Athlete's Foot: Scourge of the Gym

Athlete’s foot (tinea pedis) is aTrichophytonfungal infection of the foot that manifests as itchy, dry, red, and sometimes flaky skin eruptions. Some patients will have obvious cracks and fissures in their skin. It most often occurs between and around the toes, or it may encase the entire bottom of the foot, in which case it’s called a “moccasin presentation.” Athlete’s foot loves moisture and humidity, which is why people who prefer to walk in bare feet rarely contract the infection.

Up to 70% of Americans contract athlete’s foot at some time in their lives. Predisposing factors include wearing heavy or tight shoes that don’t allow the foot to breathe. Shoes that are made primarily of plastic—such as athletic shoes and sneakers—keep feet too warm and moist, creating a perfect environment for fungal infection. Wearing heavy socks that retain moisture can compound the problem. If a bacterial infection superimposes on the fungal infection, the condition can quickly spiral out of control.

Patients can contract athlete’s foot either by direct contact with someone who has the infection, or by having exposure to contaminated surfaces, clothing, shoes, sheets, or towels. People who use community swimming pools and showers are at highest risk. Retail health care providers should be especially aggressive with treatment when patients who are immunocompromised present with athlete’s foot.

Start with Self-Management

Hygiene is an important aspect of care. TheTABLEdescribes interventions that patients can (and should) employ consistently to self-manage their athlete’s foot.

TABLE:SELF-MANAGEMENT OF ATHLETE’S FOOT

Intervention

Patient Counseling

Washing and hygiene

· For the first few days, patients can soak their feet in nonprescription Burow’s solution or diluted vinegar solution several times a day.

· Patients should wash their feet carefully with mild soap and water twice every day. Some evidence indicates that tea tree oil can also help resolve the infection.

· It’s critical to dry feet completely and make sure there’s no moisture left between the toes. Some people use a hairdryer set on low heat and gently dry them to make sure that every drop of moisture is gone. Rubbing them with powder or cornstarch also helps.

· Always wear shower shoes (flip-flops) when using communal showers.

· Do not share socks, shoes, or towels. Wash linens frequently.

Increasing air circulation

· Whenever possible, patients should keep their feet open to the air to increase exposure to light and air circulation—bare or in socks only.

Shoe care

· Discard old shoes that may be heavily infected with fungus at this point.

· Advise patients to have at least 2 and possibly 3 pair of shoes Tell them not to wear the same pair of shoes 2 days in a row. Leather or canvas shoes are healthier for the feet than athletic shoes.

· Tell patients that when they remove their shoes at the end of the day, to open the laces and pull the tongue to increase air circulation. Then, they should sprinkle shoes with cornstarch, baby powder, or any absorptive powder so that it will absorb some of the moisture in the shoe.

· Allow at least 24 to 48 hours for shoes to air out and dry.

· Before wearing the shoes again, patients should tap the powder out of the shoe into the trash.

Treatment Options

Numerous OTC products (clotrimazole, econazole, ketoconazole, miconazole, terbinafine, sulconazole) are available to treat mild to moderate athlete’s foot, and patients may need guidance in the OTC aisle. They come in several formula, including liquids, sprays, and creams. Some patients don’t like the feel of the heavier creams; for them, a liquid or a spray may be a better choice to increase adherence.

More severe cases may need treatment with a prescription medication. Fluconazole and naftifine are topical treatments available by prescription. Recently, the FDA approved econazole foam. This prescription-only product is easy to apply, aesthetically appealing, and more effective than OTC medications in moderate to severe athlete’s foot.

Griseofulvin, itraconazole, and terbinafine are appropriate systemic drugs, and their selection depends on patient-specific factors. Retail health care providers should remember that all of the azole antifungals need stomach acid to be absorbed properly. Avoid these drugs in patients who take proton pump inhibitors or who use antacids fairly often. Azoles should also be avoided in patients who have hepatic dysfunction.

Counseling for Complete Adherence Is Critical

The most critical counseling point for patients who have athlete’s foot is that premature discontinuation of treatment and inattention to hygiene will cause recurrence. Counsel patients to follow the products’ directions and continue the treatment without interruption for the entire duration. They may need to use some topical antifungals for up to 6 weeks. Prescribing a enough medication for the entire treatment period is a good strategy to improve adherence. Having to obtain a refill can create a barrier for patients, and they may discontinue treatment prematurely.

Patients will need to pay close attention to hygiene for the rest of their lives. Supplement good verbal counseling with written materials so that patients can refer to your directions days, weeks, and months later.

Recommended Reading

Inouye S, Uchida K, Nishiyama Y, Hasumi Y, Yamaguchi H, Abe S. Combined effect of heat, essential oils and salt on fungicidal activity against Trichophyton mentagrophytes in a foot bath.Nihon Ishinkin Gakkai Zasshi.2007;48(1):27-36.

Krinsky DL, Ferrere SP, Hemstreet B, et al.Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care.18th ed. Washington, DC: American Pharmacists Association; 2014;611-625.

Rosen T. Tinea and onychomycosis.Semin Cutan Med Surg.2016 Jun;35(6 suppl):S110-113. doi: 10.12788/j.sder.2016.035.