Athlete's Foot

Athlete’s foot is a fungal infection of a foot that invades the outer layer of the skin, sometime is called tinea pedis. It is present as itchy, flaky skin and normally macerated with the peeling effect.

It is important to note that if the infection involved at toenail part, referral to doctor is necessary. Patient suffering athlete’s foot and diabetic at the same time should also be referred to doctor as this may impair circulation or innervations of the feet, promoting secondary infections.

Treatment failure is usually due to the reason that patients didn’t continue using the treatment long enough. However, if the patients have used the antifungal in correct way but still didn’t show any improvement, then referral to doctor is necessary. Unresponsiveness to treatment after 2 weeks is also an indication for referral.

Treatment

• 1. Topical allylamines e.g. terbinafine

a. More effective at preventing recurrence than azole

b. Once or twice daily for 1 week in athlete’s foot and 1-2 weeks in jock itch

c. Can cause redness, itching and stinging; contact with the eyes should be avoided

d. Not for children under 16 years old

• 2. Azoles e.g. clotrimazole, miconazole, ketoconazole

a. 2-3 times daily for 1 week

b. May cause mild irritation to the skin

Both need to be continued even after symptom resides. A minimum of 2-4weeks’ treatment is necessary.

Topical hydrocortisone should not be recommended as it may worsen the fungal infection despite its anti-inflammatory effect since it does not heal fungal infection. Combination products of hydrocortisone and antifungal agent are available OTC (Over the counter) for athlete’s foot and are limited to 7 days treatment.

Practical points

Sweating on the feet, moist environment, tight shoes and synthetic material can promote to athlete’s foot. Leather shoes, however, can help to reduce the symptom by allowing circulation of the skin. Cotton socks can facilitate evaporation of moisture while nylon socks act oppositely.

Acne

Acne usually occurs in teenagers and is due to hormonal changes during puberty (increase level of androgen), increase level of keratin and sebum production during adolescence. This is because the excessive sebum can encourage the growth of bacteria, e.g. Propionibacterium acnes. Young children present with acne should be referred as this is extremely rare. Rosacea is different than acne as rosacea only affecting face characterised with reddening and papules.

Lithium, phenytoin, progestogens, levonorgestrel and norethisterone may precipitate acne. People with acne which do not respond to treatment within 8 weeks should be referred to doctor.

Acne Treatments are available in lotions, creams and gels. Gels contain of alcohol base and dry very quickly, causing irritation. Aqueous base however dry slower and less irritating. Gels are suitable for oily skin while cream for dry skin. One of the treatments is benzoyl peroxide, which is best used after washing face and rinsed off with water. Benzoyl peroxide prevents new formation of acne rather than shrinkage the existing one. People using this should be warned about its stinging, drying and peeling effects. It is best to use at lower strength, 2.5% and increase gradually after 2-3 weeks. Contact of benzoyl peroxide to eyes, mouth and other mucous membranes should be avoided.

Antiseptic agents, e.g. chorhexidine that present in some soap have degreasing effect and reduce the skin flora.

Exposure to sunlight is thought to be beneficial as it is believed that ultraviolet (UV) light has peeling effect that helps to unblock follicles as well as drying or degreasing the skin. But don’t try to use artificial UV light as it increases the risk of melanoma. It is thought that chocolate and fatty foods can worsen acne.

Oral antibiotic such as erythromycin is also used in the treatment of acne but it has high bacteria resistance, therefore it is more recommended using trimetroprim which has less bacteria resistance. Apart from that, minocycline is also commonly used due to its lower resistance and better absorption which only required a dose once daily. Patients should be reminded not to drink or eat any dairy products up to 1 hour before or after taking the antibiotic.

P/s: The use trimethroprim above is an unlicensed indication.

Practical points

Acne is a chronic skin condition which require up to 6 months for the treatment to elicit full benefit. Therefore, patients are encouraged to maintain using the treatment and not to be discouraged if the results are not immediate. Continuous treatment is essential.

Patients are advised to avoid taking any topical hydrocortisone as the steroids can potentiate the effects of androgenic hormones, causing acne worse.