close

Log in

Access to premium content is restricted to healthcare professionals / registered members. Login with your email address to continue.

Forgot Your Password?

Don't have an account? Sign up

By signing in or creating an account, you agree to our Terms and conditions and Privacy notice

This site is intended for Healthcare Professionals only
Back to CKS

Infections and infestations Skin and nail

Fungal skin infection - foot

Last revised in June 2023

Fungal infection of the foot (athlete's foot or tinea pedis) is a skin infection of the feet and toes, predominantly caused by dermatophytes

Fungal skin infection - foot: Summary

  • Fungal infection of the foot is also known as 'athlete's foot' or 'tinea pedis', and it describes superficial skin infection of the feet and toes, predominantly caused by dermatophytes. Different sub-types include:
    • Interdigital — most common; affects the lateral toe web spaces first and is usually caused by Trichophyton rubrum.
    • Moccasin or dry — diffuse chronic scaling and hyperkeratosis affecting the sole and lateral foot; usually caused by Trichophyton rubrum.
    • Vesicobullous — least common; multiple small vesicles and blisters mainly on the arches and soles of the feet and is usually caused by Trichophyton interdigitale.
  • Risk factors for acquiring infection include hot, humid climates or working environments; occlusive footwear; hyperhidrosis; walking on contaminated surfaces; and immunocompromised states.
  • Infection is common in adolescents but rare in pre-pubertal children.
  • The diagnosis of suspected fungal foot infection should be made on the basis of clinical features which allows classification into different sub-types. There may be a history of itchy, flaky, or painful skin on the feet.
  • Assessment of suspected fungal foot infection should include:
    • Asking about the nature, site, and duration of symptoms; previous treatments; close contacts; and co-morbidities.
    • Examining the pattern, extent, and severity of infection, and for any associated inflammation or fungal infection at other sites.
    • Arranging for skin sampling for fungal microscopy and culture if there is severe or extensive disease in adults, or the diagnosis is uncertain.
  • Initial management of fungal foot infection should include:
    • Advice on self-care strategies and sources of information.
    • Advice on treatment with a topical antifungal cream such as terbinafine, an imidazole, undecenoic acid, or topical preparations containing tolnaftate, if there is mild, non-extensive disease in children and adults.
    • Prescribing a short-term mildly-potent topical corticosteroid such as hydrocortisone cream, in addition, if there is associated marked inflammation.
    • Considering prescribing an oral antifungal such as terbinafine first-line if an adult has severe or extensive disease, depending on fungal microscopy or culture results and/or clinical judgement. Alternative options are oral itraconazole or oral griseofulvin, if terbinafine is not tolerated or is contraindicated.
    • Managing concomitant fungal nail, hand, or groin infection, if present, to reduce the risk of reinfection.
  • If there are persistent signs of infection following topical antifungal treatment in adults:
    • Any underlying cause of treatment failure should be managed, such as non-adherence to self-care advice or the treatment regimen; or reinfection from close contacts.
    • Skin sampling for fungal microscopy and culture should be arranged.
    • Oral antifungal treatment should be prescribed depending on microscopy or culture results and/or clinical judgement.
  • Referral to a dermatology specialist should be arranged, the urgency depending on clinical judgement, if:
    • There is severe or extensive disease, or topical antifungal treatment is unsuccessful in a child.
    • The diagnosis is uncertain.
    • Treatment in primary care is unsuccessful.
    • The person is immunocompromised, depending on clinical judgement.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the diagnosis and management of fungal infection of the foot (athlete's foot or tinea pedis).

This CKS topic does not cover the management of other fungal infections of the skin or nails.

There are separate CKS topics on Candida - skin, Fungal nail infection, Fungal skin infection - body and groin, and Fungal skin infection - scalp.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

June 2023 — reviewed. A literature search was conducted in June 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to recommendations have been made. 

Previous changes

July 2022 — minor update. Added drug interaction between clotrimazole and tacrolimus.

April 2018 — reviewed. A literature search was conducted in March 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. A Complications node has been added to the Background information section. A Differential diagnosis node has been added to the Diagnosis section. The management recommendations have been updated in line with the current literature. The Prescribing Information section has been updated and expanded in line with current CKS style.

September 2014 — minor update. Revision to the text in Prescribing information section on terbinafine, to state that a baseline liver function test is required before starting treatment with terbinafine.

January 2014 — minor update. Text amended to include information from the manufacturer regarding how much clotrimazole to apply to the skin.

December 2013 — minor update. Text updated to reflect that the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) has suspended the marketing authorisation for oral ketoconazole, and it should not be prescribed for the treatment of fungal infections.

September 2013 — reviewed. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made. Prescribing information has been added to support the prescribing of topical and oral antifungal treatments.

August 2013 — minor update. Nizoral® cream (ketoconazole 2%) is no longer licensed for use in children.

August 2013 — minor update to the text to reflect recent guidance from the European Medicines Agency (EMA) regarding the use of oral ketoconazole.

November 2012  — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

August 2010 — minor update. Sulconazole 1% cream (Exelderm®) has been discontinued. The prescription has been removed. 

June 2009 — minor update. Econacort® cream (econazole 1% plus hydrocortisone 1% cream) has been discontinued. The prescription has been removed. 

January to May 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Together with the CKS topics on Fungal skin infection - body and groin and Fungal skin infection - scalp, this CKS topic replaces the former topic on Fungal skin infections. There are no major changes to the recommendations.

September 2008 — minor correction to the Changes section. 

August 2008 — minor update. Nystatin cream and ointment discontinued; text amended. 

April 2008 — minor update to the text for oral ketoconazole, which now reflects the most recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance.

March 2008 — minor update. New text inserted regarding rare cases of changes in international normalized ratio (INR) when warfarin and oral terbinafine have been given concomitantly. 

October to December 2005 — written. Validated in March 2006 and issued in May 2006.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2023.

Systematic reviews and meta-analyses

No new systematic reviews since 1 June 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2023.

New policies

No new national policies or guidelines since 1 June 2023.

New safety alerts

No new safety alerts since 1 June 2023.

Changes in product availability

No changes to product availability since 1 June 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a working diagnosis of fungal foot infection.
  • Be aware of when to suspect fungal foot infection and exclude similar conditions.
  • Assess suspected fungal foot infection.
  • Offer appropriate treatment in primary care.
  • Arrange referral to secondary care if appropriate.
  • Provide advice and information to people with fungal foot infections.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Fungal infection of the foot is also known as 'athlete's foot' or 'tinea pedis', and it describes superficial skin infection of the feet and toes, predominantly caused by dermatophytes. 
    • Different sub-types of fungal foot infection include:
      • Interdigital — most common, usually caused by Trichophyton rubrum (isolated in about 80% of infections).
      • Moccasin or dry — usually caused by Trichophyton rubrum.
      • Vesicobullous — least common, usually caused by Trichophyton interdigitale (isolated in about 15% of infections).
    • In addition, Epidermophyton floccosum causes a small number of cases in the UK.

 [UKHSA, 2017; BMJ Best Practice, 2022; Nigram, 2022]

What are the risk factors?

  • Risk factors for developing fungal foot infection include [BMJ Best Practice, 2022; Nigram, 2022]:
    • Hot, humid climates or working in high-temperature environments.
    • Wearing occlusive footwear, such as athletes, miners, and soldiers.
    • Hyperhidrosis — see the CKS topic on Hyperhidrosis for more information.
    • Walking on floor surfaces contaminated with infectious desquamated skin scales, for example, communal shower facilities, swimming pools, and saunas.
    • Immunocompromised states — may lead to severe, resistant, or extensive disease, for example, spread to the dorsum of the feet.

How common is it?

  • The prevalence of fungal foot infection increases with age.
    • Infection is common in adolescents (mean average at onset 15 years), but rare in pre-pubertal children [Nigram, 2022].
    • It is the most common form of fungal skin infection in the post-puberty period [BMJ Best Practice, 2022].
    • The risk of acquiring infection is greater in men than in women [Nigram, 2022].
    • It is most common between 31 and 60 years [Rasner, 2022].
    • 70% of the population may be affected at some point in their life [BMJ Best Practice, 2022].

What are the complications?

  • Possible complications of fungal foot infection include:
    • Secondary bacterial infection — immunocompromised people are at increased risk [BMJ Best Practice, 2022].
    • Recurrent cellulitis of the lower leg — fungal foot infection may impair the skin barrier and act as the portal of entry for bacteria. See the CKS topic on Cellulitis - acute for more information.
    • Fungal infection of the hand (tinea manuum) — this may develop as a result of scratching of the affected foot, and may result in 'two feet-one hand' syndrome. See the CKS topic on Fungal skin infection - body and groin for more information.
    • A dermatophytid (id) reaction — a reactive phenomenon to the dermatophyte causing a disseminated and itchy, papular or vesicular eruption, commonly affecting around the outer helix of the ear, which may also affect the trunk or limbs. This may accompany the start of oral antifungal treatment and may be misinterpreted as a widespread fungal infection.
    • Tinea incognito — inappropriate use of topical corticosteroids can lead to the spread of fungal infection, and a change in the morphology of lesions, leading to difficulty in diagnosis [Verma, 2017; Rasner, 2022].

What is the prognosis?

CKS found limited evidence in the literature on the prognosis of fungal foot infection.

  • Prognosis is generally excellent but infection often relapses after successful treatment in susceptible people, and may become a chronic problem [BMJ Best Practice, 2022].

Diagnosis of fungal skin infection - foot

When should I suspect fungal foot infection?

The diagnosis of suspected fungal foot infection should be made on the basis of clinical features, which allows classification into different sub-types.

  • There may be a history of scaly, itchy, or painful skin of the feet.
  • On examination there may be:
    • Interdigital type (most common) — white or red, fissured, scaling skin or macerated areas between the toes. Typically, this affects the lateral interdigital space between the fourth and fifth toes and then extends medially.
    • Moccasin or dry-type — a more diffuse, chronic presentation causing scaling, erythema, and hyperkeratosis of the sole and lateral aspect of the foot. The dorsal surface is usually unaffected.
    • Vesicobullous type — an inflammatory variant with hard, tense, small (1–5 mm) vesicles, blisters, bullae, and pustules on an erythematous base, mainly on the arches and soles of the feet.

Basis for recommendation

The recommendations on when to suspect fungal foot infection are based on the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022] and expert opinion the review articles Tinea Pedis [Nigram, 2022], and Superficial fungal infections [Kovitwanichkanont, 2019].

How should I assess suspected fungal foot infection?

If fungal foot infection is suspected on the basis of clinical features:

  • Ask the person about:
    • The nature, site, and duration of any symptoms, such as any itchy, flaky skin on the feet.
    • Any previous treatments, including over-the-counter preparations.
    • Any family or close contacts affected.
    • Any co-morbidities such as underlying causes of immunosuppression.
  • Examine the person to assess:
  • Be aware that diagnostic tests are not usually needed in primary care, but arrange for skin sampling for fungal microscopy and culture to confirm the diagnosis and identify the underlying cause if:
    • There is severe or extensive disease in adults.
    • The diagnosis is uncertain or there is an atypical presentation.
  • Be aware that Wood's light examination is not needed to aid diagnosis in primary care.

Taking skin samples

  • When taking skin samples for fungal microscopy and culture:
    • Wipe off any creams from the skin before sampling.
    • Scrape skin from the advancing edge of the lesion(s) with a blunt scalpel blade to collect skin scale. Sampling the edge of lesions may provide a higher yield of dermatophyte.
    • Collect at least 5 mm2 of skin flakes into folded dark paper squares secured with a paper clip. Alternatively, commercially available packs are available. Label the sample clearly.
    • Keep the samples at room temperature and do not refrigerate them (dermatophytes are inhibited at low temperatures, and humidity facilitates the growth of contaminants).
    • Ensure clinical details provided on the microbiology request form include any treatment used, animal contacts, and overseas travel.
    • Inform the person that microscopy results (to identify hyphae or spores) should be available within 1–2 days and culture results (to identify the causative organism) within 2–3 weeks.
    • Be aware that testing for antifungal susceptibilities is not required.
  • Consider arranging a skin swab for bacterial and fungal microscopy and culture if the skin is very macerated.

[UKHSA, 2017]

Basis for recommendation

The recommendations on assessment are based on expert opinion in the Public Health England (PHE) publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017]; the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022], and expert opinion in the review articles Tinea Pedis [Nigram, 2022], Superficial fungal infections [Kovitwanichkanont, 2019], and Steroid modified tinea [Verma, 2017].

Assessing the person

  • The recommendation on asking about any underlying causes of immunocompromise is based on the fact that this can lead to atypical presentations: extensive and severe fungal skin infections that can be challenging to diagnose and treat in primary care [Verma, 2017].
  • The recommendation for assessing other body sites is based on the fact that fungal foot infection can be an important reservoir for infection elsewhere, and can be transmitted, often by autoinoculation, to the hands, groin, or nails [Kovitwanichkanont, 2019].

Arranging skin sampling

  • The recommendation that skin sampling is not needed if there are clinical features of mild, uncomplicated fungal foot infection is based on expert opinion in the PHE publication [UKHSA, 2017] and expert opinion in review articles [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].
  • The recommendation on arranging skin sampling if there is an atypical appearance and the diagnosis is uncertain is based on the PHE publication [UKHSA, 2017] and BMJ Best Practice guidelines [BMJ Best Practice, 2022].
  • The recommendation for arranging skin sampling, if there is severe or extensive disease in adults, is based on the fact that this population group may need oral antifungal treatment [UKHSA, 2017].
  • The recommendation that antifungal susceptibility testing is not needed is based on the fact that antifungal resistance is rare, and there is no known correlation between antifungal susceptibilities and outcome [UKHSA, 2017].

Wood's light examination

  • Wood's light examination is not recommended in primary care as the dermatophyte organisms that typically cause fungal foot infection in the UK, such as Trichophyton rubrum, do not fluoresce under Wood's light [BMJ Best Practice, 2022].

What else might it be?

Other conditions that may present similarly to fungal foot infection include:

  • Allergic or irritant contact dermatitis — often characterized by an erythematous and vesicular demarcated rash whose distribution may match footwear (where an external agent such as rubber, glues, or dyes acts as an allergen or irritant). Chronic involvement may produce skin dryness, lichenification, and fissuring. Typically, the interdigital skin is spared. See the CKS topic on Dermatitis - contact for more information.
  • Atopic eczema — there is usually a history of eczema in infancy, and a family or personal history of atopy. Typically the interdigital skin is spared. See the CKS topic on Eczema - atopic for more information.
  • Pompholyx eczema — typically produces itchy vesicles on the lateral aspects of digits, often with hand involvement. This can mimic vesicobullous infection.
  • Localized (palmoplantar) pustular psoriasis — may present as yellow-brown pustules within established psoriasis plaques on the soles of the foot, or redness, scaling, and pustules at the tips of the toes. This may mimic vesicobullous infection. There may be involvement of other skin sites. See the CKS topic on Psoriasis for more information.
  • Plantar keratosis — localized callus on the sole of the foot, typically over pressure areas such as metatarsal heads. This may mimic moccasin-type infection.
  • Pitted keratolysis — a superficial and sometimes malodorous infection of the pressure-bearing areas of the soles of the feet, characterized by crateriform pitting which may coalesce to form irregular erosions. This may be associated with hyperhidrosis.
  • Gram-negative bacterial infection, cellulitis, or impetigo — may cause interdigital erythema, scaling, and maceration. See the CKS topics on Cellulitis - acute and Impetigo for more information.
  • Candida skin infection — may cause interdigital erythema, scaling, and maceration. See the CKS topic on Candida - skin for more information.

Basis for recommendation

The information on the differential diagnosis of fungal foot infection is based on the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022] and expert opinion in the review articles Tinea Pedis [Nigram, 2022] and Superficial fungal infections [Kovitwanichkanont, 2019].

Management

Scenario: Management of fungal skin infection - foot

From age 1 month onwards.

How should I initially manage fungal foot infection?

  • Advise on self-care management strategies:
    • Wear well-fitting, non-occlusive footwear that keeps the feet cool and dry. Consider replacing old footwear which could be contaminated with fungal spores.
    • Maintain good foot hygiene by wearing a different pair of shoes every 2–3 days.
    • Wear cotton, absorbent socks.
    • Avoid scratching affected skin, as this may spread the infection to other sites.
    • After washing the feet, dry them thoroughly, especially between the toes.
    • Do not share towels and wash them frequently, to reduce the risk of transmission.
    • Wear protective footwear when using communal bathing places, locker rooms, and gymnasiums, to reduce the risk of transmission.
    • If a child is affected, it is not necessary to exclude them from school or nursery.
  • Provide information on sources of advice and support, such as:
  • Advise treatment with a topical antifungal cream if there is mild, non-extensive disease in children and adults.
    • Options include terbinafine cream or an imidazole such as clotrimazole, miconazole, or econazole cream (available over-the-counter for specific age groups).
    • Alternative options include over-the-counter undecenoic acid cream or topical preparations containing tolnaftate.
    • Advise that the use of other topical treatments such as tea tree oil is not recommended.
    • Advise that treatment with a topical antifungal cream may be repeated in the future if there is a good response to topical treatment and there are recurrent episodes of mild, non-extensive disease.
  • Consider prescribing a mildly-potent topical corticosteroid in addition, if there is associated marked inflammation, such as:
    • Hydrocortisone 1% cream to be applied once daily for a maximum of 7 days.
    • Advise that a topical corticosteroid preparation should not be used alone on skin lesions.
  • If an adult has severe or extensive disease, consider prescribing oral antifungal treatment if there is:
    • A positive skin sample fungal microscopy or culture result.
    • A strong clinical suspicion of fungal foot infection before mycology results are back, depending on clinical judgement.
    • A negative mycology result, but clinical features are very suggestive of infection.
      • Arrange for repeat skin sampling, and start oral antifungal treatment.
  • If oral antifungal treatment is offered in primary care:
    • Consider prescribing terbinafine first-line.
    • Consider prescribing oral itraconazole or oral griseofulvin if terbinafine is not tolerated or is contraindicated.
  • If a child has severe or extensive disease, arrange referral to a paediatric dermatologist.
  • If there is concomitant suspected fungal nail, hand, or groin infection, arrange appropriate management. See the CKS topics on Fungal nail infection and Fungal skin infection - body and groin for more information.
  • Advise the person to arrange for follow-up if there is an inadequate response to initial treatment.

Basis for recommendation

The recommendations on initial management are largely based on the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022]; the Public Health England (PHE) publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017]; the UK Health Security Agency (UKHSA) guideline Health protection in children and young people settings, including education [UKHSA, 2023a]; two Cochrane systematic reviews, Topical treatments for fungal infections of the skin and nails of the foot [Crawford, 2007] and Oral treatments for fungal infections of the skin of the foot (Review) [Bell-Syer, 2012]; the meta-analysis Efficacy of topical antifungals in the treatment of dermatophytosis: a mixed-treatment comparison meta-analysis involving 14 treatments [Rotta, 2013]; and expert opinion in the review articles Tinea Pedis [Nigram, 2022], Superficial fungal infections [Kovitwanichkanont, 2019], and Steroid modified tinea [Verma, 2017].

Advice on self-care strategies
  • The recommendations on self-management are based on expert opinion in the PHE document on health protection in schools and other childcare facilities [UKHSA, 2023b] and in review articles [Kovitwanichkanont, 2019; Mochizuki, 2019].
    • The PHE document states that exclusion is not needed from school or other childcare facilities, but appropriate self-care measures and antifungal treatment should be started.
Offering topical antifungal treatment
  • The recommendations on topical antifungal treatments are largely based on the BMJ Best Practice guide [BMJ Best Practice, 2022], a Cochrane systematic review of topical antifungal treatments [Crawford, 2007], a meta-analysis of the efficacy of topical antifungal treatments for fungal skin infections [Rotta, 2013], and expert opinion in the PHE publication [UKHSA, 2017] and in review articles [Kovitwanichkanont, 2019; Mochizuki, 2019].
    • The Cochrane systematic review analysed randomized controlled trials (RTs) of fungal foot infections and found similar pooled risk ratios of treatment failure for allylamines including terbinafine, azoles, tolnaftate, and undecanoates.
      • Meta-analysis of 11 RCTs comparing allylamines and azoles showed a risk ratio of treatment failure of 0.63 in favour of allylamines, such as terbinafine.
      • There was no evidence to support the use of tea tree oil, and it did not show a greater benefit than placebo.
    • This is supported by a mixed-treatment comparison meta-analysis that combined direct and indirect data from 65 RCTs (n = 7629) of fungal infections of the foot as well as body and groin.
      • It found no statistically significant differences in the outcome of mycological cure for different topical antifungal agents up to 7 days after the completion of treatment. However, it found allylamines, including terbinafine, were significantly more efficacious than clotrimazole at maintaining mycological cure at least 14 days after completion of treatment.
      • It notes that allylamines are fungicidal compared with azoles, which are fungistatic, and concludes that allylamines can reduce the frequency of relapse episodes and improve the chances of sustained cure.
      • CKS notes various limitations of the study, including the fact that comparisons were made with different drug preparations, concentrations, regimens, and durations of treatment, and data were combined from studies of fungal infections of the feet, body, and groin. In addition, studies often involved short follow-up periods, only 51% of studies were noted to have satisfactory blinding, and no cost-effectiveness study was undertaken.
    • A 2022 systematic review of randomised controlled trials (7 studies met the criteria - 1042 patients) found terbinafine was superior to placebo for treating tinea pedis [Ward, 2022].
    • Expert opinion in the PHE publication supports the use of topical terbinafine first-line for fungal foot infection, and states that one week duration of this treatment is as effective as four weeks' duration of an azole.
Offering topical corticosteroid treatment
  • The recommendation to prescribe a mildly-potent topical corticosteroid in addition to a topical antifungal preparation, if there are signs of inflammation, is extrapolated from expert opinion in review articles, as short-term use can reduce inflammation and symptoms of pain and itch while minimizing the risk of corticosteroid-related adverse effects [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].
  • The recommendation to prescribe a topical corticosteroid separately to the topical antifungal is pragmatically based on what CKS considers to be good clinical practice, as this allows the corticosteroid to be used short-term, while the antifungal may be continued longer term depending on the recommended frequency and duration for each specific antifungal preparation.
  • The recommendation to avoid topical corticosteroid monotherapy is based on expert opinion in review articles [Kovitwanichkanont, 2019; BMJ Best Practice, 2022]. 
    • Topical corticosteroid use may cause the development of tinea incognito, where there is alteration of the morphology of fungal infection lesions, with flattening of the edge and loss of surface scale, which then makes clinical diagnosis more difficult.
    • Furthermore, topical corticosteroid monotherapy does not eliminate fungus from the skin surface. As a result, fungal lesions may spread and proliferate, and there may be treatment failure and the development of antifungal resistance [Verma, 2017; Rasner, 2022].
  • The recommendation on prescribing a mildly-potent topical corticosteroid for 7 days maximum is extrapolated from the manufacturer's Summary of Product Characteristics (SPC) for the combination product containing miconazole nitrate 2% and hydrocortisone 1% cream [EMC, 2021a].
Prescribing oral antifungal treatment
  • The recommendation to prescribe oral antifungal treatment if there is severe or extensive disease is based on expert opinion in review articles [Kovitwanichkanont, 2019; Mochizuki, 2019].
  • The recommendation to consider prescribing oral antifungal treatment before fungal culture results are available is based the BMJ Best Practice guide [BMJ Best Practice, 2022].
  • The recommendation to consider prescribing oral antifungal treatment if there is a strong clinical suspicion, but negative culture results, is extrapolated from thBMJ Best Practice guide, which states that macerated or vesiculobullous lesions may be co-infected with Gram-negative bacteria that reduce culture sensitivity, and, therefore, negative mycology results do not exclude the possibility of underlying fungal infection [BMJ Best Practice, 2022].
  • The recommendation to prescribe oral terbinafine first-line is based on a Cochrane review of 15 RCTs (n = 1438) of oral antifungal treatment, which assessed the primary outcome of mycological cure rates of fungal foot infection [Bell-Syer, 2012].
    • Two RCTs (n = 71) comparing oral terbinafine and griseofulvin produced a pooled risk ratio of 2.26 in favour of terbinafine.
    • No significant difference was found between terbinafine and itraconazole cure rates, but the trials were small.
    • Two RCTs (n = 31 and 72 respectively) showed that terbinafine and itraconazole were effective compared with placebo.
    • Generally, the trials were at unclear risk of bias, due to the lack of reporting of randomization techniques and allocation concealment.
    • A 2022 systematic review of randomised controlled trials found terbinafine was efficacious in treating tinea pedis [Ward, 2022].
Management of severe or extensive disease in children
  • The recommendation on arranging dermatology referral for children with severe or extensive disease is pragmatic, based on what CKS considers to be good clinical practice. It is also supported by the expert opinion of previous external reviewers of this CKS topic.
Treating concomitant fungal nail and/or other skin infection
  • The recommendation on identifying and managing concomitant fungal nail and other skin infection is based on the fact that the nails, in particular, can be a source of reinfection if inadequately treated [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].

When should I follow up and refer?

Arrange for the person to be reviewed if there is an inadequate response to initial management.

  • If there are persistent signs of infection following topical antifungal treatment in adults:
    • Consider and, if possible, manage any underlying cause of treatment failure. This may include:
      • Non-adherence to self-care advice or the treatment regimen.
      • Drug-resistant or multiple organisms.
      • Drug interactions or adverse effects.
      • Reinfection from close contacts or recurrence of infection.
      • An immunocompromised host.
      • An alternative diagnosis.
    • Arrange for skin sampling for fungal microscopy and culture, and consider prescribing oral antifungal treatment if there is:
      • A positive skin sample fungal microscopy or culture result.
      • A strong clinical suspicion of fungal foot infection before fungal microscopy and culture results are back, depending on clinical judgement.
      • A negative mycology result, but clinical features are very suggestive of infection. Arrange for repeat skin sampling, and start oral antifungal treatment.
  • Arrange referral to a dermatology specialist, the urgency depending on clinical judgement, if:
    • There is severe or extensive disease, or topical antifungal treatment is unsuccessful in a child.
    • The diagnosis is uncertain.
    • Treatment in primary care is unsuccessful.
    • The person is immunocompromised, depending on clinical judgement.

Basis for recommendation

The recommendations on follow-up and referral are based on the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022], the Public Health England (PHE) publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and expert opinion in review articles Tinea Pedis [Nigram, 2022], Superficial fungal infections [Kovitwanichkanont, 2019], and Steroid modified tinea [Verma, 2017].

Managing treatment failure
  • The recommendation on arranging skin sampling if the infection is refractory to initial topical antifungal treatment is based on the PHE publication, which states that occasionally Gram-negative bacterial infection can cause interdigital cracking that can mimic the appearance of fungal foot infection [UKHSA, 2017]. This is supported by the BMJ Best Practice guide [BMJ Best Practice, 2022].
  • The recommendation on considering oral antifungal treatment for failed topical treatment is extrapolated from the PHE publication [UKHSA, 2017] and the BMJ Best Practice guide [BMJ Best Practice, 2022].
  • The recommendations on arranging for repeat skin sampling if there are negative culture results, and starting treatment if clinical appearances are very suggestive of fungal foot infection, are based on expert opinion in the PHE publication [UKHSA, 2017] and the BMJ Best Practice guide [BMJ Best Practice, 2022].
Arranging referral to dermatology
  • The recommendations on referral are extrapolated from expert opinion in a review article [Verma, 2017], and are pragmatic, based on what CKS considers to be good clinical practice.

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical antifungals

Application

The following application regimens are recommended for the treatment of fungal foot infection:

  • Terbinafine 1% cream (children above 12 years of age)
    • Apply thinly to the affected area once or twice a day for up to 7 days.
  • Clotrimazole 1% cream
    • Apply to the affected area 2–3 times a day and continue for at least 4 weeks. A strip of cream about half a centimetre long is enough to treat an area about the size of the hand.
  • Miconazole 2% cream
    • Apply to the affected area twice a day for 2–6 weeks depending on the severity of the lesions, and continue for 10 days after all skin lesions are healed.
  • Econazole 1% cream
    • Apply to the affected area twice a day and continue until all skin lesions are healed.

[ABPI, 2018; EMC, 2020a; EMC, 2021a; ABPI, 2021; ABPI, 2022; EMC, 2023; BNF, 2023; BNFC, 2023]

Contraindications and cautions

  • Terbinafine 1% cream is licensed for the treatment of fungal foot infection in those above the age of 12 years.
  • Clotrimazole 1% cream, miconazole 2% cream, and econazole 1% cream are licensed for the treatment of fungal foot infection in children and adults.
    • Advise the person to avoid contact with the eyes and mucous membranes during use.

[EMC, 2023; BNF, 2023; BNFC, 2023]

Adverse effects

  • Possible adverse effects with topical antifungals are uncommon and may include erythema, hypersensitivity reactions, itching, mild burning sensation, and occasional local irritation.

[BNF, 2023; BNFC, 2023]

Drug interactions

  • Topical terbinafine cream — there are no known significant drug interactions.
  • Clotrimazole — concurrent prescribing with tacrolimus causes an increase in plasma tacrolimus levels.
  • Topical miconazole and econazole cream — oral miconazole and econazole are known to interact with oral anticoagulants, but due to the limited systemic availability of topical preparations, clinically relevant drug interactions are rare. The manufacturer advises, however, that caution should be exercised and the anticoagulant effect should be monitored during concurrent use with an oral anticoagulant.

[Preston, 2019]

Oral terbinafine

Dosing schedule

  • For adults, prescribe terbinafine 250 mg once daily for 2–6 weeks, depending on the severity of the infection.

[BNF, 2023]

Contraindications and cautions

Do not prescribe terbinafine to people with:

  • Hepatic impairment — the manufacturer recommends that terbinafine should not be prescribed in people with chronic or active hepatic disease. It recommends for other people, liver function tests (LFTs) should be performed. Hepatotoxicity may occur in people with and without pre-existing hepatic disease, therefore, periodic monitoring of LFTs (after 4–6 weeks of treatment) is recommended. Terbinafine should be stopped immediately if LFTs are deranged.
  • Severe renal impairment.

Prescribe terbinafine with caution to people with:

  • Autoimmune disease — risk of lupus erythematosus-like effect.
  • Psoriasis — increased risk of exacerbation of psoriasis.
  • Renal impairment — the BNF recommends that half the normal dose of terbinafine should be used if the estimated glomerular filtration rate (eGFR) is less than 50 mL/min/1.73 m2 and there is no suitable alternative. However, the manufacturer does not recommend using terbinafine in these people, as it has not been adequately studied.

[EMC, 2020b; BNF, 2023]

Adverse effects

Adverse effects of terbinafine include:

  • Gastrointestinal — abdominal distension, dyspepsia, nausea, abdominal pain, diarrhoea, feeling of fullness (very common), and pancreatitis (unknown frequency).
  • Nervous system — headache (common); taste disturbance (uncommon); and dizziness, paraesthesia, and hypoaesthesia (rare).
  • Skin and subcutaneous tissue — urticarial rash (very common). Very rarely Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, skin eruption, dermatitis exfoliative, dermatitis bullous, photosensitivity reaction, and alopecia.
  • Other
    • Anaphylaxis.
    • Arthralgia, myalgia, and decreased appetite.
    • Hepatic dysfunction, jaundice, hepatitis, and cholestasis — people taking terbinafine tablets should be warned to report immediately any signs and symptoms of unexplained persistent nausea, decreased appetite, fatigue, vomiting, right upper abdominal pain, jaundice, dark urine, or pale faeces. If these symptoms develop, terbinafine treatment should be stopped, and liver function tests (LFTs) should be immediately performed.
    • Malaise, neutropenia, agranulocytosis, thrombocytopenia, and vertigo.

[EMC, 2020b; BNF, 2023; BNFC, 2023]

Drug interactions

Possible drug interactions with terbinafine include:

  • Codeine — the analgesic effect may be reduced or abolished by terbinafine. Monitor for analgesic efficacy.
  • Rifampicin — levels of terbinafine are reduced. Dose increases of terbinafine may be necessary.
  • Tamoxifen — avoid concurrent use. Metabolism to an active metabolite of tamoxifen may be inhibited by terbinafine. 
  • Terbinafine levels may be increased by the following drugs if taken concomitantly:
    • Amiodarone.
    • Fluconazole and ketoconazole.
  • Terbinafine may increase levels of the following drugs if taken concomitantly, thereby increasing or prolonging their effects, including adverse effects:
    • Anti-arrhythmics (flecainide, mexiletine, and propafenone).
    • Aripiprazole and risperidone.
    • Beta-blockers (carvedilol, metoprolol, nebivolol, propranolol, and timolol).
    • Dextromethorphan.
    • Monoamine oxidase inhibitors Type B (MAOIs-B, such as selegiline).
    • Selective serotonin reuptake inhibitors (sertraline and paroxetine).
    • Tramadol — terbinafine may increase levels of tramadol, but not the active metabolite; which causes an increase in adverse effects, but not in analgesic effect.
    • Tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline).

[EMC, 2020b; BNF, 2023; Preston, 2019]

Oral itraconazole

Dosing schedule

  • For adults, prescribe itraconazole 100 mg once daily for 30 days, alternatively 200 mg twice daily for 7 days.

[BNF, 2023]

Contraindications and cautions

Do not prescribe itraconazole to people with:

  • Acute porphyria.
  • Ventricular dysfunction or a history of heart failure — itraconazole has been shown to have a negative inotropic effect.

Prescribe itraconazole with caution in people:

  • At high risk of heart failure, including people on treatment with negative inotropic drugs (such as calcium-channel blockers).
  • Who are immunocompromised (for example people with AIDS, on chemotherapy, with neutropenia, or have had previous organ transplants).
  • With acute liver disease or a history of hepatotoxicity with other drugs — consider monitoring liver function tests (LFTs). Advise immediate LFTs if symptoms of possible liver toxicity develop, such as anorexia, nausea, vomiting, fatigue, abdominal pain, or dark urine.
  • With renal impairment.
  • Taking drugs such as astemizole, pimozide, quinidine, or terfenadine that may prolong the QT interval, as there is a risk of cardiac arrhythmias.

 [ABPI, 2018; BNF, 2023]

Adverse effects

Adverse effects of itraconazole include:

  • Gastrointestinal — nausea, abdominal pain (common); vomiting, diarrhoea, constipation, dyspepsia, taste disturbance, and flatulence (uncommon); and pancreatitis (rare).
  • Hepatobiliary — hyperbilirubinaemia (uncommon). Rarely hepatotoxicity (including acute liver failure).
  • Nervous system — headache, dizziness, and paraesthesia (uncommon).
  • Skin and subcutaneous tissue — rash (common); alopecia, urticaria, and pruritus (uncommon).
  • Other — arthralgia, myalgia, heart failure, erectile dysfunction, menstrual disorders, oedema, tinnitus, and visual disturbance.

[ABPI, 2018; BNF, 2023]

Drug interactions

Itraconazole is metabolized by the cytochrome p450 3A4 (isoenzyme CYP34A) and it interacts with a number of liver enzyme-inducing and liver enzyme-inhibiting drugs.

  • Itraconazole levels may be reduced by the following drugs:
    • Carbamazepine, phenobarbital, and phenytoin — monitor itraconazole efficacy and increase the dose if necessary.
    • Rifampicin and rifabutin — monitor itraconazole efficacy and increase the dose if necessary.
    • St John’s wort — avoid concurrent use.
  • Itraconazole levels may be increased by the following drugs:
    • HIV protease inhibitors (ritonavir and indinavir) — monitor for adverse effects.
    • Clarithromycin and erythromycin — monitor for adverse effects.
  • Itraconazole may increase levels of the following drugs:
    • Aliskiren — monitor for adverse effects.
    • Aripiprazole, quetiapine, and risperidone — dose reductions may be necessary.
    • Quetiapine — concurrent use with itraconazole is contraindicated. If considered necessary, monitor for adverse effects and adjust the dose.
    • Phospodiesterase-5 inhibitors (avanafil, sildenafil, and vardenafil) — avoid concurrent use with avanafil; reduce the dose of sildenafil or vardenafil.
    • Benzodiazepines (alprazolam, triazolam, and midazolam) — dose reductions may be required.
    • Calcium-channel blockers (amlodipine and verapamil) — monitor for adverse effects.
    • Colchicine — dose adjustment may be necessary.
    • Corticosteroids (budesonide and dexamethasone) — avoid concurrent use.
    • Digoxin — monitor the effects of digoxin; digoxin dose may need to be reduced by 50–75%.
    • Disopyramide — avoid concurrent use.
    • Domperidone — possible increased risk of ventricular arrhythmias. Avoid concurrent use.
    • Eplerenone — concurrent use is contraindicated.
    • Ergot alkaloids (such as ergotamine and ergometrine) — increased risk of ergotism. Concurrent use is contraindicated.
    • Ivabradine — concurrent use is contraindicated.
    • Mizolastine — monitor for adverse effects.
    • Oral anticoagulants (warfarin, apixaban, and dabigatran) — Monitor for adverse effects and adjust doses if required.
    • Pimozide — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Quinidine — increased risk of torsades de pointes. Concurrent use is contraindicated, but if considered necessary, monitor for adverse effects and reduce dose if required.
    • Ranolazine — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Reboxetine — monitor for adverse effects and adjust dose if required.
    • Solifenacin — restrict dose of solifenacin to 5 mg daily.
    • Statins (lovastatin and simvastatin) — avoid concurrent use.

[ABPI, 2018; BNF, 2023; Preston, 2019]

Oral griseofulvin

Dosing schedule

  • For adults, prescribe griseofulvin 500 mg daily, increased if necessary to 1000 mg daily for severe infections, for at least 4 weeks; reduce the dose when treatment response occurs.
    • The daily dose may be taken once daily or in divided doses. Treatment should be continued for at least two weeks after lesions have healed.

[EMC, 2021b; BNF, 2023]

Contraindications and cautions

  • Do not prescribe griseofulvin to people with:
    • Acute porphyria.
    • Severe liver disease.
    • Systemic lupus erythematosus — increased risk of exacerbation.

[EMC, 2021b; BNF, 2023]

Adverse effects

  • Possible adverse effects of griseofulvin include:
    • Gastrointestinal — such as nausea, vomiting, diarrhoea, abdominal pain, dyspepsia, and anorexia.
      • Advise the person to take griseofulvin after a high-fat meal to increase systemic absorption and reduce the risk of adverse effects.
    • Hepatobiliary — alteration in liver function tests (LFTs), intrahepatic cholestasis, and hepatitis.
    • Neuropsychiatric — headache, dizziness, confusion, taste disturbance, impaired coordination and hearing, peripheral neuropathy, sleep disturbances, agitation, and irritability.
      • Advise the person that griseofulvin may enhance the effects of alcohol and impair the performance of skilled tasks, such as driving.
    • Skin — rashes such as erythema multiforme, toxic epidermal necrolysis, photosensitivity, bullous reactions (including Lyell's syndrome), and urticarial reactions.
    • Other — fatigue, leucopenia, neutropenia, and anaemia (usually resolve upon stopping treatment).

[EMC, 2021b; BNF, 2023]

Drug interactions

Possible drug interactions with griseofulvin include:

  • Alcohol — concurrent use of alcohol and griseofulvin may cause a disulfiram-like reaction (flushing and tachycardia). Warn people about the possibility of this reaction.
  • Oral contraceptives — the efficacy of oral contraceptives may be reduced with concurrent griseofulvin use. The clinical significance of this effect is unknown.
    • The Faculty of Sexual and Reproductive Healthcare (FSRH) recommends avoiding the use of combined oral contraceptives (COCs) and progestogen-only contraceptives (POPs), the progestogen-only implant, and ulipristal acetate, and using an alternative method of contraception when using griseofulvin, and within 28 days of stopping treatment.
      • If a woman wishes to use the COC when taking griseofulvin, consider an increased ethinylestradiol dose (at least 50 micrograms) during treatment and for a further 28 days after stopping griseofulvin, with a continuous or tricycling regimen plus a pill-free interval of four days.
      • See the CKS topic on Contraception - assessment for more information.
  • Warfarin — griseofulvin potentially decreases the efficacy of warfarin. Monitor the international normalized ratio (INR), and adjust the anticoagulant dose accordingly. 
  • Phenobarbital — may result in a decreased plasma level of griseofulvin, leading to a reduction in efficacy.
  • Primidone — may result in a decreased plasma level of griseofulvin, leading to a reduction in efficacy.

[EMC, 2021b; CoSRH, 2022; BNF, 2023; Preston, 2019]

Supporting evidence

This CKS topic is largely based on the Public Health England (PHE) publications Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and Health protection in schools and other childcare facilities [UKHSA, 2023c]; the British Medical Journal (BMJ) Best Practice guide Dermatophyte infections [BMJ Best Practice, 2022]; a Cochrane systematic review Topical treatments for fungal infections of the skin and nails of the foot [Crawford, 2007]; a systematic review Consensus for the Treatment of Tinea Pedis: A Systematic Review of Randomised Controlled Trials [Ward, 2022]; and expert opinion in review articles Superficial fungal infections [Kovitwanichkanont, 2019], Guidelines Committee of the Japanese Dermatological Association. Guidelines for the management of dermatomycosis [Mochizuki, 2019], Tinea Pedis [Nigram, 2022]. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of fungal skin infections of the foot (athlete's foot).

Search dates

March 2018 - June 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Dermatomycoses/, dermatomycos?s.tw., exp Foot Dermatoses/, foot dermatos?s.tw., exp Tinea Pedis/, tinea pedis.tw., athlete$ foot.tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2018) SPC for Itraconazole 100 mg Capsules. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2021) SPC for Pevaryl 1% topical cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • ABPI (2022) SPC for Erythrocin 250 Tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Bell-Syer, S.E.M., Khan, S.M. and Torgerson, D.J. (2012) Oral treatments for fungal infections of the skin of the foot (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
  • BMJ Best Practice (2022) Dermatophyte infections. BMJ Publishing Group. https://bestpractice.bmj.com
  • BNF (2023) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • BNFC (2023) British National Formulary for Children. National Institute for Health and Care Excellence. https://bnfc.nice.org.uk
  • CoSRH (2022) Drug interactions with hormonal contraception. The College of Sexual and Reproductive Healthcare. https://www.cosrh.org [Free Full-text]
  • Crawford, F. and Hollis, S. (2007) Topical treatments for fungal infections of the skin and nails of the foot (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
  • EMC (2020a) SPC for Daktarin 2% Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2020b) SPC for Terbinafine 250mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2021a) SPC for Daktacort Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2021b) SPC for Griseofulvin 125mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2023) SPC for Lamisil 1% w/w Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Kovitwanichkanont, T. and Chong, A.H. (2019) Superficial fungal infections. Australian Journal of General Practice 48(10), 706-711. [Free Full-text]
  • Mochizuki, T., Tsuboi, R., Iozumi, K., et al. (2019) Guidelines Committee of the Japanese Dermatological Association. Guidelines for the management of dermatomycosis. Journal of Dermatology 47(12), 1343-1373. [Free Full-text]
  • Nigam, P.K. and Saleh, D. (2022) Tinea Pedis. In: StatPearls [Internet]. Treasure Island (FL). StatPearls Publishing. [Free Full-text]
  • Preston, C. (2019) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical Press.
  • Rasner, C.J., Kullberg, S.A., Pearson, D.R. and Boull, C.L. (2022) Diagnosis and Management of Plantar Dermatoses. Journal of the American Board of Family Medicine 35(2), 435-442. [Free Full-text]
  • Rotta, I., Ziegelmann, P.K., Otuki, M.F., et al. (2013) Efficacy of Topical Antifungals in the Treatment of Dermatophytosis: A Mixed-Treatment Comparison Meta-analysis Involving 14 Treatments. JAMA Dermatology 149(3), 341-349. [Abstract]
  • UKHSA (2017) Fungal skin and nail infections: Diagnosis and laboratory investigation. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2023a) Health protection in children and young people settings, including education. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2023b) Health protection in children and young people settings, including education. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • UKHSA (2023c) Health protection in schools and other childcare facilities. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • Verma, S. (2017) Steroid modified tinea. BMJ 356, 1-4. [Abstract]
  • Ward, H., Parkes, N., Smith, C., et al. (2022) Consensus for the Treatment of Tinea Pedis: A Systematic Review of Randomised Controlled Trials. Journal of Fungi 8(4), 351. [Abstract] [Free Full-text]
Change privacy settings