Treatment of Refractory Extensive Athlete's Foot

Immediate Next Steps

Before switching therapy, obtain fungal cultures and consider discontinuing antifungals for a few days to optimize specimen collection, as recommended by the guideline society, to verify treatment failure 1
Use pulse dosing of oral itraconazole, 200-400 mg per day for 1 week per month, for the treatment of extensive athlete's foot, as recommended by the guideline society 1

Oral itraconazole is the recommended alternative when terbinafine fails, with similar mycological efficacy to terbinafine but may have slightly higher relapse rates, according to the British Journal of Dermatology 1
For extensive tinea pedis, consider continuous dosing of itraconazole for 2 weeks at 100 mg daily, as recommended by the British Journal of Dermatology 2
Itraconazole should be taken with food and acidic pH for optimal absorption, as recommended by the British Journal of Dermatology 3
Fluconazole is less effective than both terbinafine and itraconazole for dermatophyte infections, but can be used as an alternative option, with dosing of 150 mg once weekly as pulse therapy, according to the guideline society 1

Apply foot powder after bathing to reduce recurrence, from 8.5% to 2.1%, as recommended by the guideline society 1
Change socks daily and clean athletic footwear periodically to prevent reinfection, as recommended by the guideline society 1
Examine and treat concomitant onychomycosis, as nail infection serves as a reservoir for reinfection, according to the guideline society 1
Check for dermatophyte infection at other body sites, present in 25% of cases, and treat all infected family members simultaneously to prevent reinfection, as recommended by the guideline society 1

Monitor liver function tests at baseline and during prolonged therapy, especially with itraconazole, as recommended by the British Journal of Dermatology 3
Follow up carefully to ensure treatment effectiveness, as recommended by Clinical Infectious Diseases 4
Consider culture at end of treatment to confirm mycological clearance, as recommended by the British Journal of Dermatology 2

Do not assume treatment failure is due to drug resistance alone, as poor compliance, inadequate drug penetration, bacterial superinfection, or reinfection from nails/footwear are more common causes, according to the British Journal of Dermatology 3
Do not treat the feet in isolation, failure to address nail involvement or other body sites leads to recurrence, as recommended by the guideline society 1