Exploring The Issues In Treating Tinea Pedis

Tinea pedis is the most common dermatophyte host in the world. Seventy percent of the population will be infected at some point in their lives and the incidence rate increases with age. Tinea pedis currently makes up about 12 percent of the foot problems seen in the U.S. Approximately 26.5 million people are infected annually.
Seven out of 10 cases usually occur among male patients and tinea pedis rarely occurs in children. There is no racial predilection. People who get tinea pedis usually wear occlusive footwear, which is one of the risk factors leading to hyperhidrosis and maceration, providing a favorable environment for the dermatophyte. With regard to geographic factors, tinea pedis usually occurs in warmer climates.
In diagnosing tinea pedis, it’s important to do a good history and physical. I think a lot of physicians are very quick to make a diagnosis of tinea pedis when it’s really something else. There’s a whole list of differential diagnoses out there: eczema, xerosis, atopic dermatitis, psoriasis, contact dermatitis, Reiter’s syndrome, lichen planus or keratodermas. A good history and physical are especially important for those patients who have already seen a few doctors and come in with a bag of creams. We can also get into the issue of doing biopsies, which probably should be done more often than they are for questionable conditions.

Once the diagnosis of tinea pedis is made, there are actually four different types to consider. There is chronic squamous tinea or papulosquamous tinea which has a moccasin type distribution. There are dry thick scales and fissuring on the plantar surface of the foot. The next type is interdigital, which is actually the most common type. This occurs in the web spaces and you will see maceration, scaling and itching. The next type is vesicular, which occurs in the arch and interdigital spaces and typically in nonweightbearing areas. You get those small vesicles and bullae forming on the erythematous bases. The fourth type is ulcerative in which you would see maceration, weeping, denuded tissue and desquamation of layers of the skin. There is a foul odor secondary to the breakdown of tissue. This type can lead to bacterial infections because of the large surface area of tissue breakdown. Actually, the other types can also lead to bacterial infections, but I think the ulcerative type has the greater chance of bacterial infection. The patient may have to be put on an antibiotic in addition to an antifungal. I will talk about some of the risk factors with that a little later on.

What The Research Reveals
About Combination Therapy
Dr. Spielfogel: On the issue of topical versus systemic medications, Dr. Gupta also touched upon the studies that were done comparing ultramicrosize griseofulvin with the use of a topical. The results are excellent. In one study for the treatment of interdigital tinea pedis, when they used ultramicrosize griseofulvin and a topical together, there was an 89 percent cure rate.1 When they used ultramicrosize griseofulvin alone, there was a 79 percent cure rate. When they used a topical medication alone, there was a 47 percent cure rate.
At the three-month follow-up, they found an 84 percent cure rate with the combination of ultramicrosize griseofulvin and a topical, a 43 percent cure rate using ultramicrosize griseofulvin alone and a 20 percent cure rate with just the topical medication.1 I think this says volumes on efficacy in comparing a topical versus the oral. It is also important to remember that his study was conducted in a sub-tropical climate with a high incidence of tinea pedis.
It gets even better when you talk about plantar tinea pedis. In the Zaias study, when they treated tinea pedis with only ultramicrosize griseofulvin, there was a 94 percent cure rate as opposed to the 31 percent cure rate with topical medication alone.1 For the three-month follow-up, there was a 69 percent cure rate when using only ultramicrosize griseofulvin and a 19 percent cure rate when using only a topical medication.1

Do Oral Medications Enhance Compliance?
Dr. Spielfogel: As far as my own clinical experience goes, I actually started using ultramicrosize griseofulvin several years ago on select cases. I was using it here and there, and I was getting excellent results. When patients came in for a follow-up visit, they said their skin never looked and felt so good. I started using it more and more, and I’m at a point now where I’m rarely writing for topical antifungals anymore.

Besides great results, the main thing that I’m finding is greater patient compliance. Often, if you put patients on a topical medication, they’ll come back and say they used it for a few days, stopped and restarted or they used it once a day instead of twice a day. Then they come in and say: “Why isn’t this getting any better?” I’ve found that it’s a lot easier for a patient to take a pill twice a day, once in the morning and once at night. I’m getting much better results so I think compliance is a major issue.

Addressing The Potential Complications
Of Untreated Tinea Pedis
Dr. Spielfogel: As far as the risks of ineffective treatment, I’m sure we all know that there is a very high correlation, if not a 100 percent correlation, with tinea pedis and onychomycosis. If they are not treated properly, the patients who have tinea will eventually develop onychomycosis. You have to be careful about this with select groups of patients—diabetics, patients with PVD and elderly patients. Tinea pedis can also lead to bacterial infections. There is a high risk of developing cellulitis and/or lymphangitis.
There was actually a study that showed that the majority of patients with cellulitis of the leg had fungal infections at multiple sites.4 They either had tinea pedis plantarly, interdigitally or they had mycotic nails. I think it’s very important to treat these patients aggressively because of the risk factor of developing cellulitis. If you have a diabetic patient with a thick mycotic nail, it puts pressure on the nail bed. This may lead to an ulceration under the nail. Since it’s very close to the underlying bone, the patient may develop osteomyelitis and the next thing you know, the leg is gone. I think a lot of people are not treating these conditions and it’s leading to other serious problems.
Based on my clinical experience and the studies that have been done, I feel that ultramicrosize griseofulvin should be the drug of choice to treat tinea pedis.

Discussing The Prevalence
Of Fungal Infections And The Risk
Of Secondary Complications
Dr. Joseph: Tinea pedis is so ubiquitous now. It seems like every one of our patients comes in with tinea pedis, especially if they are over 60 or 70 years of age. However, this condition wasn’t always so common. In his book Topical Dermatology, which was published in France in 1890, Sabouraud actually came out and said dermatophytosis of the foot is a rare condition. So in only 114 years, even internationally, this condition that we see in just about everybody was a rare condition. This is truly an epidemic that we have.
I also want to touch upon the whole issue of tinea pedis causing complications. We do know that people with diabetes tend to be more prone to at least onychomycosis. In fact, Dr. Gupta showed that in one of his large epidemiologic studies and I’d like him to talk about that with tinea pedis also.5 There are a number of complications that occur among patients with tinea pedis and diabetes. Patients may also have tinea pedis after they’ve had vein harvesting for CABG (coronary artery bypass graft) procedures. You mentioned leg cellulitis and there is a very high correlation with tinea pedis.

There was also a recent paper published on methicillin resistant Staph aureus (MRSA) that actually comes right out and implies that dermatophytes form beta lactams.6 That has been known, not so much T. rubrum as T. mentagrophytes. However, it’s actually theorized in this paper on MRSA that dermatophyte infection by causing the formation of beta lactams may select out MRSA. So now we may actually have fungal infections contributing to the issue of MRSA that we’re having such a problem with from a bacterial standpoint.
I think this is a critically important thing. Many people see fungal infections and just write them off. Dr. Gupta, why don’t you talk a little bit about fungal infections in patients with diabetes?
Dr. Gupta: When it comes to onychomycosis, certainly among patients with diabetes, we showed that one-third of all diabetics at some point in their lifetime would be expected to have onychomycosis.5 This was the first large study to report a high prevalence of onychomycosis in diabetics. In terms of tinea pedis, I think what is lacking is good incidence data or prevalence data. It takes some logistics to do a study to look and see what the proportion of patients with tinea pedis is in the normal population.
I would like to know, Dr. Joseph, if you have any good data on this. I know you mentioned 12 percent. I have a feeling it’s much higher.
Dr. Joseph: I’ll take Zaias’ work one step further.1 I remember him talking about this whole syndrome that people with onychomycosis have tinea pedis, tinea corporis or tinea cruris because of the genetic disposition. It appears to be an autosomal dominant, cell-mediated immune deficit that’s out there.
I would almost latch on to your diabetic foot data with onychomycosis since we know, and I think we can all pretty much agree, that everybody with onychomycosis has tinea pedis.5 If we know that everybody with onychomycosis has tinea pedis and people with diabetes are 2.7 times more likely to have onychomycosis, are they also then X percent more likely to have tinea pedis? It follows. I agree with you there’s no data. I would also say that the data would be similar to what has been shown with onychomycosis in that there is an age correlation. Just as people are more prone to onychomycosis as they get older, they’re also going to have more tinea pedis when they are perhaps 70 or older. I would venture a guess that greater than 50 percent of them have tinea pedis. Again, this is totally empirical. I don’t have the data. It’s just my thinking.
Dr. Spielfogel: I agree with you. I also think that the incidence rate is much higher. From a clinical perspective, patients come in and present with the typical signs of itching, scaling and erythematous skin, and you diagnose tinea pedis. However, often patients come in and they don’t have the typical symptoms of itching and erythematous skin. It doesn’t have to itch to be a tinea and I think people are misdiagnosing tinea pedis as xerosis or something else when it really is tinea. These patients may have had it for so long, they just don’t have the classic symptoms any more.
Dr. Joseph: Good point.

What About Tinea Pedis
In The Pediatric Population?
Dr. Shin: I don’t think it is as common in the pediatric population. In my clinical experience, I don’t typically see tinea pedis in the pediatric population until adolescence. However, the data regarding its true incidence is limited. When I see children with scaling of the feet or with dystrophic nails, I don’t always think of fungus first. I am more likely to think of something like juvenile plantar dermatosis (JPD) or trachonychia (twenty nail dystrophy). I usually culture anything that is red and scaly because I have been fooled. I’ve had a few cases in which the scaling was classic for JPD. Then I cultured it and the culture grew T. rubrum.
I would also like to comment on secondary problems related to tinea pedis. I have found that there is a subset of school-age to teenage boys who have horrible hygiene. They allow the skin condition on their feet to get out of control, creating an ideal environment for secondary infections. I’ve seen cases of recurrent cellulitis and even a case of septic arthritis related to poor hygiene.

Taking A Closer Look
At The Issues With Culturing
Dr. Joseph: Both Dr. Spielfogel and Dr. Shin bring up a very interesting point. That’s the whole issue of diagnosis and culturing, and being able to differentiate between tinea pedis and things that mimic tinea pedis. I’m guessing that most people in clinical practice, most podiatrists in clinical practice and probably most derms, aren’t taking cultures or doing KOHs or sending off biopsies. We know that there are a lot of things that mimic tinea pedis. My personal feeling is that the disease is horribly underdiagnosed, as I think Dr. Shin was kind of alluding to, that things she thought were classic conditions turned out to be T. rubrum.
I remember a study that was done by Harvey Lemont, DPM, who was Chairman of Medicine at the Temple University School of Podiatric Medicine. I don’t think he ever published the data.7 He looked at something called tinea incognito. Now in the derm world, that’s a different disease. Tinea incognito was talked about with steroid use. However, Dr. Lemont coined the phrase for people who would come in with no symptoms like the itching and all that you would traditionally associate with it, as Dr. Spielfogel talked about. They just have kind of a white powdery look on the bottom of their feet. When he aggressively cultured that, he found T. rubrum growing and that didn’t even have the classical serpiginous sort of scale. It is something that is probably underdiagnosed. I’d like to go around and ask each of you whether you do a tinea culture and how you make that diagnosis.

Dr. Blass: Well, I culture, but I think one of the problems that has come up in proper diagnosis is how difficult it is for the average practitioner who doesn’t do it 20 times a day to get an adequate culture. I have always said that positive cultures mean something whereas negative cultures may mean absolutely nothing other than the fact that you just didn’t recover the organism or the laboratory didn’t do it properly.
Unfortunately, some of the larger HMOs, which unfortunately dictate the way many practitioners practice in their offices, went from the approach of, “We’re not going to give you this drug unless you can show us a positive culture” to “Oh, never mind, we’ll give it to you anyway.” This was one of the worst things that ever happened to cultures. Now you can write a script and it’s filled with no questions asked. I think that has cut down on the amount of cultures that are being done. It’s the fact that people are not getting paid for it and the fact that theoretically you would have to go through the hassles of getting a license to do waived testing. If you’re not in a facility where the facility just handles it, I think there is a horrible underusage of cultures. Certainly, if you looked at every podiatrist in the country, the number who actually have a microscope in their office could be counted by one person with only one of their shoes off.
Dr. Joseph: Good point.
Dr. Gupta: I think there’s various issues in doing a culture. Often, you will see xerosis and fungal infection together.

What About The Reliability Of Lab Testing?
Dr. Spielfogel: If you do an adequate history and physical exam, I think you can make the appropriate diagnosis. When it comes to situations in which I’m not sure what I’m dealing with, then I will do my culture or biopsy. I also have a lot of trouble with these large labs. Even with a mycotic nail, I’ll send something out for a PAS stain. I know it is mycotic and it’s coming back negative. It doesn’t happen all the time but it happens often enough. There were a few times where I put the patient on an antifungal anyway and it resolved. So why am I getting a negative report?

Other Pertinent Points On Culturing
Dr. Joseph: I think that all gets to what Dr. Gupta was saying. Is it going to change your management? I think we’re pretty good. The derm world, especially in the onychomycosis arena, has always pushed for years that we must do cultures, and Dr. Gupta is as guilty of this as anybody. You may hear that 50 percent of dystropic nails are not fungal. They are something else and you ask them what something else is and I hear psoriasis or lichen planus. I’m sorry, but there are not 30 million lichen planus patients out there.
I don’t think culturing changes your management, especially with tinea pedis because I see the scaling. Now if I see something abnormal like Dr. Shin was talking about, then I’m not sure. However, there’s a difference when you see that classic mocassin distribution and the little serpiginous scales all over the bottom interdigitally. I think most podiatrists and dermatologists, at least, are probably pretty comfortably treating it empirically. It really doesn’t matter from an organism standpoint because we know the antifungals we’re currently using work against pretty much all the organisms that cause tinea pedis.
Dr. Shin: When it comes to children, I probably do culture more than the norm. There’s a reason for this. If you are going to be committing someone to a few months of topical therapy or an oral treatment, most parents do not feel comfortable unless they really know what you are treating and that they are getting the appropriate medication.
Dr. Blass: This is especially the case if you’re going to put them on orals.

Emphasizing The Link Between Onychomycosis And Tinea Pedis
Dr. Joseph: On another issue, we should also emphasize that tinea pedis is a precursor to the onychomycosis. Once the onychomycosis becomes established, then it serves as a reservoir to re-infect skin that has been cleared. If you’re treating onychomycosis, you must treat the tinea pedis. If you’re treating tinea pedis, you must treat the onychomycosis. You need to address the fungus just like you need to address the shoes and the environment. Epidemiologically, these patients have tinea. You could be using a four- to eight-week course of griseofulvin from now until the cows come home, but if the patients have onychomycosis, they’re going to be getting the tinea back . You need to treat both.
Dr. Gupta: It’s not just tinea pedis. You can also get tinea cruris. If people with a fungal infection of the foot don’t put on their socks before they put on their underwear, they’re going to get it in the groin. In fact, when I see newer patients with tinea cruris, the first thing I do is ask to look at their feet. I have found that when patients have tinea cruris, six out of 10 times they will have tinea of the foot.
We should also emphasize looking at the palms and soles because the two go together. This is important for practitioners.

When Is Combination Therapy Appropriate?
Dr. Joseph: You might see even more of a benefit with combination therapy for tinea pedis. It would be similar to what we talked about doing for onychomycosis, with the oral medication working from the inside out and the topical working from the outside in. We’ll get to a little bit of what Dr. Gupta was talking about. He handles the xerosis. Well, in some of the cream formulations, you’ve got the cosmetic benefit of using the combination to moisturize the skin a little bit so the patient’s foot is less scaly. You also have the antifungal benefit with the oral. From a discussion standpoint, what are everyone’s feelings about combination therapy?
Dr. Spielfogel: Actually, for plantar tinea pedis, I don’t use a topical, but if you start dealing with an interdigital tinea pedis, I think there’s a high incidence rate of having a Candida component. The griseofulvin is not going to really knock out the Candida, so that’s when I start using the topical in conjunction with the ultramicrosize griseofulvin. If you look at the Zaias study, there was a higher cure rate only when treating the interdigital tinea pedis with topical medication and the ultramicrosize griseofulvin together. So I think it’s only because of the Candida. That’s what I’ve been doing and I’ve been getting good results.
Dr. Joseph: I’ll go one step further on the Candida. I think the use of the topical interdigitally also helps the environment. For instance, if I’ve got an interdigital tinea, especially the macerated interdigital, I use a gel, which tend to be alcohol-based and dry out a little bit easier. A lot of that work —not only the gels per se, but the whole environmental work—was done by Jim Leyden, MD, where he used the terms dermatophytosis simplex versus dermatophytosis complex and showed how it was an environmental issue.8 I like using something interdigitally. I don’t know if it’s the Candida so much. I just like it from an environmental standpoint.
Dr. Spielfogel: The whole issue of occlusive footwear and patient hygiene comes into play, and I think it’s very important. In addition to treating these infections, we have to tell our patients to take care of their feet. We have to emphasize drying the feet and using powders. This will also aid in clearing infections.

Dr. Joseph: I’m going to talk about the maintenance strategies in a little bit. Dr. Shin, what are your feelings about combination therapy in your pediatric population?
Dr. Shin: If you are concerned about a possible secondary infection like Candida or a bacteria, some of the newer topicals may be beneficial. Terbinafine and ciclopirox actually have antiinflammatory as well as antibacterial activity. Terbinafine does not cover Candida, but ciclopirox does. So I think in theory, there is an added benefit with topical therapy. However, the evidence for combination therapy is limited.
Dr. Blass: I do not use a lot of combination therapy. If you look at the Zaias study carefully, the point where he gets the most effectiveness of combination therapy is interdigitally.1 Now that is the only place where I will emphasize to a patient the use of anything else other than the oral I’m going to use. Call me one of the old guys, but I still send patients to a pharmacy that still has white Iodide, which is also known as a tincture of iodides. You are talking about something that will kill Candida and is extremely drying.
I’m not completely sure the combination therapies do not work as well for the other forms as they do for the interdigital form. I’m not sure it doesn’t have to do with the fact that you’re making patients get down there between their toes. I don’t know how much importance there is in what they put between their toes. However, if they’re going to apply it twice a day, it means getting out of the shower or bath, and addressing the interdigital areas, which most people do not. They get out of the shower, stand on a bath mat and assume their feet are dry. If you’ve got to get down there and rub something in between your toes, and there’s moisture there, you’re going to have to wipe out that moisture. I’m not sure how much of the benefit is coming from the drug versus the mechanical need for the patients to get in there and increase their hygiene in the interspaces.
Dr. Joseph: It’s important that we do whatever we can to get patients, especially diabetic patients, to pay more attention to their feet. It’s an interesting point.

Emphasizing The Need For More Evidence-Based Studies On Combination Therapy
Dr. Gupta: I hate to put a damper on everything, but I think we need to go back and look at evidence-based medicine. It’s important to look and see what the evidence is for monotherapy versus combination therapy. It is important that we do in vitro susceptibility tests. Why has the dosing of griseofulvin gone up over the years? We need to look at the in vitro susceptibility to the T. rubrum, for example, for tinea pedis and see whether the MICs have gone up.
Dr. Joseph: A consensus panel is good, but randomized control trials are the best way to go. We know fungus is an area that needs a lot more study. To the best of my knowledge, there are still no published NCCLS guidelines on the dermatophytes. I mean it’s getting there. They are including some fungus now. However, they still haven’t gotten to the point of dermatophyte testing. Also keep in mind that the average hospital lab that you are sending a fungus to is not doing susceptibility tests, because the NCCLS has not approved any sort of clinical usage. It’s not included in the guidelines.

Can Keratolytics Be Effective?
Dr. Shin: Is there a role for keratolytics in these patients? In the population that I see, hyperkeratosis is not as much of an issue, but I am curious if there is any added benefit when using them.
Dr. Joseph: That’s a real good point. Some keratolytic formulations may actually have some inherent antifungal activity also. Plus they are keratolytic so you are making the skin look better and possibly also killing the fungus at the same time. So I think that’s a great point.
Dr. Gupta: As far as interdigital tinea pedis goes, I don’t think you need a keratolytic. It’s probably going to be counterproductive. In treating plantar tinea pedis, I think a keratolytic would be helpful in some instances and unnecessary in others.
Dr. Spielfogel: I may use a keratolytic in addition to griseofulvin when there is plantar scaling and fissuring on the heel in combination with the tinea. We have to address the fissured skin which can be very painful. I think that’s a good opportunity to use a keratolytic in combination with griseofulvin.
Dr. Joseph: I think that’s a good place. I find the fissures a good place for a keratolytic.

Discussing The Disparity Of Tinea Prevalence Between Men And Women
Dr. Joseph: I’m just curious what everyone’s feeling is on this. The point was made that men have a higher incidence of tinea pedis than women. Do you think this can be attributed to lifestyle, a hygiene thing or is there anything else associated with that?

Dr. Spielfogel: I really don’t know what the answer is. Maybe it is a hygiene issue. Maybe men wear more occlusive footwear than women do. Maybe women are more meticulous in taking care of themselves. Other than that, I don’t know. Does anybody else have any ideas?
Dr. Joseph: How many pairs of shoes do you have, Dr. Shin? I’ve been wearing these for three days now.

Are There Any Ethnic Or Racial Differences
For Tinea Pedis Prevalence?
Dr. Joseph: As far as the incidence of tinea pedis goes, has anyone seen any racial differences? Are there any ethnic background differences?
Dr. Blass: I think there certainly is with tinea capitis. I have a very mixed population in Tampa. Although I haven’t sat down and done a study, just from my clinical experience, I don’t see a lot of racial or ethnic differences with tinea pedis other than which groups seek medical care more frequently.
Dr. Gupta: I don’t think there is any racial predisposition. However, there are certain countries in the world, like India and China for example, that have much more diabetes. Eventually, they may end up with more tinea pedis for that reason.

Moist Skin, Dry Skin Or Genetic Predisposition: What Plays A Greater Role In Tinea Pedis?
Dr. Shin: Is there any correlation with the amount of sweating? Are patients with hyperhidrosis more likely to have tinea pedis?
Dr. Blass: I see it much more. A lot of my patients work in the shrimp business where they are wet all the time. Now, of course, hyperhidrosis is just liquid. It doesn’t matter where the liquid originates. However, the number of people in the shrimping business who come into my office with outrageous fungus infections is really odd.
Dr. Shin: So the moisture is a factor no matter where it is coming from.
Dr. Joseph: Glynn Evans, MD, did some work on pool decks in the UK. He cultured pool decks and found a lot of T. rubrum and a higher rate of infection.9 The whole theory was as the stratum corneum becomes hydrated, the cells kind of move apart a little bit, which gives more access. Theoretically, moist skin would have more fungus.
However, I think this gets back to the genetic predisposition because somebody might get the fungus if they are able to mount some mediated response. In the VA population, we see more of the elderly patients who have real dry skin and have the tinea pedis, so the tinea seems to be associated with the drying skin more than the wet skin.
Dr. Blass: When I was in school, we tried to put together a study that never really went anywhere because we needed a group of people with tinea infections. We brewed tinea rubrum and took a bunch of people and soaked their feet in it. About 40 percent of them developed skin fungus infections and the other 60 percent did not. We postulated that perhaps because of the thickness of the stratum corneum or whatever, this stuff just wasn’t getting in there. So we ran the same study but we abraded the skin before soaking. With just two exceptions, the same people who got it the first time got it the second time and the same people who didn’t were spared. In our profession, we handle tinea constantly yet I don’t know if I’ve ever read of a higher incidence of tinea in the hands in podiatrists or in health care workers.
Dr. Joseph: I think it’s just genetic predisposition.

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