Therapy guide · medical education
Ringworm, jock itch & athlete's foot (tinea infections): the full therapy pathway
One organism, three postcodes, and a failure mode written into the packaging: the itch stops in days, the label asks for weeks, and the gap between those two numbers is where almost every recurrence is born. Here is what the shelf genuinely cures, how long the cure actually takes, and the point at which a rash that will not clear stops being a shopping problem.
Before anything else
Not everyone should start at the bottom of this pathway. These presentations are reasons to
see a clinician without waiting out an over-the-counter trial first.
- Spreading redness with pain, warmth, swelling or fever Seek care quickly
Cracked, macerated skin between the toes is one of the recognised doorways for bacterial cellulitis, and cellulitis moves on a scale of hours to days rather than weeks. Heat, tenderness, an advancing edge or feeling unwell alongside a foot infection is a same-week problem at the latest, and antifungal treatment is not the answer to it.
- Any foot rash, crack or ulcer in someone with diabetes or poor circulation See a dermatologist soon
In a foot with reduced sensation or blood supply, split skin is not a cosmetic detail — it is an entry point in tissue that heals badly. Assessment happens early rather than after a course has been tried, and self-directed cutting, filing or strong keratolytics come off the table entirely.
- A widespread or fast-moving rash during immunosuppression See a dermatologist soon
Transplant medication, chemotherapy, long-term high-dose steroids and untreated HIV all change how dermatophyte infection behaves — it spreads further, invades deeper, and answers less predictably to short topical courses. Extensive disease in this setting is assessed rather than self-treated.
- Scaling, pustules or hair loss on the scalp or beard, especially in a child See a dermatologist soon
Infection inside hair follicles cannot be reached by anything applied to the surface, and untreated it can end in permanent scarring hair loss. It is treated with oral medication as standard, and a boggy, tender swelling on a child's scalp needs assessment quickly rather than at the next convenient slot.
- A rash that keeps expanding while a steroid cream is being used on it Worth a clinician visit
Corticosteroids relieve the itch of tinea genuinely, which is what makes them dangerous here: the symptom improves while the infection spreads underneath, and the rash that emerges weeks later is larger, less typical and harder to identify. Expansion under a steroid is a reason to re-open the diagnosis, not to increase the strength.
Which route on this page applies?
Six branches sit below, and they split on treatment history rather than on body part — because the ladder is nearly identical whether this is on a shoulder, in a groin or between two toes. Six questions, about a minute.
Answers stay in this browser. Nothing is sent anywhere and one button clears them.
One thing to be clear about. This places a reader on the map; it cannot identify an organism, and neither can a mirror. Several common conditions imitate this one closely, and the only thing that settles it is a scraping under a microscope. Wherever this routing lands, that test outranks it.
What this looks like
There is no staging system for tinea in the sense that psoriasis or acne has one. What clinicians actually sort on is extent, thickness and interference — how much skin is involved, whether the surface has thickened enough to keep drug out, and whether anything has already been applied that changed the picture. Those three questions decide topical versus oral more reliably than which body part is affected.
Localised and untouched
One or a few defined patches, or peeling confined to the toe-webs, on skin that has had nothing applied to it yet.
What it looks like: A ring or oval with a raised, scaly, sometimes blistered edge and a paler centre; or damp, white, split skin between the fourth and fifth toes; or a sharply bordered rash spreading from the groin crease onto the inner thigh. This is the presentation the shelf was built for, and it clears reliably when the course is finished.
Extensive or multi-site
Large areas, several separate patches, or two and three sites at once — typically feet plus groin, feet plus hand, or trunk plus limbs.
What it looks like: Rings that have merged into scalloped sheets, or an infection that has clearly travelled: both feet scaling and one palm thickened, or the groin flaring every summer in someone whose toe-webs have peeled for a decade. Creams still work here, but the area to be covered and the number of sites make oral treatment a reasonable first move rather than a failure.
Thickened and dry — the moccasin pattern
Diffuse scaling across the soles, heels and side of the foot, often for years, frequently filed under dry skin.
What it looks like: A fine, silvery, powdery scale over the whole weight-bearing surface, with cracked heels and a sharp edge where it stops partway up the side of the foot. It rarely itches much, which is exactly why it goes untreated. The thickened surface is a physical barrier to cream, so this presentation responds slowly to topicals and is the one most likely to need softening first or tablets instead.
Already treated, and no longer looking like itself
The picture after a steroid cream, a combination cream used too long, or several partial antifungal courses.
What it looks like: A patch that lost its scale and its ring, spread outward with a vague pink border, and possibly thinned or striped the skin where the cream sat longest. The itch improved, then returned larger. Nothing about the surface can be trusted at this point, which is why this presentation is a confirmation problem before it is a treatment one.
Three things that change the plan regardless of severity
An untreated reservoir somewhere else
Groin and body infections are frequently seeded from feet, and feet are frequently seeded from nails — the same organism moving on hands, towels and trouser legs. Treating the visible patch while leaving the source untreated produces a clean cure followed by a reliable relapse, which is then filed as the cream not working. Finding every site before treating one is the single change that turns a recurring problem into a finished one.
Heavy sweating, occlusive footwear, long shifts
Humidity inside footwear is a measured risk factor rather than a folk belief, and the length of time shoes stay on matters as much as the shoes themselves. Nurses, soldiers, chefs, hikers and anyone in safety boots are treating an infection while the conditions that caused it continue, so the microclimate work is not optional garnish here — it is the part that decides whether the cure survives the next month.
Diabetes, poor circulation or suppressed immunity
The infection behaves the same; the consequences do not. Cracked, macerated skin between toes is a recognised entry point for bacterial cellulitis, and a foot that heals poorly turns a nuisance into a risk. Thresholds drop accordingly: earlier assessment, lower tolerance for a rash that is not settling, and a preference for finishing treatment properly the first time.
A corticosteroid has been applied to it
Corticosteroids suppress the inflammation that produces the ring, the scale and the itch, so the rash looks better while the colony has one less obstacle. Weeks later the area is larger and harder to recognise, and the skin where the cream sat may be thinned. This is the one modifier that changes the diagnosis rather than the plan, and it is why a laboratory confirmation earns its keep here more than anywhere else on the page.
What else it could be
- Discoid eczema — Coin-shaped, itchy plaques that can be almost indistinguishable from ringworm — and are the commonest reason an antifungal gets used for months on something that was never fungal. Eczema tends to be scaly all the way across rather than clearing in the middle, and it usually arrives on dry skin in company rather than alone.
- Inverse psoriasis in the groin — Smooth, shiny, sharply bordered redness in the crease with little scale, and often the same thing under the breasts or in the armpits. It does not advance as a ring, it does not usually itch as fiercely, and antifungals do nothing for it.
- Erythrasma — A bacterial look-alike in the same folds — flat, brown-pink, finely wrinkled, remarkably unimpressive. It glows coral-pink under a Wood's lamp, which is a thirty-second test that separates it from tinea in the clinic room and nowhere else.
- Irritant or allergic contact dermatitis — Common on feet, where shoe rubber, adhesives and chromium in leather all cause it. The giveaway is geography: contact dermatitis follows the shape of the contact, tends to spare the toe-webs, and often affects the top of the foot rather than the sole.
- Granuloma annulare — A ring that fools people precisely because it is a ring — but a smooth, firm, bumpy one with no scale at all and usually no itch. Scale is the sorting feature: dermatophytes shed, this does not.
The list matters more here than on most pages because the treatment is cheap, easy and available without a prescription, which means the wrong diagnosis can be treated persistently for a very long time before anyone questions it. Microscopy on a skin scraping settles it in minutes; culture names the organism in a couple of weeks. Both are worth asking about whenever a rash has already resisted one complete, correctly finished course.
Why it happens
Dermatophytes are fungi that eat keratin, and skin is made of it. A colony lands on the outer layer, digests its way outward, and the immune response follows the advancing front — which is why the classic lesion is a ring: an inflamed, scaly, itchy border with a quieter centre the fungus has already finished with. Trichophyton rubrum causes most of it worldwide, with Trichophyton mentagrophytes behind it. The names change with the address and nothing else does: on the trunk and limbs it is called tinea corporis and gets called ringworm, in the groin it is tinea cruris and gets called jock itch, on the feet it is tinea pedis and gets called athlete's foot. One organism, one treatment ladder, three vocabularies. What differs between the sites is not the fungus but the microclimate: warm, damp, occluded skin is where it thrives, which is why feet inside shoes and skin folds under clothing are where it keeps returning.
Anyone looking at a scaly ring that appeared last month; anyone whose toe-webs have peeled and itched on and off for years and who has quietly accepted it; anyone who has cleared jock itch three times and concluded the creams do not work; and anyone who was handed a steroid cream for an itchy patch and watched it get larger. It also covers the reader whose soles have been dry and flaking for so long that nobody, including several clinicians, has thought to test them.
Orientation, not diagnosis. This page maps dermatophyte infection of ordinary skin. It deliberately stops at three borders. Hair-bearing scalp and beard are excluded, because infection there sits inside the hair follicle where creams cannot follow and oral treatment is standard. Nails are excluded for the same physical reason and have their own page here. And yeast infection of skin folds, which looks similar and answers to different treatment, is a separate problem. The over-the-counter labels state this border themselves, in one line: not effective on the scalp or nails.
Everything in this section is sold without a prescription The over-the-counter pathway
This is one of the shorter distances on this site between a shelf and a cure. Localised dermatophyte infection of ordinary skin is genuinely curable with products sold without a prescription, and the evidence behind them is unusually solid — systematic review evidence covers dozens of trials across the groin, trunk and feet. The ceiling is not potency. It is anatomy, extent and interference. Anatomy: hair-bearing scalp, beard and nails sit behind a physical barrier no cream crosses, and the labels say so outright. Extent: a rash across large areas, at several sites at once, or in someone whose immune system is suppressed is a reasonable place to start with tablets rather than to finish with them. Interference: once a corticosteroid has been over the top of it for weeks, the appearance stops being trustworthy and the useful next step is confirmation rather than a different tube. Within those three limits, the aisle does the whole job — provided the course actually gets finished.
Appropriate for: Localised, uncomplicated infection of ordinary skin on the trunk, limbs, groin or feet, in someone whose immune system is intact and who can keep applying a cream daily for the number of weeks printed on it. That description covers the large majority of people who ever get this.
Very little on this site can be cured outright with a purchase from a pharmacy shelf. This can. What makes it fail is almost never the product and almost always the calendar, so the chart below is built around a number rather than a shopping list: the number of weeks printed under Directions, and the very different number of days it takes for the skin to look fine.
The rule the whole ramp is built on: the box counts weeks, the itch counts days
Symptoms settle first and fastest. The itch usually eases within two or three days of the first correct application and the redness follows within a week or so — at which point, on a monograph azole cream for ringworm or athlete's foot, roughly a quarter of the authorised course has been used. The label's four weeks were set against laboratory clearance of the organism, not against how the skin looks, and the packaging says so in its own way by asking for a doctor's opinion if nothing has improved by that point. Stopping when the skin looks normal therefore ends treatment in the middle of it, and the colony that survives regrows over the following weeks. That return is then read as a treatment that did not work, and the same course gets bought and abandoned again. It did work. It was interrupted.
Four rules that matter more than which tube gets bought
- Read the duration off the box before the first application, and treat that number as the plan — two weeks for jock itch, four for ringworm and athlete's foot on the monograph creams, one to two for the allylamines.
- Find every site before treating one. Feet reinfect groins, nails reinfect feet, and a towel reinfects everything.
- Apply beyond the visible border, not onto it. The advancing edge is ahead of what can be seen.
- A corticosteroid cream does not belong on an unexamined itchy ring — it relieves the symptom while removing an obstacle for the infection.
Answer as you go and the chart tracks where you are. Nothing is sent anywhere.
- Before the first purchaseYou are here
Map every site first
Treat one infection rather than one patch of it.
What this step involves
Morning
- Check the whole map, not the complaint Both feet including every toe-web, the groin and buttock crease, the trunk and limbs, both palms, and all twenty nails. Dermatophyte infection travels, and the site that itches is often not the site it started at.
Evening
- Note what is outside this page Hair-bearing scalp or beard, and any thickened, discoloured or crumbling nail. Neither answers to anything applied to the skin surface, and both change what the appointment is about.
Why this step: Groin infections are frequently supplied by feet and feet are frequently supplied by nails; treating the visible complaint alone is the commonest structural reason a completed course still ends in recurrence.
Ready for the next step?
Has every site been checked, including both feet and all the nails?
Yes, the full map is known: Continue to step 1 below and treat everything found at the same time. Go to step 1 ↓
Scalp, beard or nails are involved: Those sit outside what this section can treat. The rest of the map can still be treated as below, but the appointment is now the priority rather than the purchase.
- Week 0You are here
Choose one active and read its course
Turn a purchase into a fixed-length commitment.
What this step involves
Morning
- Pick one active ingredient, not one brand Allylamine for the shortest course, monograph azole for the cheapest, either for the same destination. Front-of-pack names cover different molecules across products and countries; the active line on the panel is the only reliable identifier.
Evening
- Write the finish date down The end date computed from the box, on a phone reminder or the tube itself. This single act does more for the outcome than any upgrade in product.
Why this step: The whole ramp depends on the course being a known quantity from the start. A course with no end date written down is a course that ends when the symptoms do.
Ready for the next step?
Is one active chosen and its finish date written down somewhere?
Yes, dated: Go to step 2 and start applying it properly. Go to step 2 ↓
Not yet: Worth doing before starting. An undated course is the single strongest predictor of the recurrence this page exists to prevent.
- Daily, from week 0You are here
Wash, dry, then apply past the edge
Get the drug where the colony actually is.
What this step involves
Morning
- Wash the area and dry it completely Especially between the toes and in skin folds, where residual moisture both feeds the organism and dilutes what goes on next. A plain, non-stripping wash is all this needs. Browse all cleansers →
- Apply a thin layer well beyond the visible border A margin of roughly two centimetres of normal-looking skin around the patch, or the whole foot including the sole and both sides where the feet are involved rather than just the peeling web.
Evening
- Repeat as the label directs Once or twice daily depending on the product and the site — the frequency is part of the licensed course rather than a suggestion, and halving it halves the course.
Why this step: The infection extends past what is visible, which is why treating only the ring leaves a live margin behind. Treating the entire foot rather than the itchy web is the same principle applied to the site where it is most often ignored.
Ready for the next step?
Is the whole area plus a clear margin being covered, at the labelled frequency?
Yes: Continue, and go to step 3 if the soles are thickened rather than merely peeling. Go to step 3 ↓
Only the visible patch: Widen the application before changing anything else. Undertreating the margin looks exactly like a product that is not strong enough.
- Only where the soles are dry and thickenedYou are here
Thin a thickened sole before expecting a cream to work
Remove the physical barrier keeping the drug out.
What this step involves
Morning
- Antifungal to the whole sole and sides The affected zone is usually larger than it looks and has a sharp upper edge partway up the side of the foot; the whole area within that edge is treated.
Evening
- Moisturise with a keratolytic on the thickened area A urea or salicylic acid preparation intended for hard skin, applied at night for one to two weeks and then as needed, over the top of the day's antifungal rather than instead of it. Browse urea moisturizers →
Why this step: Compacted dead keratin is a poor surface for any topical drug to cross, which is why the moccasin pattern so often looks like antifungal failure when it is actually a delivery failure.
Ready for the next step?
Are the soles genuinely thickened and scaling, rather than just peeling between the toes?
Yes, thickened: Run this step alongside step 2 and expect the whole course to take four to six weeks rather than two. Go to step 4 ↓
No, ordinary skin: Skip this step entirely — keratolytics on thin skin cause irritation and contribute nothing. Go to step 4.
- Ongoing, from day oneYou are here
Change the conditions that allowed it
Stop treating an infection inside the environment that produced it.
What this step involves
Morning
- Dry socks, dry shoes, rotated Two pairs of shoes worn alternately so each dries fully, socks changed daily and washed hot, and feet dried deliberately between the toes rather than in passing. Humidity inside footwear is a measured risk factor, not a folk belief.
Evening
- Powder the fabric, not the split skin An absorbent powder in socks and shoes helps; the same powder packed into an already macerated toe-web does not. Loose clothing does the equivalent job in the groin. Browse all starches powders products →
Why this step: The organism needs warmth and trapped moisture to establish. Removing those does not clear an existing colony, but it decides whether the cleared skin stays that way once the tube is finished.
Ready for the next step?
Are the shoes rotating, the socks daily, and the feet dried properly between the toes?
Yes, all three: Go to step 5 — the part where most courses are lost. Go to step 5 ↓
Not consistently: These are the cheapest interventions on the page and the ones that determine whether this is the last course or the first of several. Continue the treatment either way and go to step 5.
- From the day it looks clear until the labelled finish dateYou are here
Keep going after it looks better
Complete the course rather than the symptom.
What this step involves
Morning
- Apply exactly as before No reduction in frequency, no shrinking of the treated area, no switching to every other day because the skin looks fine. Clear-looking skin at week one is the expected midpoint of a four-week course, not the end of it.
Evening
- Let discolouration go untreated A brown or pale mark where the patch was is pigment recovering and can persist for months after the fungus has gone. It is not a reason to extend treatment, and it is not a reason to restart it.
Why this step: This is the step the entire ramp exists for. Discontinuing once symptoms abate is the classic route to recurrence, and the recurrence is then attributed to the treatment rather than to its interruption.
Ready for the next step?
Has the course reached the finish date written down at step 1?
Yes, finished on schedule: The checkpoint below is now meaningful, because the course being judged was actually completed. Go to the checkpoint ↓
Not yet: Then there is nothing to judge yet. The checkpoint reads a finished course; a shortened one produces an answer about adherence rather than about the infection.
The checkpoint sits at the label's finish date, not at the mirror's
At the end of the labelled course: two weeks for jock itch and four for ringworm or athlete's foot on the monograph creams, one to two weeks for an allylamine, four to six for a thickened sole.
How to judge it: By the border and the scale rather than by the colour. A flat, non-scaly, non-advancing area is a cleared one even if it is still discoloured. A raised, scaly or expanding edge at the finish date is an unfinished infection regardless of how much better it feels.
At the labelled finish date, with the course genuinely completed, what is the skin doing?
Cured — and the next fortnight decides whether it stays that way.
This is the ordinary outcome and it is what the over-the-counter tier is for. The work that remains is not treatment but defence: the untreated sites found at step 0 get finished too, footwear keeps rotating, and where the pattern has historically been seasonal or occupational, a licensed preventive product has a standing role. Residual discolouration fades over months and needs nothing.
A real response that has not finished.
Partial response at the finish date usually means one of three things: the area treated was smaller than the area infected, the frequency slipped, or the site simply turns over slowly — which is normal for thickened soles. Extending an over-the-counter course beyond its labelled duration is a conversation for a pharmacist rather than an assumption, and it is a reasonable one where the direction of travel is clearly right.
The course has done its job as a test: this needs identifying rather than re-treating.
A completed, correctly applied course that changed nothing is informative. Four explanations sit behind it — the rash was never fungal, an untreated reservoir kept supplying it, the course was less complete than it felt, or the organism is resistant — and a scraping separates them for less than the price of the next tube. The packaging itself directs this outcome to a clinician, at two weeks for the groin and four for the feet and body.
Stop rather than escalate.
Worsening is not a stronger version of no response. A rash that worsens in the exact outline of where cream was applied points at an allergy to the cream; one that spreads with pain, warmth, swelling or fever points at a bacterial infection needing prompt attention rather than an antifungal; and one enlarging under a corticosteroid points at an infection being masked. Each has a different answer and none of them is a bigger tube.
These do not wait for the finish date
Spreading redness with pain, warmth or fever, particularly on a foot with split skin between the toes, because that is the classic doorway for bacterial cellulitis and it moves on a scale of days. Any foot problem at all where there is diabetes, neuropathy or poor circulation. A widespread or fast-moving rash during immunosuppression. Scalp or beard involvement, especially in a child, where untreated infection can end in permanent hair loss. And a rash still expanding under a steroid cream, which needs the diagnosis re-opened rather than the prescription renewed.
Photographs at the start and at the finish date are worth more than memory here, because improvement is gradual and the border is the thing being judged. Anyone treating the groin or trunk should also photograph the feet, since they are the most frequently missed source and the least likely to be remembered accurately weeks later.
Where the over-the-counter pathway ends
It ends at three borders and one event. The borders are anatomical and physical: scalp and beard, nails, and skin so extensively involved that covering it daily by hand is not a realistic plan. The event is a finished course that changed nothing — which is the most useful thing this tier produces, because it converts a vague complaint into a specific question a clinician can act on. What crosses over is a known active, a known duration that was genuinely completed, a map of every site, and the answer to whether anything with a steroid in it has been over the top. Those four facts turn the next appointment from a guess into a decision.
See the prescription pathway →Ringworm, jock itch & athlete's foot (tinea infections): the full therapy pathway · dermapproved.com/treatments/ringworm-and-athletes-foot/ · not a diagnosis — confirm anything you act on with a clinician
What to expect
Two timescales run at once here and confusing them is the whole difficulty. The symptom clock is fast: itch eases in days, redness in a week or so, and the skin looks essentially normal long before treatment is due to end. The organism clock is slow, and it is the one the label was written against — two weeks in the groin, four on the body and feet for the monograph creams, longer again for a thickened sole. Between those two clocks sits every recurrence on this page. Expect the visible result early and keep going anyway. Expect discolouration where the patch was to outlast the infection by months, and expect it to need nothing. Expect a thickened sole to improve slowly and unevenly rather than in a clean sweep. And expect that if this returns, the likeliest explanation is not a resistant organism but an interrupted course or an untreated site — which is good news, because both are fixable without a prescription.
- Write the finish date down before the first application; an undated course ends when the symptoms do
- Treat every site at once, not in sequence — sequential treatment is how a household or a body re-supplies itself indefinitely
- Judge the border and the scale rather than the colour; pigment change is the last thing to go and means nothing
- Keep a completed course completed even during the final week, when it feels most pointless and matters most
- Bring the tube and the dates to any appointment, because an interrupted course and a failed one look identical and lead in opposite directions
This page is due for review whenever the regulatory or resistance picture moves, and both are live: the over-the-counter active list has been stable for a generation while terbinafine-resistant organisms have gone from a regional epidemic to reported cases across several continents in a few years. If that spreads far enough to change what a first course should be, this page changes with it — and the ingredient library and the nail infection guide here carry the parts of the story that sit outside the skin.
What would bring you back sooner
Whatever step you are on, these do not wait for the end of a trial period. They are the same
presentations listed at the top of this page — repeated here because that is where they
matter, rather than where they were easiest to put.
- Spreading redness with pain, warmth, swelling or fever Seek care quickly
- Any foot rash, crack or ulcer in someone with diabetes or poor circulation See a dermatologist soon
- A widespread or fast-moving rash during immunosuppression See a dermatologist soon
- Scaling, pustules or hair loss on the scalp or beard, especially in a child See a dermatologist soon
- A rash that keeps expanding while a steroid cream is being used on it Worth a clinician visit
Prescription only — from here on, this is a clinician's decision The prescription pathway
Why this tier exists. Four things this tier cannot do, and no amount of persistence changes them. It cannot treat hair-bearing scalp, beard or nails. It cannot reliably clear infection spread across large areas or several sites at once. It cannot tell a dermatophyte from the several conditions that imitate one, which is why a rash that survives a completed course needs identifying rather than re-treating. And it cannot undo what a corticosteroid has done to the picture — only time off it, and a scraping, can do that.
The ladder barely changes between the trunk, the groin and the feet, so the routes on this map split on something else: how far the infection has spread, whether it has already been treated, and whether a steroid cream has been over the top of it. Only the last of those changes the biology; all of them change what happens next.
The same pathway in full below — each step names what it involves, why it sits where it does, and what tells you it's time to move up. Tap any therapy to jump to its detail.
A first, localised patch — trunk, groin or toe-webs
One or a few defined patches on skin that has had nothing applied to it, in someone otherwise well. The commonest route on the page, and the one the over-the-counter tier was designed to finish.
You reach this column when: The labelled course was genuinely completed and the rash is unchanged, or it is still visibly advancing at the packet's own review point — two weeks for jock itch, four for ringworm and athlete's foot.
- Prescription topical
A prescription topical, or a short combination for severe itch
Why this step sits here: Two different reasons to be here. Where the obstacle was tolerance or an awkward site, a prescription topical widens the choice and sometimes shortens the course. Where inflammation and itch are severe enough to be the problem in themselves, a licensed antifungal-plus-corticosteroid combination has a narrow, time-boxed place — one to two weeks, and the licence itself instructs a diagnosis review if nothing improves. Where a complete course has already failed, a scraping belongs here rather than a third tube.
When to move up
- A fair trial
- The licensed course for whichever agent is prescribed, which is between one and four weeks.
- Improvement looks like
- A settled, flat, non-scaly surface with no advancing border at the end of the course.
- Move up if
- No meaningful change after a completed prescription course, or the area is expanding while a combination cream is being used on it.
→ The next step up this pathway.
- Prescription oral
A systemic course
Why this step sits here: A localised patch that has resisted two complete topical courses is no longer behaving like an ordinary localised patch, and the productive move is to change the route of delivery and confirm what is actually being treated. Tablets solve the delivery problem; the scraping answers the question the two failures raised.
Two questions are worth settling before a systemic course on a small patch: whether the diagnosis has ever been confirmed in a laboratory, and whether an untreated site elsewhere — feet, nails, a household contact — has been quietly reinfecting the treated one. Both are cheaper to answer than a repeat course is to run.
After it clears, and the fortnight that decides whether it stays clear
Reinfection in the weeks after a cure comes from three places, in roughly this order: an untreated site on the same body, footwear and towels, and a household or training contact. Handling all three at once is cheap. The feet get checked whether or not they were the site treated, shoes get rotated so each pair dries, towels stop being shared, and where the pattern is seasonal or occupational the licensed prevention option has a standing role rather than a course.
Extensive, or several sites at once
Large areas, merged patches, or two and three sites simultaneously — commonly feet plus groin, or feet plus one hand. Creams still work; the question is whether covering that much skin daily for a month is the realistic plan.
You reach this column when: The area involved is genuinely too large to treat reliably by hand, sites keep reappearing as others clear, or immunity is suppressed — in which case systemic treatment is a reasonable first move rather than a last one.
- Prescription oral
A systemic course covering all sites together
Why this step sits here: Where infection is widespread or at several sites, the obstacle is coverage rather than potency, and a tablet solves coverage by definition. Consensus guidance places systemic treatment at extensive, chronic or recurrent disease precisely for that reason, and confirming the organism before a systemic course is standard practice rather than an extra hurdle.
When to move up
- A fair trial
- The prescribed course, with the verdict read a few weeks after the last tablet rather than on the day of it — the drug persists in skin after the course ends.
- Improvement looks like
- All sites flattening and de-scaling over the weeks following the course, with no new patches appearing.
- Move up if
- A completed systemic course leaves the rash unchanged, or new areas appear during it.
→ The next step up this pathway.
- Specialist care
Specialist assessment and identification
Why this step sits here: Extensive disease that survives a systemic course raises questions a further prescription cannot answer: what the organism is, whether it is resistant, whether immunity is intact, and whether the diagnosis holds. Dermatology and the laboratory answer those together.
Widespread dermatophytosis that resists standard treatment is also worth reviewing for what sits behind it — undiagnosed diabetes and suppressed immunity both present this way, and neither is found by looking harder at the rash.
Thickened, scaling soles — the moccasin pattern
Diffuse dry scaling across the soles and heels, often for years and often filed as dry skin. Frequently barely itchy, which is why it is the presentation most likely to be treated last and least.
You reach this column when: Scaling persists after six weeks of genuinely consistent treatment, fissures keep splitting, or the toenails are visibly involved — nails do not answer to any of this and keep the foot supplied.
- Prescription topical
A prescription topical, on a properly prepared surface
Why this step sits here: A wider choice of agent applied to a surface that has actually been thinned is a genuinely different attempt from the first one, rather than a repeat with a better label. Confirmation belongs here too, because psoriasis and long-standing eczema of the sole imitate this pattern closely and answer to nothing on this page.
When to move up
- A fair trial
- The licensed course, run to its end on a maintained, thinned surface.
- Improvement looks like
- Progressive de-scaling across the whole affected zone rather than in patches.
- Move up if
- No change after a completed course on a prepared surface, or confirmation comes back pointing at something other than a dermatophyte.
→ The next step up this pathway.
- Prescription oral
A systemic course, with the nails considered alongside
Why this step sits here: Chronic hyperkeratotic foot infection is one of the classic indications for treating from the inside, and it is also the presentation where nail involvement most often turns out to be part of the same problem. Where both are present, the treatment decision is made once for both rather than twice in sequence.
Where the toenails are involved as well as the sole, the clocks differ enormously — skin answers in weeks, nail in months to a year — so a course that clears the sole and leaves the nails looking untouched has not failed. The nail page here covers what that timeline actually looks like.
Keeping a cleared sole cleared
A foot that has carried this for years has usually also been supplying the shoes, the socks and possibly the nails, so the period after clearance is when reinfection is most likely and least expected. Ongoing attention to the surface, footwear that dries between wears, and the licensed preventive option through the months and settings that historically triggered it are what convert a cure into an ending.
It clears, then comes back
Two, three or ten rounds of the same thing: treatment works, the skin looks normal, and weeks or months later it returns to the same place. The single most misread pattern on this page, because it looks like resistance and is almost never resistance.
You reach this column when: It returns despite a genuinely completed course across all sites with the preventive measures held, or the nails are involved and untreated.
- Prescription oral
A systemic course, with the source identified
Why this step sits here: Recurrent and chronic infection is a listed indication for systemic treatment, and reaching it after a properly run topical round is the sequence guidance describes rather than a shortcut. A scraping alongside answers whether the returning rash is the same organism or a different condition arriving in the same place, which are managed very differently.
When to move up
- A fair trial
- The prescribed course plus a defended interval afterwards, judged over months rather than weeks.
- Improvement looks like
- A clear interval that outlasts every previous one.
- Move up if
- It returns again after a systemic course, or it never fully cleared during one.
→ The next step up this pathway.
- Specialist care
Look for what keeps supplying it
Why this step sits here: Repeated recurrence after systemic treatment shifts the question from the rash to its supply: an untreated nail, a household or occupational contact, an animal, an immune reason infection keeps taking hold, or an organism that is not what was assumed. Each has a different answer and none is found by prescribing again.
Pets are a genuine and frequently missed source, particularly kittens and rabbits, and an animal can carry and transmit without any visible patch of its own. Where recurrence tracks a household rather than a person, a veterinary check and simultaneous treatment of everyone affected is what breaks the loop.
The defended baseline
For a minority of people this stops being an infection to cure and becomes an exposure to manage — communal changing rooms, safety boots, hot climates, heavy sweating. The licensed preventive option exists for exactly that situation, and treating the first day of an itch rather than the third week of one is what keeps each episode small.
A steroid cream has been on it
Any rash treated with a corticosteroid, or with an antifungal-plus-steroid combination beyond its short licensed course. The itch improved, the appearance changed, and the area is now larger and less recognisable.
You reach this column when: The area keeps expanding, the skin looks thinned or striped where the cream sat, or the diagnosis has never been confirmed in a laboratory — which at this point it needs to be.
- Prescription topical
Confirmation, then treatment aimed at what is actually there
Why this step sits here: A scraping does the work no amount of looking can here, and it is worth taking after a gap off antifungal treatment so the laboratory sees an untreated sample. If a dermatophyte is confirmed, treatment proceeds on a course chosen for the extent. If nothing fungal is found, the far more useful discovery is that a steroid was suppressing the symptoms of something else entirely.
When to move up
- A fair trial
- The licensed course of whichever treatment the result points to.
- Improvement looks like
- The border settling and holding rather than advancing, with steroid-related skin thinning recovering slowly over months.
- Move up if
- Confirmed dermatophyte infection that is extensive by this point, or that does not settle on a completed topical course.
→ The next step up this pathway.
- Prescription oral
A systemic course for what the steroid allowed to spread
Why this step sits here: Long-suppressed infection is often larger and more deeply established than anything that reached this page untreated, and the same coverage argument that applies to extensive disease applies here. It is treated as extensive disease with an unusually good explanation for how it got that way.
Where the steroid arrived by prescription for a rash nobody scraped, that is a common and forgivable sequence rather than anything to be embarrassed about — a very large volume of steroid-antifungal combination is prescribed for undiagnosed itchy rashes, and the diagnosis usually gets revisited only when someone finally asks for a scraping.
A complete, correct course finished — and it is still there
Not a rash that came back, and not one that was stopped early: one that was treated properly, to the end of the labelled course, and did not clear. That is a specific, informative event and it has four possible explanations.
- In-office procedure
Establish what is actually being treated
Why this step sits here: The four explanations are: the rash was never fungal, an untreated reservoir kept re-supplying it, the course was less complete than remembered, or the organism is resistant. Only one of those is a drug problem, and a scraping taken after a break from treatment separates them at a cost far below another course. False negatives on microscopy are common enough that a convincing rash with a negative result goes to culture rather than to a conclusion.
When to move up
- A fair trial
- One scraping, taken after a week or two off antifungal treatment so the sample is representative.
- Improvement looks like
- Not a treatment step — the outcome here is an answer, and an answer redirects everything downstream.
- Move up if
- A dermatophyte is confirmed and the previous course was genuinely completed, which points at delivery or at the organism itself.
→ The next step up this pathway.
- Prescription oral
Systemic treatment, chosen against the organism
Why this step sits here: Where infection is confirmed and topical treatment has genuinely failed, the systemic tier is the next step; where a terbinafine-resistant organism is suspected, the choice moves to the azole group, which acts on a different enzyme and remains effective against the resistant genotype, usually over a longer course than would otherwise be needed. This is a decision made against a laboratory result rather than a preference between drugs.
When to move up
- A fair trial
- The prescribed course, which for a resistant organism is characteristically longer than a standard one.
- Improvement looks like
- Steady flattening and de-scaling over the weeks of the course and the weeks after it.
- Move up if
- The infection persists through a completed systemic course.
→ The next step up this pathway.
- Specialist care
Species identification and susceptibility testing
Why this step sits here: At this point the useful question is no longer which drug but which organism, and how much drug it takes to inhibit it. Terbinafine resistance through mutations in the drug's own enzyme target is now documented, including in patients in the United States, and it is identified in a laboratory rather than inferred from frustration.
Travel history, household contacts and any previous courses taken abroad are directly relevant at this rung rather than incidental, because the resistant genotype has a geography and a treatment history behind it. Bringing that information to the appointment shortens it considerably.
Ringworm, jock itch & athlete's foot (tinea infections): the full therapy pathway · dermapproved.com/treatments/ringworm-and-athletes-foot/ · not a diagnosis — confirm anything you act on with a clinician
When the rules change
Two groups meet this condition on different terms, and in both cases most of the pathway stays open rather than closing.
Pregnancy and breastfeeding
The over-the-counter route stays open almost entirely, and the systemic tier is the part that waits — which costs very little, because skin infection of this kind is not urgent and topical treatment cures most of it anyway.
What can be used
- Topical antifungal creams, which are absorbed only minimally through intact skin and are commonly used during pregnancy
- The full microclimate and footwear routine, which is the half of the treatment that involves no medicine at all
- Keratolytics on limited areas for thickened soles, with a pharmacist confirming the strength
- A skin scraping, which carries no implications at all
What comes off the table
- Oral azole antifungals, which carry pregnancy restrictions in their labelling
- Assuming a systemic course is needed urgently — deferring it until afterwards is the usual and comfortable choice
- Applying anything on or near the nipple while feeding without asking first
Oral terbinafine sits in a middle category rather than a forbidden one: human pregnancy data are limited, so it is generally deferred, and where treatment genuinely cannot wait the decision is made individually with a clinician rather than by rule.
Children
Skin infection in children is treated on the same ladder with two adjustments: an age floor on the over-the-counter products, and a much lower threshold for involving a clinician where the scalp is anywhere near it.
What can be used
- Over-the-counter antifungal creams, which carry a general instruction not to use under two years of age without a doctor's direction
- The drying, footwear and towel routine, which works identically at any age
- Prescription topical and oral options, prescribed and dosed by a clinician
What comes off the table
- Antifungal-and-steroid combination creams, the most widely dispensed of which is not licensed under seventeen
- Treating scalp or beard involvement with anything applied to the surface
- Waiting on a boggy, tender, swollen area of scalp, which needs assessment quickly
Scalp infection is far more common in children than in adults, is treated with oral medication as standard, and can cause permanent scarring hair loss if it is left. Where a child has a scaly patch on the scalp with broken hairs or bald areas, that outranks anything on this page.
How an appointment actually happens, what to take to it, and how to keep your skin liveable while a prescription or procedure does its work.
What seeing a dermatologist actually looks like
Primary care covers most of this map: a general practitioner can examine the rash, take a scraping, prescribe both the topical and the oral tiers, and review the medication list that decides which oral agent is suitable. Pharmacists handle the over-the-counter tier and, in many countries, are the fastest route to a straight answer about which active and which duration a particular box carries. Podiatry is the parallel track for thickened, fissured or high-risk feet. Dermatology referral fits the harder questions: infection that survived a completed systemic course, a diagnosis that keeps changing, extensive disease during immunosuppression, or a rash that has been under a steroid long enough that nobody is certain what it was.
What to bring
- The exact product used, ideally the tube itself — the active ingredient and the printed duration are the two facts the appointment turns on
- How long it was applied for, and whether it was stopped when the skin looked better or at the date on the box
- Whether anything containing a corticosteroid has been on it, and for how long
- Photographs from the start of treatment, since improvement is gradual and memory is unreliable about borders
- A note of every site checked, including feet and nails that were not the reason for the appointment
- Travel history and any antifungal courses taken in another country, which are directly relevant where a course has already failed
Questions worth asking
- Can this be scraped and sent to a laboratory before we treat it again?
- Is the plan a topical or a systemic course, and what makes it that one for this presentation?
- How many weeks should this run, and what should the skin look like at the end of them?
- Is anything here containing a steroid, and if so, how long is it licensed to be used for?
- Are the feet and the nails part of this problem, and do they need treating alongside?
- If a completed course does not clear it, what happens next — a different drug, a culture, or a referral?
Cost and access. The economics on this page are unusually friendly. The monograph creams are among the cheapest drugs in any pharmacy, the allylamines cost slightly more and run shorter courses, and the generic oral agents are inexpensive in most systems. A skin scraping is a low-cost test and is frequently the best value on the page, because it either confirms a plan or cancels months of the wrong one. The expensive things here are indirect: repeated partial courses of the wrong product, and the months lost to a rash that was never fungal.
One sentence changes this appointment more than any other: asking whether the rash can be scraped before it is treated again. It is a cheap, quick test that is routinely skipped on a first presentation for perfectly good reasons, and becomes distinctly worth having once a full course has already failed or a steroid has been over the top of it. The second useful sentence is naming the exact product and the exact number of days it was used — the difference between an interrupted course and a failed one is invisible from the outside and decides the entire plan.
Finding someone to see
Most of this is handled without a specialist. Where a referral is needed, these are the national starting points for finding one, and a general practitioner or pharmacist remains the sensible first stop everywhere.
- US Find a dermatologist American Academy of Dermatology Searchable directory of board-certified dermatologists.
- UK Athlete's foot NHS The NHS route, including when to move from a pharmacist to a general practitioner.
- Canada Find a dermatologist Canadian Dermatology Association National directory.
- Australia Tinea healthdirect Australia Government-funded health information with a symptom checker and referral guidance.
Regions are listed only where a national service could be verified directly.
Skincare alongside therapy
Nothing in this section is a treatment, and one part of it decides more outcomes than the choice of cream does. Dermatophytes need warmth and trapped moisture to establish, so the habits below are less about comfort than about whether cleared skin stays cleared once the tube is finished.
Skin care around this condition has one job and one prohibition. The job is to keep treated skin intact and the surrounding environment dry, because cracked skin invites bacteria and damp skin invites the fungus back. The prohibition is corticosteroids on an unexamined rash: they relieve the itch honestly, which is exactly why they are so effective at hiding an infection that is still spreading.
While a course is running, on any site
The drug does the work; the routine keeps the drug's job small. Two failures dominate this period, and neither is pharmacological — an area treated smaller than the area infected, and a course that ends when the symptoms do.
Do
- Wash and dry the area properly before applying, particularly between the toes and in folds where residual water dilutes what goes on next
- Cover a margin of normal-looking skin around the visible patch, and the whole foot rather than the peeling web
- Use a separate towel for the feet, and never the same towel on feet and groin in the same session
- Put socks on before underwear where the groin and feet are both involved, so the trouser leg stops being the delivery route
- Wash bedding, towels and socks hot during the course rather than after it
Avoid
- Any corticosteroid cream over the top of it unless a clinician who has examined it has said so
- Switching product mid-course, which restarts the clock rather than accelerating it
- Covering a treated area with an occlusive dressing, which recreates the microclimate the treatment is fighting
What that looks like on a shelf: .
Where the soles are thickened rather than merely peeling
This is the one presentation where skin care is genuinely part of the pharmacology: a compacted surface keeps the drug out, so thinning it changes what the antifungal can reach. It is also the presentation where enthusiasm does damage, because a callus that is thinned too aggressively stops protecting the foot beneath it.
Do
- Apply a keratolytic intended for hard skin at night, over the day's antifungal rather than instead of it
- Expect the whole course to run four to six weeks rather than the packet's default two
- Treat the entire zone within the sharp upper edge, which usually runs partway up the side of the foot
- Deal with heel fissures as a wound rather than as dryness, since they are also a bacterial entry point
Avoid
- Keratolytics anywhere the skin is not visibly thickened, where they simply irritate
- Blades, credit-card scrapers and aggressive foot files, which remove more than the softened layer
- Doing any of this at home where there is diabetes, neuropathy or poor circulation — that step belongs with a podiatrist
What that looks like on a shelf: .
In the groin and the flexures specifically
Skin folds are warm, occluded and rubbed, which is why infection settles there and why potent steroids do more damage there than anywhere else. The same fold that makes the rash likely makes the cream more absorbed and the thinning more visible.
Do
- Choose loose cotton over anything synthetic and close-fitting while a course runs
- Dry the crease deliberately after washing, and change out of damp gym clothing promptly rather than eventually
- Treat the feet at the same time, since they are the commonest supply line to this site
Avoid
- Long or repeated courses of a steroid-containing cream in a fold, where the licence itself limits groin use to two weeks and asks for sparing application
- Talc and heavily fragranced powders in an already irritated crease
- Scratching, which spreads the organism onto fingers and from there onto everything else
What that looks like on a shelf: .
The weeks after it clears, which decide whether it stays clear
Reinfection arrives from three places in roughly this order: an untreated site on the same body, footwear and towels, and a household or training contact. All three are cheap to address and none of them requires a prescription.
Do
- Finish treating every site found at the start, including the ones that never itched
- Rotate two pairs of shoes so each dries fully between wears, and pull the insoles out overnight
- Wear sandals in communal wet areas permanently rather than during treatment only
- Treat the first day of a returning itch rather than the third week of one
Avoid
- Going straight back into the shoes worn throughout the infection without letting them dry out thoroughly
- Sharing towels, socks or footwear within a household while anyone is still being treated
- Assuming a nail that looks unchanged is uninvolved — it is the most patient reservoir on the foot
What that looks like on a shelf: .
The supporting shelf
Everything above is habit rather than product, which is unusual for this site and worth stating plainly: on this condition the shopping decisions are nearly all made in the treatment section, and the maintenance decisions are made with a second pair of shoes and a towel. Where a product does help — an absorbent powder, a keratolytic for thickened soles, a licensed preventive for feet that reinfect every summer — it is named in the chart above rather than here.
Every therapy named above, in full. Look things up here; it is not meant to be read end to end.
Every therapy, explained
Reference, not reading — every therapy named anywhere above, described the way a clinician would describe it. Nobody reads this section end to end; open the one you were sent here for. Which one is right for you is the appointment's job, not this page's.
Over the counter
Available without a prescription. Each one opens with what to look for on a label, which is the part that stays true regardless of which brand is on the shelf that month.
Over-the-counter Allylamine creams
Fungicidal topical, shortest course
Generally compatible
Allylamine creams
Fungicidal topical, shortest course
The over-the-counter creams that kill the organism outright rather than holding its growth in check, and the reason a one-week course can be a complete course.
At the shelf
The active ingredient line on the Drug Facts panel, and the duration printed under Directions.
Front-of-pack names are close to useless in this aisle: the same brand family covers different molecules across products and countries, and the version marketed for jock itch and the version marketed for athlete's foot are frequently the identical cream with a different course printed on the box. The active line and the directions line are the only two that decide anything. Where a product is sold as a gel, spray or solution rather than a cream, that is a preference about how it feels on macerated skin, not a difference in what it does.
Watch out for: Combination kits pairing a cream with a powder at a premium, and anything marketed on soothing botanicals alongside the active — the active is doing all the work.
- Terbinafine 1% cream, gel or solution — Sold without prescription in most markets; in the United States under an approved drug application rather than the antifungal monograph.
- Butenafine 1% cream — Chemically a benzylamine, functionally the same family and the same short courses.
Read the label
- Butenafine 1% cream — Drug Facts label DailyMed, US National Library of Medicine
How it works
Both block squalene epoxidase, an enzyme early in the fungal pathway that builds ergosterol for the cell membrane. Two things follow: the membrane cannot be maintained, and squalene accumulates inside the cell to toxic levels. The drug is also strongly lipophilic, so it lodges in the outer skin and keeps acting for days after the tube is put away.
What the evidence says well established
Systematic review evidence across the groin, trunk and feet places the allylamines among the most effective topical options, with cure rates that comfortably beat placebo and courses shorter than the azoles need.
Typical course
Short and site-specific on the label: between the toes, twice daily for a week; on the sole or side of the foot, twice daily for two weeks; for jock itch and ringworm, once daily for a week. Butenafine's interdigital option runs twice daily for one week or once daily for four.
Commonly discussed side effects
- Stinging or burning on first application, usually brief
- Dryness or peeling of treated skin
- Occasional contact allergy, which presents as the rash worsening in the exact shape of the application
Worth knowing
- The short course is short because the drug persists, not because the infection is nearly gone — cutting a one-week course to three days removes the reservoir the design depends on
- Apply well past the visible border; the advancing edge is ahead of what can be seen
- A rash that worsens in the precise outline of where cream was applied is more likely an allergy to the cream than a failure against the fungus
Pregnancy: Topical antifungals are absorbed only minimally through intact skin and are usually regarded as acceptable during pregnancy and breastfeeding; a pharmacist or clinician can confirm for the specific product and site, and application around the nipple is a separate conversation while feeding.
Why it sits where it does: It opens the ladder because it offers the highest cure rate on the shelf for the shortest commitment, and the commitment is the part people actually fail.
Over-the-counter Monograph azole creams
Growth-arresting topical, longer course
Generally compatible
Monograph azole creams
Growth-arresting topical, longer course
The long-established, widely stocked, inexpensive creams that most people mean when they say antifungal cream.
At the shelf
Clotrimazole 1% or miconazole nitrate 2% on the active line, and the four-week or two-week direction underneath it.
These are commodity products and price differences between them are largely packaging. What is worth reading is which condition the box is labelled for, because the directions differ by site rather than by molecule, and the shorter groin course on one box does not license a shorter foot course from the same tube. Anything in this aisle labelled for prevention rather than treatment is a different active with a different licence, and swapping one for the other mid-course restarts the clock.
Watch out for: Premium branding on a monograph active, and any pack whose distinguishing feature is a scent or a cooling sensation.
- Clotrimazole 1% — Monograph active; the labelled course is four weeks for ringworm and athlete's foot, two for jock itch.
- Miconazole nitrate 2% — Monograph active, and the one with additional professional labelling for superficial yeast infection.
Read the label
- OTC Monograph M005 — actives, warnings and directions US Food and Drug Administration
How it works
The azoles inhibit a different enzyme in the same ergosterol pathway, further downstream. The practical consequence is that they mostly stop the fungus multiplying rather than killing it outright, so the skin's own turnover has to carry the colony away — which takes weeks, and is why the labelled courses are as long as they are.
What the evidence says well established
Cochrane review evidence supports azole creams as effective against placebo for infections of the groin, trunk and feet; head-to-head data generally favour allylamines on speed rather than on final outcome.
Typical course
Twice daily, and the labelled duration is where the whole page turns: four weeks for athlete's foot and ringworm, two weeks for jock itch, with the packet's own instruction to consult a doctor if there is no improvement by that point.
Commonly discussed side effects
- Mild stinging or itching where applied
- Dryness
- Uncommon contact allergy
Worth knowing
- The four-week figure is not padding — it is the interval the label was authorised on, and the interval at which the packaging says to seek help if nothing has changed
- Symptoms typically settle in the first week, which is roughly a quarter of the way through the course for ringworm or athlete's foot
- Rubbing cream only onto the visible ring leaves the untreated margin the infection is already occupying
Pregnancy: Topical azoles have long, reassuring use in pregnancy including in vaginal preparations, and skin absorption is low; the usual caveat about confirming the specific product with a pharmacist applies, particularly for large treatment areas.
Why it sits where it does: It sits alongside the allylamines rather than below them because for most localised infections the destination is the same — the difference is how many weeks of adherence the destination costs.
Over-the-counter Tolnaftate
Monograph active with a licensed prevention claim
Generally compatible
Tolnaftate
Monograph active with a licensed prevention claim
A monograph antifungal with an unusual regulatory position: the only one in the United States list permitted to be sold for preventing athlete's foot as well as treating it.
At the shelf
Tolnaftate 1% on the active line, and whether the box is labelled for treatment or for prevention.
The two labels are not interchangeable even when the tube is identical: prevention wording authorises indefinite daily use on unaffected feet, treatment wording authorises a defined course on affected ones. For the person whose infection returns each summer, that distinction is the difference between an annual ritual and a defended baseline. Foot powders in this category do double duty by keeping the microclimate dry, which is a real contribution even where the drug delivery is modest.
Watch out for: Shoe sprays and insole treatments sold on the promise of sterilising footwear; the drying is useful and the sterilising claim is not supported.
How it works
Tolnaftate acts on the same early step in ergosterol synthesis as the allylamines, distorting the growing fungal filament rather than killing the colony outright. Against dermatophytes it is effective; against yeasts it is not, which is part of why it sits in a narrower niche than the azoles.
What the evidence says strong
Effective against dermatophyte skin infection in the trial base underpinning its monograph status, though generally outperformed on speed by the allylamines in comparative work.
Typical course
For treatment, the same monograph durations as the azoles. For prevention, a thin layer to the feet once or twice daily as an ongoing habit rather than a course with an end date.
Commonly discussed side effects
- Mild local irritation
- Rarely, contact allergy
Worth knowing
- Powders and sprays deposit far less drug than they appear to; for treating an active infection a cream reaches the skin more reliably
- The prevention licence applies to the foot, not to the groin or trunk
Pregnancy: Minimal absorption through intact skin and long over-the-counter history; as with the other topicals, confirming with a pharmacist takes a minute and settles it.
Why it sits where it does: It earns a card less for its treatment performance than for the licensed prevention role, which is the only regulated answer on the shelf to the reader whose feet reinfect every summer.
Over-the-counter Keratolytics for thickened skin
Penetration aid, not an antifungal
Generally compatible
Keratolytics for thickened skin
Penetration aid, not an antifungal
The step that exists because a thickened sole is a physical problem before it is a microbiological one.
At the shelf
Urea at a strength intended for hard skin on the feet, or a foot preparation naming salicylic acid.
Most urea on the shelf sits at low percentages intended purely as a moisturiser, which will not shift a built-up sole; the products that will are labelled for hard skin, callus or heel repair and say so. Application is worth getting right — a thick layer at night, covered if the packaging allows it, works far better than a smear in the morning. Once the surface has thinned, the antifungal goes on first and the keratolytic afterwards, so the drug meets skin rather than a layer of cream.
Watch out for: Foot peel masks marketed for smoothness; a single dramatic shed does not maintain the thinner surface that treatment needs over weeks.
- Urea preparations — Softens and breaks down built-up keratin; higher strengths are sold for hard skin on the feet.
- Salicylic acid preparations — Sheds the surface layer; the classic component of older compound antifungal ointments.
Browse all urea products in our catalog →
How it works
Neither ingredient touches the fungus. They break the bonds holding dead keratin together, thinning a surface that has built up over months or years. The antifungal applied afterwards then meets living, drug-permeable skin rather than a compacted shield, which is why the moccasin pattern so often improves only once this is added.
What the evidence says promising
Widely used as an adjunct in hyperkeratotic foot infection on a clear mechanical rationale; the trial evidence sits on combination preparations rather than on the keratolytic step in isolation.
Typical course
Applied to the thickened area, usually at night, for one to two weeks before and alongside antifungal treatment rather than instead of it.
Commonly discussed side effects
- Stinging on cracked or fissured skin
- Irritation if used on ordinary thin skin
- Over-thinning of a callus that was doing a protective job
Worth knowing
- Never a treatment on its own — softening a sole without an antifungal changes the surface and nothing else
- Not for the groin, the flexures, or any skin that is not visibly thickened
- In diabetes or impaired circulation this step belongs with a podiatrist, because deliberately breaking down foot skin in a foot that heals poorly is not a home procedure
Pregnancy: Urea on limited areas is unproblematic; salicylic acid is best kept to small areas during pregnancy, and a pharmacist can advise on the specific strength.
Why it sits where it does: It sits on the over-the-counter rung of the thickened-sole branch specifically, where topical failure is frequently a delivery problem masquerading as a drug problem.
Over-the-counter Drying and microclimate control
Environmental control
Generally compatible
Drying and microclimate control
Environmental control
The unglamorous half of the treatment: changing the conditions the organism needs, so the cure has somewhere dry to hold.
At the shelf
A plain absorbent foot powder, moisture-wicking socks, and a second pair of shoes.
The cheapest interventions on this page live here and none of them are drugs. Two pairs of shoes worn on alternate days lets each dry fully, which matters more than what either pair is made of. Socks changed daily and washed hot, feet dried deliberately between the toes rather than in passing, and sandals in communal wet areas are the whole list. Where powder is used, the sock and the shoe are better targets than the skin between the toes.
Watch out for: Copper, silver or bamboo socks sold on antimicrobial claims, and ultraviolet shoe sanitising devices.
Browse all starches powders products in our catalog →
How it works
Dermatophytes need warmth and moisture to establish, and humidity inside footwear has been measured as a risk factor in its own right rather than assumed as one. Drying the toe-webs properly, rotating shoes so each pair dries fully, changing socks daily, and keeping powder where fabric traps sweat all remove the conditions rather than the organism — which is what stops the next infection rather than this one.
What the evidence says promising
Observational evidence links footwear humidity, occlusive shoe types and wearing time to tinea pedis incidence; the habit changes themselves have not been trialled head-to-head against each other.
Typical course
Permanent, at a low level — and intensified during any active course and for the weeks afterwards when reinfection is most likely.
Commonly discussed side effects
- Powder caking in already macerated toe-webs, which makes things worse rather than better
Worth knowing
- Powder belongs on dry skin and in shoes and socks, not packed into a wet, split toe-web
- This is an adjunct; on its own it manages a colony rather than clearing one
Pregnancy: Nothing in this step raises any pregnancy question.
Why it sits where it does: It runs alongside every rung on the page rather than at one of them, because every treatment above works better and lasts longer over skin that is not permanently damp.
Browse the whole catalog for this condition:
What changed recently: The American over-the-counter list itself has barely moved in a generation: the monograph's actives were set in 1993 and last amended in 2002, and terbinafine and butenafine are not on it at all — they reached the shelf by drug approval instead, which is why the two shortest courses in the aisle sit outside the framework that governs everything beside them. The genuine news of the last few years is not a new product but an organism: a terbinafine-resistant dermatophyte first described in South Asia, now reported in patients in the United States and elsewhere. It changes nothing about how a first, localised rash is treated. It changes a great deal about how a properly finished course that failed should be interpreted.
Prescriptions and procedures
About the brand names below. Brand names in this aisle are unusually unreliable guides to what is in the tube: the same family name covers different molecules across products and across countries, and the version sold for jock itch is often the identical cream to the version sold for athlete's foot with a different course printed on the box. The active ingredient line and the directions line are the only two that decide anything. Where a region is missing from a brands section on this page, that reflects what could be verified rather than proof of absence.
Label links go to the primary regulatory document or the national medicines source, never to a retailer and never back to this site. They are included on the cards where the labelled duration and the labelled limits are themselves the clinical point.
Prescription topical Prescription topical antifungals
Wider choice, some shorter courses
Generally compatible
Prescription topical antifungals
Wider choice, some shorter courses
The prescription end of the same shelf: a longer list of molecules, some with courses shorter than anything sold over the counter.
How it works
Chemically these span the same two families plus a few outsiders — newer azoles, a second allylamine, and ciclopirox, which works by a different route again, disrupting metal-dependent enzymes inside the fungal cell. The practical differences are potency at the skin surface, how long the drug stays there, and how many days the licence therefore requires.
What the evidence says well established
Multiple agents in this group carry high-grade trial evidence for tinea corporis, cruris and pedis, with several licensed on courses of one to two weeks rather than four.
Typical course
Once or twice daily for one to four weeks depending on the agent and the site, with the foot generally requiring the longest of whatever range the product carries.
Commonly discussed side effects
- Local burning, stinging or dryness
- Contact allergy, uncommon but easily mistaken for treatment failure
Worth knowing
- Reaching this rung after an incomplete over-the-counter course usually means repeating the same mistake with a more expensive tube
- A shorter licensed course is a convenience advantage rather than a rescue for something the previous course could not clear
Pregnancy: The topical route keeps systemic exposure very low and prescribers commonly use this group during pregnancy, choosing agent and area on an individual basis.
Why it sits where it does: It sits one rung above the shelf because it broadens the choice without changing the strategy — useful when tolerance, adherence or a difficult site is the obstacle, rather than when extent is.
Prescription topical Antifungal with a corticosteroid
Symptom control, narrow licence
Individualized — ask a clinician
Antifungal with a corticosteroid
Symptom control, narrow licence
A licensed combination product, and the most misused item anywhere near this condition — worth describing precisely for both reasons.
Read the label
- Clotrimazole and betamethasone dipropionate cream — prescribing information DailyMed, US National Library of Medicine
How it works
The antifungal component treats the infection; the corticosteroid suppresses the inflammation causing the itch and the redness. On a genuinely inflamed, intensely itchy infection that combination is a legitimate short-term choice. The difficulty is that the second component also suppresses the immune response the body is using against the colony, so once the course runs long, or once the diagnosis was never confirmed, the visible improvement and the underlying spread move in opposite directions.
What the evidence says strong
Approved on trial evidence for symptomatic inflammatory tinea of the feet, groin and body, with the licence itself setting hard limits: one to two weeks of treatment and an explicit instruction to review the diagnosis if there is no improvement.
Typical course
Deliberately brief on the label: twice daily for one week for the groin and body with a two-week absolute ceiling, and twice daily for two weeks on the feet with a four-week ceiling. Groin use is specified as sparing, with loose clothing, for two weeks only.
Commonly discussed side effects
- Thinning of the skin, stretch marks and visible vessels where a potent steroid sits on thin or occluded skin
- Suppression of the body's own adrenal hormone production with prolonged use over large areas
- A rash that improves, then rebounds larger when the cream stops
Monitoring
Reassessment at one to two weeks is built into the licence rather than left to judgement, precisely because a lack of improvement here means the diagnosis needs revisiting.
Worth knowing
- The groin and the flexures are exactly the sites where potent steroids do the most skin damage, and exactly where these products are most often used longest
- Not licensed for children in the combination most widely dispensed, and not for the face or underarms
- Where a rash is itchy but not confirmed as fungal, this product treats the symptom of whichever condition it turns out to be, which is how months get lost
Pregnancy: Prescribers weigh potency, area and duration rather than applying a blanket rule; a short course on a small area is a different question from repeated use across a large one, and a plain antifungal avoids the question entirely where itch control is not the priority.
Why it sits where it does: It appears on the ladder as a narrow, time-boxed symptom option, and it appears in the cautions because the gap between how it is licensed and how it is used is the second-largest source of avoidable harm on this page.
Prescription oral Oral terbinafine
First-line systemic treatment
Individualized — ask a clinician
Oral terbinafine
First-line systemic treatment
The standard tablet for dermatophyte infection that topical treatment cannot reasonably cover.
How it works
The same enzyme target as the cream, delivered through the bloodstream and concentrated into the outer skin, where it persists after the course finishes. That distribution is what allows courses measured in a small number of weeks to keep working for longer than they last.
What the evidence says well established
Systematic review evidence supports oral terbinafine for skin dermatophytosis, and consensus guidance places it first among the systemic options for treatment-naive infection of the body, groin and feet.
Typical course
A daily tablet for a small number of weeks — shorter for the body and groin, longer for the feet — with the verdict read after the course rather than during it.
Commonly discussed side effects
- Taste disturbance, occasionally prolonged and the side effect people most often stop for
- Stomach upset and headache
- Rash, and rarely severe skin reactions
- Rare liver injury, which is the reason for the pre-course conversation
Monitoring
A medication and liver history before starting, with blood tests at the prescriber's discretion and a lower threshold for them in anyone with existing liver disease or a long medication list.
Worth knowing
- Worth confirming the diagnosis before a systemic course, because a tablet aimed at a rash that was never fungal carries the risk without any of the benefit
- A completed course that leaves the rash unchanged is a specific and informative event, not a reason for a longer repeat
Pregnancy: Human pregnancy data are limited, and because skin dermatophytosis is rarely urgent, treatment is commonly deferred until after pregnancy or handled topically instead; where systemic treatment cannot wait, the decision is made individually with a clinician.
Why it sits where it does: It anchors the oral rung because extent, thickness and multi-site involvement are delivery problems rather than potency problems, and a systemic drug solves delivery.
Prescription oral Oral azoles
Alternative and second-line systemic treatment
Avoid in pregnancy
Oral azoles
Alternative and second-line systemic treatment
The systemic alternatives, reached when terbinafine is unsuitable, unavailable, or has been tried and the infection is still there.
How it works
Same family logic as the topical azoles, delivered systemically: blockade further down the ergosterol pathway, with the drug distributing into skin and being carried outward by keratin turnover. Because the enzyme target differs from terbinafine's, resistance to one does not imply resistance to the other — which is the whole reason this rung exists as a separate step rather than a preference.
What the evidence says well established
Trial and consensus evidence supports the oral azoles for dermatophytosis of the skin, and they are the recommended route where a terbinafine-resistant organism is suspected or confirmed.
Typical course
Daily or weekly dosing depending on the agent, over a period usually longer than a terbinafine course, and longer again where a resistant organism is involved.
Commonly discussed side effects
- Nausea, abdominal discomfort and headache
- Liver enzyme changes
- For one member of the group, effects on heart rhythm and on the heart's pumping function that shape who can take it
- A long list of interactions with other medicines, which is the practical constraint more often than the drug itself
Monitoring
A full medication review is not a formality here — the interaction profile is the main reason a prescriber chooses between the members of this group, alongside liver and cardiac history.
Worth knowing
- The interaction list includes commonly prescribed medicines, so a complete list including supplements changes the choice
- Reaching for a longer course of the same drug that already failed is the step this rung exists to replace
Pregnancy: The oral azoles are avoided in pregnancy for skin infection: one is associated with birth defects at higher and prolonged doses and the group carries pregnancy restrictions in its labelling. Since dermatophyte infection of the skin is not urgent, topical treatment during pregnancy and systemic treatment afterwards is the usual course.
Why it sits where it does: It sits above terbinafine on the non-responder route rather than beside it, because a different enzyme target is what makes it a genuine next step rather than a lateral one.
Procedure Confirming the organism
Diagnosis
Generally compatible
Confirming the organism
Diagnosis
Scraping the active edge and sending it to a laboratory — microscopy for a same-day answer, culture or a molecular test for the name of the organism.
How it works
Skin scales from the advancing border are treated with potassium hydroxide, which dissolves human keratin and leaves fungal filaments visible under a microscope. Culture grows the organism over a couple of weeks and identifies the species; molecular testing does the same faster and more sensitively where it is available. Scrapings are taken from the edge with a blunt curette rather than the centre, because the edge is where the living colony is.
What the evidence says well established
Direct microscopy on a potassium hydroxide preparation is the standard rapid screen and lets treatment begin while culture is pending. It is not perfect: reviews of conventional dermatophyte diagnosis put false negatives in routine practice at roughly fifteen to thirty percent, which is why a negative result on a convincing rash goes to culture rather than to a conclusion.
Typical course
A single painless scraping. Microscopy reports within a day where the service exists; culture takes one to three weeks and is what names the species.
Commonly discussed side effects
Worth knowing
- Antifungal already applied suppresses the result, so a gap of a week or two off treatment before scraping gives the laboratory a fair look
- A negative microscopy on a rash that still looks the part is a reason to culture, not a reason to conclude
Pregnancy: A skin scraping raises no pregnancy considerations at all.
Why it sits where it does: It is not a treatment and does not sit on a ladder as one; it appears wherever a rash has survived a complete course, has been under a steroid, or is about to be treated systemically.
Procedure Species identification and susceptibility testing
Specialist workup
Generally compatible
Species identification and susceptibility testing
Specialist workup
The step for infection that has survived correct treatment: naming the organism precisely and, where indicated, testing what it is still sensitive to.
How it works
Culture and molecular methods identify the species; susceptibility testing measures how much drug is needed to inhibit it. This matters now in a way it did not a decade ago, because a genotype of Trichophyton mentagrophytes named Trichophyton indotineae carries mutations in the very enzyme terbinafine targets, producing genuine terbinafine resistance. First described amid an epidemic of stubborn, widespread dermatophytosis in South Asia, it has since been reported in patients in the United States and Europe.
What the evidence says strong
Case series and genomic work document terbinafine resistance in Trichophyton indotineae through squalene epoxidase mutations, with responses to azole treatment though often over prolonged courses.
Typical course
One scraping, then a laboratory turnaround measured in weeks; susceptibility testing is not universally available and is usually arranged through specialist services.
Commonly discussed side effects
Worth knowing
- Resistance is one of at least four explanations for a failed course, alongside the wrong diagnosis, an unfound reservoir and a course that was never actually completed — and testing is how they are told apart
- Travel history and household contacts are part of this assessment rather than small talk
Pregnancy: Testing itself carries no pregnancy implications; what follows from the result is where pregnancy shapes the options.
Why it sits where it does: It caps the non-responder route because at that point the useful question has stopped being which cream and become which organism.
On the horizon
Pipeline information current as of 2026-09-01
Treatments in phase 3 or later, or recently reaching the market, for dermatophyte infection of the skin specifically — not for nails, not for invasive fungal disease, and not for the yeasts that cause superficially similar rashes.
This changes nothing about what to do now. Nothing in this section changes what to do now. It is here so that a reader can tell the difference between a field that is moving and a field whose marketing is moving.
Recently arrived
A stable shelf, and a moving organism (2026). The list of antifungal actives permitted in the United States over-the-counter monograph was set in 1993 and last amended in 2002, and the two shelf products with the shortest courses are not on it at all — they arrived through drug approval instead. Meanwhile the genuinely new development of the last decade is not a molecule but a resistant organism, first described amid an epidemic in South Asia and since reported in patients in the United States and Europe. A quiet pipeline and an evolving pathogen is an uncomfortable combination, and it is the honest summary of where this field currently sits.
In late-stage development
There is no late-stage candidate worth naming here for skin dermatophytosis, and padding the list would misrepresent the field. Development activity in medical mycology is concentrated on invasive fungal disease and on nail infection, where the unmet need is larger and the trials are easier to power. What is worth watching instead is surveillance: how far terbinafine resistance spreads, whether susceptibility testing becomes routinely available outside specialist centres, and whether treatment guidance starts to differ by region as a result. Those are the developments that would change the first paragraph of this page.
What sits below the evidence line
Several popular remedies for this circulate widely, partly because the condition is visible, cheap to self-treat and slow to be taken to a clinician. Where something has a real mechanism it is said so; where it does not, that is said too.
- Tea tree oil backed by smaller studies
Has genuine antifungal activity in the laboratory and a small trial literature in athlete's foot, generally at concentrations high enough to cause contact dermatitis in a meaningful minority. It is the most credible item on this list and still substantially behind a cream that costs less and is licensed for the job.
- Vinegar or bleach foot soaks limited evidence
Popular, cheap, and supported mainly by the fact that drying the feet afterwards helps. Acidic and antiseptic soaks may reduce surface organisms and odour; there is no useful evidence that either clears a dermatophyte infection, and both irritate split skin between the toes.
- Garlic and its derivatives backed by smaller studies
Ajoene, a compound from garlic, has been trialled in athlete's foot with some positive results in small studies decades ago, and it has not been developed further. Raw garlic applied to skin causes chemical burns often enough to be a recognised presentation in its own right.
- Ultraviolet shoe sanitisers and antimicrobial socks limited evidence
Marketed on the reasonable premise that footwear is a reservoir. Whether these devices and fabrics reduce reinfection in practice has not been shown, and the same reservoir problem is addressed for nothing by owning two pairs of shoes and letting each dry.
- Colloidal silver limited evidence
No credible evidence for dermatophyte infection of skin, and a documented capacity to cause permanent blue-grey skin discolouration when taken internally. It is on this list because it is sold for this, not because it belongs in the conversation.
- Coconut oil and other plant oils limited evidence
Some have measurable antifungal activity in a dish. On an infected foot they mainly add occlusion and moisture, which is the environment the organism wants. Reasonable for dry heels after treatment; not a treatment.
- Antifungal shoe and floor sprays for prevention limited evidence
Distinct from the licensed preventive foot products, which do have a regulated claim. Sprays aimed at shoes and surfaces are sold on a plausible idea with thin evidence behind it, and the drying they cause is likely doing more of the work than the active.
Common questions
If the rash cleared in four days, why does the box say four weeks?
Because the two numbers measure different things. The four days is inflammation settling once the fungal population starts falling; the four weeks is how long the authorised course runs, set against laboratory clearance of the organism rather than against appearance. A surviving colony under normal-looking skin is invisible and entirely capable of regrowing, which is why so many people experience this as a cream that works and then stops working. The exception is the allylamine family, whose labelled courses genuinely are one to two weeks — those are short by design because the drug persists in the skin afterwards.
Is it safe to use a steroid cream for the itch while treating it?
Not on an unexamined rash, and not for long on an examined one. A corticosteroid suppresses the inflammation causing the itch, which also removes part of what is holding the colony back — the symptom improves while the infection spreads. Licensed antifungal-and-steroid combination products do exist for genuinely inflamed infection, and their own labelling is the clearest argument for caution: one week for the groin and body with a two-week ceiling, sparing application, and an explicit instruction to review the diagnosis if nothing improves. Outside those limits the itch is being treated and the infection is not.
Can this be caught from a pet?
Yes, and it is one of the most frequently missed sources. Kittens, rabbits and calves are common carriers, and an animal can transmit without any obvious bald or scaly patch of its own. Infection acquired from an animal often looks more inflamed than the usual human-to-human variety. Where a rash keeps circulating through a household rather than sticking to one person, a veterinary check alongside treating everyone at the same time is what breaks the cycle — treating people one after another while the source continues rarely does.
The groin keeps flaring every summer. Is the cream failing?
Almost certainly not. Recurrent groin infection is usually being re-supplied, and the supply is most often the feet: the same organism travels on hands, towels and trouser legs, and the feet frequently carry it with far less drama than the groin does. Treating both sites at once, putting socks on before underwear during a course, and using separate towels turns a seasonal ritual into a finished problem more often than switching product does. Where the exposure is genuinely unavoidable, one over-the-counter active carries a licensed prevention claim as well as a treatment one, which is the regulated answer to exactly this.
The soles have been dry and flaky for years. Could that be fungal rather than dry skin?
It is a recognised pattern and it is chronically under-diagnosed, largely because it rarely itches enough to demand attention. The clues are a fine powdery scale over the whole weight-bearing surface, a sharp edge where it stops partway up the side of the foot, cracked heels, and frequently a thickened toenail nearby. Moisturiser improves how it feels and changes nothing underneath. A scraping settles it, and the treatment differs from ordinary athlete's foot in one important way: the thickened surface has to be thinned before a cream can reach anything.
A full course was finished and the rash is still there. Does that mean the fungus is resistant?
It might, and it is the least likely of four explanations. The others are that the rash was never fungal, that an untreated site elsewhere kept re-supplying it, or that the course was less complete than it felt. Terbinafine resistance is real and now documented in several countries, driven by mutations in the very enzyme that drug targets, but it is identified in a laboratory rather than inferred from frustration. A scraping taken after a week or two off treatment separates all four, and it costs less than the next course would.
Is it contagious, and does anything need to be thrown away?
It spreads by direct contact and by contact with shed skin, so shared towels, mats, communal shower floors and borrowed shoes are the realistic routes rather than casual proximity. Very little needs discarding. Towels, socks and bedding washed hot during the course, footwear allowed to dry fully between wears, sandals in shared wet areas, and a separate towel for the feet cover almost all of it. Shoes worn throughout a long infection are worth airing thoroughly rather than binning, and the sterilising sprays and ultraviolet devices sold for them are not supported by evidence worth the price.
Sources and further reading
The staging, escalation points, and therapy descriptions on this page are anchored to published clinical guidelines rather than editorial judgment.
What this page is built on
- Fungal skin infection of the foot
- Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India).
- OTC Monograph M005: Topical Antifungal Drug Products for Over-the-Counter Human Use
The studies behind this pathway
Every clinical statement above traces to one of these. Where a study is cited without a link, the reference is given in full so it can be found — a citation without a URL is a deliberate choice here rather than an oversight.
- Topical antifungal treatments for tinea cruris and tinea corporis. The effectiveness of over-the-counter topical antifungals for infection of the groin and body.
- Evidence-based topical treatments for tinea cruris and tinea corporis: a summary of a Cochrane systematic review. The comparative standing of the azoles and the allylamines in the same evidence base.
- Topical treatments for fungal infections of the skin and nails of the foot. The topical evidence base for athlete's foot, and the allylamine advantage on speed.
- Oral treatments for fungal infections of the skin of the foot. The systemic tier for foot infection that topical treatment cannot cover.
- Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). Topical treatment as first line for localised disease, and systemic treatment for extensive, chronic or recurrent infection.
- Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance. The current treatment landscape for skin dermatophytosis, including the prescription topical options.
- Clinico-mycological and therapeutic updates on cutaneous dermatophytic infections in the era of Trichophyton indotineae. Azole treatment where terbinafine resistance is suspected, and the longer courses it requires.
- Clinical Course, Antifungal Susceptibility, and Genomic Sequencing of Trichophyton indotineae. Documented terbinafine resistance through squalene epoxidase mutations, and what remains effective.
- Notes from the Field: First Reported U.S. Cases of Tinea Caused by Trichophyton indotineae - New York City, December 2021-March 2023. The arrival of the resistant genotype in patients in the United States.
- The current Indian epidemic of superficial dermatophytosis due to Trichophyton mentagrophytes-A molecular study. The origin and molecular identity of the resistant genotype behind the South Asian epidemic.
- Male genital dermatophytosis - clinical features and the effects of the misuse of topical steroids and steroid combinations - an alarming problem in India. What prolonged topical steroid and steroid-combination use does to dermatophyte infection in the groin.
- Topical Antifungal Prescribing for Medicare Part D Beneficiaries - United States, 2021. The scale on which antifungal-corticosteroid combination products are prescribed, largely outside dermatology.
- Internal environment of footwear is a risk factor for tinea pedis. Footwear humidity, shoe type and wearing time as measured risk factors rather than assumed ones.
- Reappraisal of Conventional Diagnosis for Dermatophytes. The performance of microscopy and culture in routine practice, including the false-negative rate that keeps a negative result from closing the question.
- Interdigital and Plantar Foot Infections: A Retrospective Analysis of Molecularly Diagnosed Specimens in the United States and a Literature Review. What laboratory testing of foot specimens actually finds, and the limits of diagnosing this by eye.
- OTC Monograph M005: Topical Antifungal Drug Products for Over-the-Counter Human Use. The permitted over-the-counter actives, the labelled durations of four weeks and two weeks, and the instruction to consult a doctor at those points.
The sources below carry this page. Two things are worth noticing about them: the systematic review evidence for the over-the-counter tier is unusually strong for something sold this cheaply, and the most recent literature is about an organism rather than a drug.
Systematic reviews and consensus guidance
The Cochrane reviews adjudicate the topical tier across the three sites; the consensus document sets out where systemic treatment belongs.
- Topical antifungal treatments for tinea cruris and tinea corporis Cochrane Database of Systematic Reviews The evidence base for the groin and body, across dozens of trials.
- Topical treatments for fungal infections of the skin and nails of the foot Cochrane Database of Systematic Reviews The foot equivalent, including the comparison between the allylamines and the azoles.
- Expert Consensus on the Management of Dermatophytosis in India BMC Dermatology Where topical stops and systemic starts, written from the region with the most difficult recent experience of this.
The resistance story
Four years took this from a regional problem to an international one, and it is the only part of this field currently moving quickly.
- First reported US cases of tinea caused by Trichophyton indotineae MMWR, Centers for Disease Control and Prevention The point at which this stopped being someone else's problem.
- Clinical course, antifungal susceptibility and genomic sequencing of Trichophyton indotineae JAMA Dermatology What resistance looks like in patients, and what still works against it.
Patient information
Written to be read rather than cited.
- Athlete's foot NHS Short, practical, and clear about when a pharmacist stops being the right person.
- Ringworm NHS The body and groin equivalent, including the animal source.
- Tinea corporis DermNet More clinical detail than most patient pages, with a good image library for the look-alikes.
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