ORIGINAL RESEARCH

Published: 25 December 2023

Diyala Journal of Medicine Doi: 10.26505/DJM.25027470402

Management of Athlete's foot

with topical Zinc Sulphate (15%)
Solution versus Clotrimazole
(1%) Solution
Saad D Hameed (CABMS)1 , Sarmad Y Abbood (FICMS)2 ,
Attaa A Alhajji (CABMS)3
1,2,3
Baquba Teaching hospital, Diyala , Iraq

Abstract

Background: Athlete's foot (tinea pedis) is by far the commonest fungal

OPEN ACCESS infections of the integument in the developed world that usually begins
between the toes. Multiple drugs were used for the treatment of athlete's
foot and including both; topical and systemic agents.Zinc sulphate has
Correspondence Address: Saad D Hameed been used as topical antifungal agent.
Baquba Teaching hospital, Diyala , Iraq Objective: Comparison the efficacy of 15% zinc sulphate solution
Email: Sum_sum112233@yahoo.com topically in the management of tinea pedis with topical clotrimazole
Copyright: ©Authors, 2023, College of solution.
Medicine, University of Diyala. This is an
open access article under the CC BY 4.0 Patients and Methods: A therapeutic, single blind, comparative, study of
license Zinc Sulphate solution (15%) in the management of tinea pedis in
(http://creativecommons.org/licenses/by/4.0/)
Website:
comparison with clotrimazole solution (both topically), that conducted in
https://djm.uodiyala.edu.iq/index.php/djm the Unit of Dermatology and Venereology ,Baquba Teaching Hospital,
extended from March 2020- July 2021 . Fifty patients, 31 males and 19
Received: 2 April 2023
Accepted: 6 August 2023 females with tinea pedis were registered in this study. Divided to 2 groups
Published: 25 December 2023 of patients included in the study:
Group A: Use the topical zinc sulphate solution 15% .
Group B: Use the topical 1% Clotrimazole solution.
A complete history with examination clinically were done for all patients
with tinea pedis involving all the relevant points. All patients were used
the medicine twice daily for 30 days, and follow there to be seen every
14 days during the course of treatment and then follow up for two months.
The patients were examined clinically; also the scoring of feet odor was
done at each visit.
Results: Group A: Twenty five patients 9 (36%) females and 16 (64%)
males were included in this group were treated by Zinc Sulphate solution ,
and their ages ranged between 27-73(47.8±12.18) years. and the duration of
that illness was ranged from 1-120(43±46.61) months. Clinical response
after one month of the treatment was 10(40%) patients with complete
clearance, 5(20%) patients had partial clearance while 10(40%) patients
showed no response.
Group B: Twenty five patients treated by clotrimazole solution, and their
ages ranged from 24-65(43.2±11.83) years, and the duration of the illness
was ranged from 1-180(30.24±44.9) months. Clinical response after four
weeks of treatment was 19(76%) patients with complete response, 2(8%)
patients had partial response, while 4(16%) patients have no response.

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Diyala Journal of Medicine Doi: 10.26505/DJM.25027470402

There was no statistical significance difference at two weeks in

comparison between group A and B (chi square 5.37 P value =0.07) but
was slightly significant at four weeks (chi square 6.65, P value =0.04).
Side effects of treatment were mild which included itching and burning
sensation in 4(16%) patients of group A and in 1(4%) patients of group B.
These side effects did not require discontinuation of the treatment.
Conclusion: Clotrimazole solution was superior to15% Zinc sulphate
solution as effective as topical treatment for Athlete's foot.
Keywords: Tinea pedis, topical zinc sulphate, clotrimazole
Introduction
Athlete's foot or tinea pedis is one of the azole, ciclopirox, tolnaftate and undecenoic
commonest fungi that infect the skin in the acid have been used in the treatment of
humans being. Also its common superficial Athlete's feet [4]. Many of the drugs are used
fungal infection in developed countries. The as antifungal drugs (azoles group and
most frequent dermatophytes that cause it allylamines) that used currently in general
Trichophyton rubrum(the most common and practice for treatment of Athlete's foot have
the most stubborn). T. mentagrophytes var. been shown to be less than satisfaction in
interdigitale and less by Epidermophyton eliminating the disease, even with good
floccosum,and the most cases are caused by compliance from the treated patient. Azoles
that one of three organisms. The infected group that act as 14α-demethylase inhibitor
individual acts as a carrier, since when the of fungi and prevent the synthesis of the
infection occur, the organism may lasting as ergosterol; however, azoles group also inhibit
long as in the host [1]. Athlete's foot is the cytochrome P450 enzymes of
more common in the adult than in children mammalian. Allylamines prevent the
and more in males than women. The formation of squalene epoxidase, that
infection with tinea pedis occurs by the enzyme is crucial for the formation the cell
contact directly with arthroconidia (that membrane of the fungi, and have no effect on
produced by the filaments of dermatophyt), the mammalian cytochrome P450-dependent
wearing of the tightly-fitting shoes also enzymes [5, 6].
enhance the infection and it's spreading Odor in the Athlete's feet which is a
(spores in occlusive footwear encourage common socio-medical issue, that could be
relapses) [2]. The sharing of wash places, like caused either by the fungi of tinea pedis itself
the swimming pools, gymnasia, changing or by the associate microorganism like
rooms of sports clubs and the public showers Brevibacteria( most one impotant for feet
predisposes to infection [3]. Athlete's foot odor), as these microorganisms take the dead
considered as chronic fungul infection that corneocytes on the feet and produce a cheesy
often with remission with treatment and odor and the sulfuric aroma, by the process
relapse thereafter, so the management is that produce methanethiol from an amino
consider usually not so easy. There are many acid (methionine). While Propionibacteria
systemic drugs and include; terbinafin,,, which present in the sebaceous glands ducts
itraconazole, and fluconazole. Topical of the adolescent and adult it has vinegar-like
antifungal medications like, allylamine, odor as a result of propionic acid which result

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from the breakdown product of amino acids. 2021.Fifty patients, 31 males and 19 females
Another microorganism that contributes to with tinea pedis were involved in this work.
the feet odor is the Staphylococcus Study design
epidermidis that produce isovaleric acid by The chief compliant is the tinea pedis
the degradation of the leucine that present in (interdigital type) in all patients that
the sweat and give a strong cheesy odor [7, attending to the Unit of Dermatology were
8]. only included regardless the age and sex.
Zinc is an important micronutient that is an Full history were including: age of patients,
essential component for more than 300 sex, marital status, residence, social status,
metalloenzymes that involved in a variety in job, and history of the disease itself,
metabolic pathways and cellular functions, including the duration, complaint of the
that include the antioxidant enzymes, patient, duration, associated with odor,
superoxide dismutase and affects their family history, any seasonal variations and
stability, conformity, and activity [9]. Zinc what is the aggravating factors. A socks
sulphate was effective in the treatment of type that been used, frequency of changes
many skin diseases, where it used in the per day and type of the shoes also asked to all
topical, intralesional or systemic formula , patients. In addition to history of drug intake
like acne vulgaris [10], recurrent oral that associated with sweating including
aphthus [11] , cutanous leishmaniasis aspirin, fluoxetin and insulin.
[12,13],many form of viral warts like plane The assessment of severity of the disease in
warts [14],other viral infections [15,16], all cases was performed including :clinical
Tinea versicolor [17],and dermatophytes examination to the lesion, and address the
fungal infections [18].The action of zinc site, any changing in color , presence any of
sulphate by the different mechanism of action the dry scales, wet scales ,maceration ,
that may be as antioxidant, erythema and skin scraping test .Also the
immunomodulator, antiviral, anti-fungal , associated feet odor was assessed and scored.
astringent, while it is cytotoxic in high Evaluation of the patients was done every
concentration [19]. two weeks for one month and follow up was
So, objective of the study is to compare the carried out. Photo for all lesions of the
efficacy of topical 15% zinc sulphate solution patients were taken by a digital camera
in the managment of Athlete's feet in versus (Sony:Cyber shoot with resolution 9 mega
the topical clotrimazole solution. pixels), as a first visit(baseline) and then
Patients and Methods every other 14 days, in the same
Study protocol circumstances (place with fixed illumination
The single-blind, comparative therapeutic and distance).
study using topical 15% zinc sulphate Study population
solution with 1% clotrimazole solution for Exclusion criteria: patients were received
the management of tinea pedis was executed no therapy for tinea pedis in the last two
in the Unit of Dermatology, BaqubaTeaching months prior the study. Patients with diabetes
Hospital between March 2020- July mellitus or atherosclerosis that may cause

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Diyala Journal of Medicine Doi: 10.26505/DJM.25027470402

complications in the feet; deformity and significant when less than 0.05, It done by
malformation of the feet and Excell 2010, SPSS version 20 statistical
immunosuppressant conditions were also program.
excluded from the study. Results
Preparations Group A: Twenty five patients 16 (64%)
Fifteen percent of the zinc sulphate males, 9 (36%) females involved in this
solution 15% (W/V) was produced by group, with ages ranged from 27-73 and a
thawing zinc sulphate crystals (ZnSO4 mean± SD of 47.8±12.18 years. While the
7H2O=287.54 It is manufactured by: Thomas disease duration ranged between 1-120 and a
Bekar India), 15 grams in 100 ml of Distilled mean± SD of 43±46.61 months. Also
Water, and kept in cleaned container at the repeated foot washing ranged from 2-10 with
room temperature of hospital and a mean± SD of 5.24±2.66 times/day. Twenty
Clotrimazole(1% )solution is obtained from four (96%) patients had a feet odor and the
MEDICO LABS _SYRIA. manner of feet odor was cheesy odor in 20
Clinical response score (80%) patients and vinegar odor in 4 (16%)
No clearance: - If there is no any response cases while 8 (32%) patients had itching. 17
while clinically examine and no change in (68%) of cases presented with seasonal
scoring of feet odor. variation with tinea pedis that worsened
Partial clearance: - If there is some clinical during the summer time, while 16(64%) of
improvement,like change of wet scales into patients had associated with plantar
dry scales, abscence in scales and change in hyperhydrosis.While 10 (40%) cases madet
feet odor. drying of foot after the washing as a habit
Complete clearance: - There is complete while others were not.
clearance of rash and odor The socks types were nylon in 17(68%),
Scoring of feet odor cotton 6(24%) and wool 1(4%) patient.
The scoring system had been used to assess Frequency of socks changes around the day
the patients with bared feet and any odor and of was presented in 15(60%) patients. The
to evaluate the odor intensity in that case and shoes types of were leather 9(36%), sandal
involve four points: 10(40%), and rubber 6(24%) patients.
Score 0: No any odor. Histories of drugs were aspirin in 5(20%)
Score1: mild; the odor is smell only when patients while 7 (28%) patients presented
the patient's finger put between the toe webs with positive family history of tinea pedis.
of his sole. The factors that aggravating of tinea pedis
Score2: Moderate; when the doctor in close were the hyperhidrosis present in 7(28%),
to the patient can smell the odor. occlusive the feet wear in 10(40%) and
Score 3: Severe; the surrounding people can nylon socks 8(32%) patients Table (1).
smell the odor. Scoring of feet odor before treatment was
Statistical Analysis Score 0: in 1(4%) patients, Score 1: 20(80%)
It done by Excell 2010, SPSS version 20 patients and Score 2: 4(16%) patients Table
statistical program.P_value is considered (2).

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Group B: Twenty five patients presented The clinical assessment among tinea pedis
with tinea pedis were involved in this study, patients
10(40%) females and 15 (60%) males. The Group A: Clinical scoring of the odor in the
ages were ranged from 24-65 with a mean± tinea pedis after 2 weeks of treatment was
SD of 43.2±11.83 years, and the disease Score 0: 1 (4%) patient. Score 1: 20 (80%)
duration were ranged from 1-180 months, patients that changed into score 0 in 10(50%)
and the mean± SD of 30.24±44.9 months. patients, and not changed in 10(50%)
Also repeated foot washing ranged from 1-10 patients. Score 2: 4 (16%) patients changed
and the mean± SD of 4.84±2.15 times/day. into score 0 in 2(50%) patients, and not
Twenty (80%) of patients had feet odor and changed 2(50%).
also the tinea pedis, while 8 (32%) patients Scoring of the Athlete's feet odor after one
reported a positive family history of tinea month of treatment was:
pedis, itching was found in 9 (36%) patients. Score 0: 1 (4%) patient. Score 1: 20 (80%)
The quality of odor was cheesy odor in 20 patients changed into score 0 in 12(60%)
(80%) patients and vinegar odor in 2 (8%) patients, and not changed in 8(40%) patients.
patients.While 12 (48%) of caseshad history Score 2: 4 (16%) of patients that changed
of variation around the seasons with worse into score 0 in 2(50%) patients, and score 1
odor during the summer time, and 19(76%) in 1(25%) patient and no change 1(25%)
of patients had associated with plantar Table (2).
hyperhidrosis,and 12 (48%) patients had After two weeks of treatment, 2(8%)
drying habit to the feet after washing while patients showed complete clearance, 9(36%)
others were not. patients had partial of clearance and 14(56%)
Types of the socks that used by patients patients that showed no response Table (4).
were nylon in 10(40%) patients, cotton While clinical response after four weeks of
6(24%) and wool 4(16%) patients. Daily the treatment was 10(40%) patients was
changed frequency of the socks were complete clearance, 5(20%) patients had
presented in 10(40%) patients and others not. partial clearance and 10(40%) patients
Types of the shoes were: leather 10(40%), showed no response.
sandal 12(48%) and rubber 3(12%) patients. The clinical response in that patients have
History of drugs was: aspirin in 2(8%) the difference between two weeks and four
patients. weeks and was significant (chi square 7.14 P
Factors that may aggravate of the feet odor value =0.03).
were occlusive feet wear 10(40%) , Itching and burning sensation in 4(16%)
hyperhidrosis in 10(40%) patients, and nylon patients on treatment were mild side effects
socks 5(20%) patients Table (1). and these did not require discontinuation of
Scoring of the odor before starting the the drugs.
therapy was Score 0: in 3 (12%) cases, Group B: Scoring of the odorin tinea pedis
Score 1: in 20 (80%) cases and Score 2: in 2 foot after 2 weeks of treatment was
(8%) cases Table (3) Score0: 3 (12%) patients. Score1: 20 (80%)
patients that changed into the score 0 in 15

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(75%) patient, and thre is no clinical complete response, 2 (8%) patients had
diffrence in 5 (25%) of cases. Score2: 2 (8%) partially responded, and 4 (16%) patients
patients changed into score 1 in 1(50%) showed no response Table (4).
patient and no difference in 1 (50%). The clinical response was also significant
Scoring of the odor of feet after one month of (chi square 20.12 P value =0.000043) in that
treatment was: patients between two weeks and four weeks
Score 1: 20 (80%) patients changed into of treatment.
score 0 in 17 (85%) of the cases, and no Side effects of treatment were mild which
changed in 3(15%) patients. Score2: 2 (8%) included itching and burning sensation in
changed into score1 in 2 (100%) patients 1(4%) patient. These side effects did not
Table (3). require discontinuation of the medicine.
After two weeks of beginning of the There was no significant difference
treatment, 4 (16%) patients showed complete statistically in two weeks (chi square 5.37 P
clearance, 15 (60%) patients had partially value =0.07) in the comparison between
clearance and 6 (24%) patients with no group A and B ,but was slightly significant at
response Table (4). four weeks (chi square 6.65, P value =0.04).
While clinical response after four weeks from
the treatment was 19 (76%) patients was
Table (1): Study groups description the (tinea pedis)
Group (A) Group (B)
Number (%) Number (%)
1- Family history 7 28 8 32
2-Iching 8 32 9 36
4-Type of odor
--Cheesy odor 20 80 20 80
- Vinegar odor 4 16 2 8
5- Associated with sweating 17 68 19 76
6-Season variation 16 60 12 48
7-Drying of feet 10 40 12 48
8-Types of socks
-Nylon 17 68 10 40
-Cotton 6 24 6 24
-Wool 1 4 4 16
-Daily changing 15 60 10 40
9-Types of shoes
- Leather 9 36 10 40
-Sandal 10 40 12 48
-Rubber 6 24 3 12

10-Drugs history
-Aspirin 5 20 2 8
11-Aggravating factors
-Hyperhydrosis 7 28 10 40
-Occlusive footwear 10 40 10 40
-Nylon socks 8 32 5 20

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Table (2): Feet odor scoring of (Group A) after 1 month of therapy

Scoring
Score 0 Score1 Score2(4) %
before Scoring % % % total
(1) pt (2) pt pt
therapy

Scoring Score0 1 100 15 75 2 50 18 72

after Score1 0 0 5 25 1 25 6 24
Therapy Score2 0 0 0 0 1 25 1 4
*p value=0.0000001

Table (3): Feet odor scoring of the (Group B) after one month of treatment
Scoring
before Score 0 Score1(2 Score2 %
Scoring % % % total
treatmen (3) pt 0) pt (2) pt
t
Scoring Score0 3 100 17 85 0 0 20 80
after Score1 0 0 3 15 2 100 5 20
Therapy Score2 0 0 0 0 0 0 0 0

Table (4): Clinical response among patients with tinea pedis

At two weeks At four weeks
No Partial Complete No Partial Complete
clearance clearance clearance clearance clearance clearance

n. % n. % n. % n. % n. % n. %
Group A 14 56 9 36 2 8 10 40 5 20 10 40
Group B 6 24 15 60 4 16 4 16 2 8 19 76

Figure (1A): Tinea pedis(interdigital type) before 15% topical zinc sulfate solution application

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Figure (1B): Same patient above after one month of 15% topical zinc sulfate solution application

Discussion Trauma, with the excessive moisture, and

Athlete's foot considers the commonest occlusive shoes, and also the frequent usage
form of dermatophyt skin infection in the of public showers and pools these factors that
North America, United Kingdom, and might contribute to increase risk of infection:
probably throughout the developed world [23].
[20]. It is common in adults than more in There are generale measurement in
children, but may also occur in children treatment of tinea pedis like wash of feet
younger age 6years or more [21]. The daily with drying thoroughly, avoid tight
chance for presenting with tinea pedis in footwear, especially in the summer and avoid
adult males probably about 20%, while walking barefoot in the public areas, wear
among women to become chronically cotton socks and change them frequently and
infected with tinea pedis only about 5% [ 21]. also wearing the plastic shoes or other of the
It is a common problem seen among males footwear that do not allow sweat to be
and housewives, in Iraqi patients it accounted evaporate easily best to be avoided [24].
about (4.3%), with a mean age of 29 years Many of the systemic drugs like
and ranged from 17-53 years [22]. terbinafine,, itraconazole, and fluconazole,
Three species of fungi are together also topical antifungal drugs like, allylamine,
responsible for the vast majority of cases of azole, ciclopirox, benzylamine, tolnaftate and
Athlete's foot throughout the world, undecenoic acid have been used to treated
Trichophyton rubrum, Trichophyton the tinea pedis [4].
mentagrophytes var. interdigit ale, and also Feet odor is common sociomedical problem
Epidermophyton floccose. The Trichophyton among males and it's etiology and
rubrum is consider the most common pathogenesis is not well understood but there
pathogen that associated with stubborn and are multifactorial agents that play a role like
chronic Athlete's foot [1]. weather,sweating,with bacterial, and fungal

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infections, wearing closed shoes and socks University of Diyala ethical committee for
[7]. this study.
The study showed that zinc sulfate was Conflict of interest: Nil
good agent in clearance of feet odor and References
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[15]Sharquie KE, Al-Nauaimy AA. [24] Kardjeva V, Summerbell R, Kantardjiev
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actinic keratosis. J cutenous and anesthetic effective therapy for feet odor. Journal of
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Topical 15% zinc sulphate solution is an

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‫دراسة منفردة التعمية مقارنة لعالج سعفة القدم بسلفات الزنك ‪ %15‬مقارنة بمحلول‬
‫الكلوتريمازول ‪%1‬‬
‫‪3‬‬
‫سعد ظاهر حميد‪ , 1‬سرمد يحيى عبود‪ , 2‬عطاء اكرم قدوري‬

‫الملخص‬

‫خلفية الدراسة‪ :‬سعفة القدم هو عدوى فطرية جلدية تبدء بين اصابع القدمين عادة وهي شائعة لدى االشخاص الدين تصبح‬
‫اقدامهم شديدة التعرق اثناء انحشارها داخل االحدية الضيقة‪.‬‬
‫اهداف الدراسة‪ :‬لتقييم فعالية سلفات الزنك ‪ %15‬في عالج سعفة القدم بالمقارنة مع محلول الكلوتريمازول ‪. %1‬‬
‫المرضى والطرائق‪ :‬تجربة منفردة التعمية ومقارنة امالح سلفات الزنك ‪ %15‬مقارنة ب الكلوتريمازول ‪ ,%1‬في مستشفى‬
‫بعقوبة التعليمي‪ ,‬قسم المرضى ال مجموعتين‪ ,‬مجموعة (ا) عولجت بسلفات الزنك ‪ %15‬مرتين يوميا ‪ ,‬مجموعة (ب) عولجت‬
‫بمحلول الكلوتريمازول ‪ %1‬مرتين يوميا‪ .‬مع المتابعة كل اسبوعين‪.‬‬
‫النتائج‪ :‬مجموعة (ا) ‪ 25‬مريض مدة المرض ‪ 120-1‬شهر عولجت بسلفات الزنك وبعد المتابعة باربعة اسابيع من العالج كان‬
‫الشفاء التام ‪ %40‬و ‪ %40‬لم يستجيبوا للعالج ‪ ,‬ومجموعة (ب) ‪ 25‬مريض عالجها بمحلول الكلوتريمازول وكانت مدة‬
‫المرض بين ‪ 180-1‬شهر ‪ ,‬وبعد اربعة اسابيع من العالج كان الشفاء التام ‪ %76‬و ‪ %16‬لم يستجيبوا للعالج‪.‬‬
‫االستنتاجات‪ :‬امالح سلفات الزنك‪ %15‬فعالة في عالج سعفة القدم ‪ ,‬لكن الكلوترمازول فعال اكثر‪.‬‬
‫الكلمات المفتاحية‪ :‬سعفة القدم‪ ،‬كبريتات الزنك الموضعية‪ ،‬كلوتريمازول‬
‫البريد االلكتروني‪Sum_sum112233@yahoo.com :‬‬
‫تاريخ استالم البحث‪ 2 :‬نيسان ‪2023‬‬
‫تاريخ قبول البحث‪ 6 :‬آب ‪2023‬‬

‫‪ 3, 2,1‬مستشفى بعقوبة التعليمي ‪ -‬ديالى‪ -‬العراق‬

‫‪101‬‬ ‫‪December 2023 ,Volume 25, Issue 2‬‬