Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Tinea Pedis
Ringworm of the foot, or “athlete’s foot”; a superficial fungal infection of the foot.
I. Etiology: Trichophyton mentagrophytes and Trichophyton rubrum,
dermatophyte fungi, invade the skin following trauma.
II. Incidence
A. Most common of all the fungal diseases.
B. Occurs most frequently in adolescents and adults but is found with increasing frequency in preadolescent children, probably because of the use of occlusive footwear.
C. Studies have shown that a susceptibility factor must be present for infection to occur. Males are more susceptible than females.
III. Subjective data
A. One or both feet may be involved.
B. Pruritus
C. Cracks between toes
D. Scaling of feet
E. Blisters on soles
F. Pain with deep fissures
G. History of exposure to predisposing factors (e.g., communal showers, prolonged use of sneakers). Often seen following trauma or in conjunction with atopic dermatitis.
IV. Objective data
A. Interdigital fissures
B. Widespread fine scaling; extension onto sides of foot and heel is frequent.
C. Maceration
D. Vesicular eruption on plantar surface
E. Secondary infection may occur and present with cellulitis.
F. Regional adenopathy
G. Nails may be involved.
H. Vesicular eruption of the hands—an “id” reaction—may occur.
I. Unilateral tinea pedis is common.
J. Check for regional lymphadenopathy.
V. Assessment
A. Diagnosis: Diagnosis is generally made by physical findings.
1. Scrapings from lesions in potassium hydroxide fungal preparation reveal hyphae and spores.
2. Unilateral involvement is a significant positive clinical finding.
B. Differential diagnosis
1. Interdigital candidiasis: Interdigital lesions are moist and erythematous, with well-defined borders and satellite lesions.
3. Contact dermatitis: Reaction to shoes, sneakers, dye, soap, nylon socks. Diagnosis is generally done with history, distribution of rash, and appearance of erythematous, vesicular, and oozing rash.
VI. Plan
A. For acute lesions with blistering and oozing: Domeboro soaks 4 times daily, 1 tablet or powder packet to 1 pint of water
B. Antifungal creams—use one of the following:
1. Oxistat cream 1%, once daily for 4 weeks
2. Nizoral 2% cream, apply once daily for 6 weeks.
3. Lotrimin cream, apply bid for 4 weeks (also effective against
C. albicans).
1. Tinactin cream, apply tid (over-the-counter preparation; ineffective against C. albicans).
C. For severe or unresponsive cases in children over 50 lb:
1. Diflucan (fluconazole): 150 mg/wk for 4 weeks
2. Grifulvin V: 250 to 500 mg daily for 4 to 8 weeks
D. Note: For fungal infection of nails—Diflucan 200 mg once a week until nail grows out
E. Antibiotics for concurrent infection or cellulitis
1. Augmentin 500 mg, every 12 hours (over 40 kg)
2. Keflex 500 mg, every 12 hours (over 15 years of age)
VII. Education
A. Expect gradual improvement once treatment is instituted.
B. Continue treatment for at least 4 weeks to prevent relapse.
C. Soak feet bid–qid; use a small basin.
D. Domeboro solution concentrates when left exposed; store in covered container.
E. Hygiene
1. Dry interdigital areas thoroughly after bathing.
2. Use antifungal powder.
3. Use white cotton socks; no colored tights or nylons.
4. Change socks at least daily.
5. Use sandals if possible.
6. Avoid sneakers and plastic footwear.
F. Communicable as long as lesions are present
G. Causative organisms are long-lived, surviving more than 5 months.
H. Transmitted to traumatized skin by both direct and indirect contact
I. Alert child and parents to signs and symptoms of secondary infection.
J. Prevention
1. Use Tinactin or Micatin powder daily.
2. Use clogs for showers.
3. Do not lend or borrow shoes.
VIII. Follow-up
A. Telephone call contact in 3 to 4 days
B. If tinea pedis is severe with deep fissures and oozing, recheck in 5 days; recheck sooner if no improvement is noted.
C. Consider a change in topical medication if no noted improvement within 5 to 7 days.
IX. Complications
A. Secondary infection
B. Allergic response to topical antifungal cream (erythema, stinging, blistering, peeling, and pruritus)
C. Untreated or improperly treated tinea presents with scaling and erythema of the sides and dorsum of the foot, as well as interdigital areas and plantar surface. The tinea may be distributed in a shoe or sneaker pattern.
X. Consultation/referral
A. No clinical improvement after 2 weeks
B. Severe involvement or secondary infection