How to manage athlete's foot in primary care

Athlete’s foot (tinea pedis) is a common superficial fungal infection of the feet. It is primarily caused by dermatophytes, particularly Trichophyton rubrum. Athlete’s foot presents frequently in primary care and is easily treatable. However, without proper management and prevention, recurrence is common.

How to recognise and diagnose athlete’s foot

Clinical presentation of athlete’s foot usually follows of these three patterns:

1. Interdigital is the most common type. It is characterised by scaling, maceration, fissuring between the toes (often fourth to fifth interdigital space).
2. Moccasin type presents as chronic dry, scaly skin on soles and lateral feet, often with nail involvement.
3. Vesiculobullous type symptoms include acute blistering, often on the sole or instep.

Other common symptoms of athlete’s foot may include:

• Itching, burning, or stinging
• Malodor
• Redness and peeling skin

Diagnosing athlete’s foot

The diagnosis is usually clinical, based on appearance and location. In some cases, KOH preparation or fungal culture may be used to confirm diagnosis or rule out other conditions, such as eczema or psoriasis.

GPs should check for onychomycosis (nail involvement), which often coexists and may require systemic therapy.

Initial management

The first line of treatment, for mild to moderate cases, are topical antifungals. These may include:

• Azoles (clotrimazole, miconazole). These are broad-spectrum antifungals, effective against dermatophytes and yeast.
• Allylamines (terbinafine) are fungicidal. They are often more effective, with a shorter treatment duration (one to two weeks).
• Other options (tolnaftate, ciclopirox).

Application tips:

Apply twice daily to affected areas and two centimeters beyond lesion borders. Continue for at least one week after resolution of symptoms, usually for a total of two to four weeks.

For severe, recurrent, or moccasin-type infections (or if onychomycosis is present), GPs may prescribe systemic antifungals, such as:

• Terbinafine 250 mg daily for 2 weeks
• Itraconazole 200 mg daily for 1 week (pulse dosing may be used for nails)

*It is essential to check the liver function if systemic therapy is prolonged or repeated.

Adjunctive measures and patient education

Foot hygiene is vital. That means keeping the feet clean and dry (especially between toes) and using a separate towel for feet.

Changing socks daily is also important (use moisture-wicking socks), so is wearing breathable shoes and alternating pairs to allow drying.

Environmental decontamination plays an important role too:

• Treating footwear with antifungal sprays or powders.
• Avoiding walking barefoot in communal areas (locker rooms, pools).

Antifungal foot powders are very useful for prevention in high-risk individuals.

When to refer and investigate further

GPs can refer patients to dermatology if:

• They are refractory to treatment or experience frequent recurrences
• Suspected for allergic contact dermatitis or psoriasis
• There is nail involvement with failure of oral therapy

Consider investigations for:

• Immunosuppression or diabetes, if infection is unusually severe or recurrent.
• Bacterial superinfection, such as cellulitis, foul odor, increased erythema or pus.

Athlete’s foot is a straightforward condition to diagnose and treat in primary care. With proper use of antifungals, attention to hygiene, and preventive strategies, most cases resolve quickly and recurrences can be minimised. Patient education is essential for long-term success.

 – Dr Rosmy De Barros

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References

• Leung, A. K., Barankin, B., Lam, J. M., Leong, K. F., & Hon, K. L. (2023). Tinea pedis: an updated review. Drugs in context, 12, 2023-5-1. https://doi.org/10.7573/dic.2023-5-1
• García-Lira, J. R., Toledo-Bahena, M. E., Valencia-Herrera, A. M., Pérez-Cosgaya, R. A., Pardo-Estrada, E. M., Duarte-Abdala, M. R., ... & Bonifaz-Trujillo, A. (2024). Tinea pedis in adolescents: a comprehensive review. Current Fungal Infection Reports, 18(2), 112-117.
• Ptak, A., & Szyc, M. (2024). Athlete's Foot: A Common Fungal Infection in Athletes and Beyond. The Use of Terbinafine in Treating Tinea Pedis and Onychomycosis. Quality in Sport, 34, 56195-56195.
• Heymann, W. R. (2025). Going toe-to-toe in treating interdigital tinea pedis. Journal of the American Academy of Dermatology, 92(5), 1008-1009.
• BURUCU, R., İsmail, Ö. R. S., DURMAZ, M., AKDOĞAN, Y., & ÖRS, İ. Ö. (2022). Foot Care Applications of Patients with Tinea Pedis Diagnosis and Affecting Factors. Foot, 10(5), 608-614.