram-negative bacteria such as
Proteus or Pseudomonas and
for this reason is often referred
to as gram-negative athlete's
foot or dermatophytosis
complex.

Evidence of blisters, pruritic lesions, burning sensations, redness and inflammation in the favoured
locations or in a characteristic pattern on the feet may indicate the presence of tinea pedis. The skin may
appear macerated and an odour may be present. Severe cases may present with pain, peeling, cracking
and/or bleeding.[5] .

Tinea pedis may be confused with the following conditions: disturbances of the sweat mechanism;
contact dermatitis, often due to dyes or adhesives in footwear; eczema; psoriasis or bacterial infections
(including erythrasma).[9]

Figure 1 depicts an approach to assessing and managing tinea pedis.

Prevention
Give patients the following instructions:[5][7][9][14][15][16][17]

Wash feet with soap and water every day.

Dry feet thoroughly, paying special attention to areas between the toes.
Change socks daily (more frequently if feet sweat).

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Wear socks made of natural, absorbent materials or synthetic blends, e.g., acrylic, cotton,
polypropylene, wool. Individuals with hyperhidrosis should avoid socks that are made of nylon.
Avoid tight-fitting footwear.
Allow shoes to dry completely before being worn again. This may take 2–3 days and it may be
necessary to alternate pairs of shoes on different days.
Do not go barefoot in public places (e.g., swimming pool decks or gym change rooms)—wear foot
protection (e.g., sandals, pool shoes).
Do not share personal items such as towels.

Antiperspirants or absorbent powders (e.g., talcum or aluminum chloride) can be applied to the feet
to decrease sweating.

In addition to the above measures, individuals with a history of tinea pedis may regularly apply a dusting
of antifungal powder such as tolnaftate once or twice daily on their feet to prevent further recurrences.
[18] To prevent coagulation of powder and moisture buildup, antifungal powder should not be placed in

shoes.[18][19]

Nonpharmacologic Therapy
Individuals with tinea pedis should follow the guidelines described under Prevention as adjuncts to
pharmacologic treatment. Follow these measures to eliminate moisture and reduce recurrence.[14]
Absorption of moisture and decreasing moisture buildup can be achieved by separating the toes using
cotton balls.

Pharmacologic Therapy
For comparative ingredients of nonprescription products, consult the Compendium of Products for Minor
Ailments—Foot Care Products: Athlete's Foot.

Treatment of the skin with a topical antifungal agent (e.g., ciclopirox 1%, clotrimazole 1%,
ketoconazole 2%, miconazole 2%, terbinafine 1%) twice daily is the mainstay of therapy (see Table 2).
Treatment typically continues for up to 4 weeks, including 1–2 weeks after the lesions have disappeared,
to prevent recurrences.[20]

Topical terbinafine 1% may have a slightly higher cure rate compared with other topical antifungals.[21]
Inflamed infections may benefit from adding a topical anti-inflammatory such as betamethasone or
hydrocortisone; some antifungal and topical corticosteroid combinations exist commercially (e.g.,
clioquinol/hydrocortisone, clioquinol/flumethasone, clotrimazole/betamethasone). If signs and
symptoms persist beyond 6 weeks, consider referral to a foot care specialist. The main causes of
treatment failure are incorrect diagnosis and inadequate treatment.

Oral fluconazole, itraconazole or terbinafine may be indicated for tinea pedis infections that are
resistant to topical treatment.[22] Toenail involvement requires oral treatment.

There is no evidence that tea tree oil is effective in the treatment of tinea pedis, and if used it should not
be applied to open lesions.[21]

The selection of dosage form is based on individual preference. Generally, ointments remain in contact
with the affected area for a longer period of time than creams; however, there is the danger of creating
an occlusive barrier, which promotes skin maceration and retards wound healing. Powders may be either
nonmedicated or medicated and are also absorbent. Solutions, sprays or foams applied directly to the
skin should be allowed to air dry.

Monitoring of Therapy

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Rash during therapy may indicate an allergic reaction to the product. The patient should discontinue use
of the product and consult with an appropriate health-care practitioner.

If no improvement is seen within 2 weeks, or if symptoms have not completely disappeared within 6
weeks of treatment, refer the patient to a foot care specialist.

Advice for the Patient

Advise patient to:

Finish the recommended course of treatment to prevent recurrence, even though symptoms may
improve before the treatment course is complete.[5]
Dry the feet last after showering or bathing and use a clean towel every day, to prevent
autoinoculation.
Prevent transmission to others by not going barefoot around the home or in public areas until the
infection is cured.

Resources
Mayo Clinic. Patient Care & Health Information. Diseases and Conditions. Athlete's foot. Available from:
www.mayoclinic.org/diseases-conditions/athletes-foot/symptoms-causes/syc-20353841.

U.S. National Library of Medicine; National Institutes of Health. MedlinePlus. Athlete's foot. Available
from: www.nlm.nih.gov/medlineplus/ency/article/000875.htm.

Algorithms

Figure 1: Assessment and Treatment of Patients with Athlete's Foot

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Abbreviations: PVD = peripheral vascular disease.

Drug Table
Table 2: Pharmacologic Therapy for Athlete's Foot
Drug/Cost[a] Dosage Adverse Effects Comments

Drug Class: Antifungal/Corticosteroid Combinations

clioquinol Apply to Local skin irritation or Also exhibits antibacterial and

3%/flumethasone affected hypersensitivity (burning, anti-inflammatory properties.
pivalate 0.02% areas erythema, pruritus, rash, Particularly useful when
Locacorten Vioform BID × 4 stinging). inflammation is a prominent
wk feature. Available as cream.
$30–40

clioquinol Apply to Local skin irritation or Also exhibits antibacterial and

3%/hydrocortisone affected hypersensitivity (burning, anti-inflammatory properties.
1% areas erythema, pruritus, rash, Particularly useful when
Vioform HC BID × 4 stinging). inflammation is a prominent
wk feature. Available as cream.
$20–30

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Drug/Cost[a] Dosage Adverse Effects Comments

clotrimazole Apply to Local skin irritation or Particularly useful when

1%/betamethasone affected hypersensitivity (burning, inflammation is a prominent
dipropionate 0.05% areas erythema, pruritus, rash, feature. Available as cream.
Lotriderm BID × 4 stinging).
wk
$10–20

Drug Class: Antifungals, Allylamine

terbinafine 1% Apply to Local skin irritation or Patients treated with shorter

Lamisil affected hypersensitivity (burning, durations of therapy (1–2 wk)
areas erythema, pruritus, rash, continue to improve during the 2-
$10–20 BID × 4 stinging). to 4-wk period after therapy has
wk been completed. Available as
cream, spray.

terbinafine oral 250 mg GI irritation, headache, Considered for tinea pedis

Terbinafine, other once skin irritation. infections that are resistant to
generics daily topical treatment.
PO × 2
$30–40 wk

Drug Class: Antifungals, Azole

clotrimazole 1% Apply to Local skin irritation or Available as cream.

Canesten Topical, affected hypersensitivity (burning,
generics areas erythema, pruritus, rash,
BID × 4 stinging).
<$10 wk

fluconazole 150 mg No clinically meaningful Considered for tinea pedis

Diflucan One, once adverse effects at this infections that are resistant to
CanesOral, weekly dosage regimen. topical treatment.
generics PO ×
2–6 wk
<$10/wk

itraconazole 200 mg Abdominal pain, Considered for tinea pedis

Sporanox BID PO constipation, diarrhea, infections that are resistant to
Capsules, × 1 wk dyspepsia, flatulence, topical treatment.
Sporanox Oral headache, nausea,
Solution, generics pruritus, skin rash,
worsening heart failure
$60 symptoms.

ketoconazole 2% Apply to Local skin irritation or Available as cream.

Ketoderm affected hypersensitivity (burning,
areas erythema, pruritus, rash,
<$10 BID × 4 stinging).
wk

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Drug/Cost[a] Dosage Adverse Effects Comments

miconazole 2% Apply to Local skin irritation or Available as cream, spray

Micatin, Monistat affected hypersensitivity (burning, powder. Avoid inhaling powder
areas erythema, pruritus, rash, preparations.
<$10 BID × 4 stinging).
wk

Drug Class: Antifungals, Hydroxypyridone

ciclopirox 1% Apply to Local skin irritation or Available as cream, lotion.

Loprox affected hypersensitivity (burning,
areas erythema, pruritus, rash,
$10–20 BID × 4 stinging).
wk

Drug Class: Antifungals, Miscellaneous

tolnaftate 1% Apply to Local skin irritation or Available as cream, aerosol,

Tinactin, others affected hypersensitivity (burning, topical powder, spray. Avoid
areas erythema, pruritus, rash, inhaling powder preparations.
<$10 BID × 4 stinging).
wk

undecylenic acid Apply to Local skin irritation or Available as cream, liquid,

Fungicure, Flexitol affected hypersensitivity (burning, ointment, powder, aerosol spray.
Antifungal, others areas erythema, pruritus, rash, Avoid inhaling powder
BID × 4 stinging). preparations.
<$10 wk

[a]
Cost of specified duration of treatment for oral dose or smallest available pack size unless otherwise
specified; includes drug cost only.
Dosage adjustment may be required in renal impairment.

Abbreviations: GI = gastrointestinal

Suggested Readings
Andrews MD, Burns M. Common tinea infections in children. Am Fam Physician 2008;77:1415-20.

Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia 2008;166:353-
67.

Weinstein A, Berman B. Topical treatment of common superficial tinea infections. Am Fam Physician
2002;65:2095-102.

References

1. Fitzpatrick TB, Johnson RA, Wolff K et al. Fungal infections of the skin and hair. In: Fitzpatrick TB
et al., eds. Color atlas and synopsis of clinical dermatology: common and serious diseases. 4th
ed. New York: McGraw-Hill Medical; 2001. p. 684-725.

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2. Rinaldi MG. Dermatophytosis: epidemiological and microbiological update. J Am Acad Dermatol

2000;43:S120-4.
3. Antifungal agents for common paediatric infections. Paediatr Child Health 2000;5:477-91.
4. Zuber TJ, Baddam K. Superficial fungal infection of the skin. Where and how it appears help
determine therapy. Postgrad Med 2001;109:117-20,123-6, 131-2.
5. MedicineNet. Athlete's foot. Available from: www.medicinenet.com. Accessed January 5, 2018.
Registration required.
6. American Podiatric Medical Association. Athlete's foot. What is athlete's foot? Available from:
www.apma.org/Patients/FootHealth.cfm?ItemNumber=978. Accessed January 5, 2018.
7. Diabetes Québec. Chapter 23. Foot care and general hygiene. In: Benhamron C, ed. Understand
your diabetes...and live a healthy life. Montreal: Rogers Media; 2008. p. 205-14.
8. Al Hasan M, Fitzgerald SM, Saoudian M et al. Dermatology for the practicing allergist: Tinea
pedis and its complications. Clin Mol Allergy 2004;2:5.
9. Crawford F, Hart R, Bell-Syer SE et al. Extracts from “Clinical evidence”: Athlete's foot and
fungally infected toenails. BMJ 2001;322:288-9.
10. Beers M, Berkow R, eds. The Merck manual of diagnosis and therapy. 17th ed. Whitehouse
Station: Merck Research Laboratories; 1999.
11. American Diabetes Association clinical practice recommendations. Foot care in patients with
diabetes mellitus. Diabetes Care 1997;20:S31.
12. May I see the pharmacist? Aus Pharm 1997;16:223.
13. Bedinghaus JM, Niedfeldt MW. Over-the-counter foot remedies. Am Fam Physician 2001;64:791-
6.
14. Donaldson R. Athlete's foot. Can Pharm J 1998 Apr:33.
15. Canadian Podiatric Medical Association. Common conditions and ailments: athlete's foot.
Available from: www.podiatrycanada.org. Accessed January 5, 2018.
16. eMedicineHealth from WebMD. Athlete's foot. Available from: www.emedicinehealth.com.
Accessed January 5, 2018. Registration required.
17. Pickup TL, Adams BB. Prevalence of tinea pedis in professional and college soccer players
versus non-athletes. Clin J Sport Med 2007;17:52-4.
18. Smith EB, Dickson JE, Knox JM. Tolnaftate powder in prophylaxis of tinea pedis. South Med J
1974;67:776-8.
19. Field LA, Adams BB. Tinea pedis in athletes. Int J Dermatol 2008;47:485-92.
20. Weinstein A, Berman B. Topical treatment of common superficial tinea infections. Am Fam
Physician 2002;65:2095-102.
21. Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot.
Cochrane Database Syst Rev 2007;(3):CD001434.
22. Bell-Syer SE, Khan SM, Torgerson DJ. Oral treatments for fungal infections of the skin of the
foot. Cochrane Database Syst Rev 2012;(10):CD003584.

Information for the Patient

Athlete's Foot

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