I have written much over the years about the most common infection of the foot - tinea pedis. Most of the blogs has been focused on the pharmacological treatment - which drugs are best, how to use them to maximum effect etc., but of course, the big problem is not so much the treatment but the scourge of reinfection. Virtually all patients with fungal foot infection will suffer reinfection eventually [1].
So beyond the treatment, I have previously written about measures to reduce the chances of reinfection. In this blog I will look at some recent research which looks at another aspect of athlete’s foot - socks, as I ask the question: what are the best socks for patients with athlete's foot?
Socks and Athlete's foot
A study to be published in the Journal of the American Academy of Dermatology [2], looks at a design feature which potentially may enhance treatment of this common clinical infection. The authors focus on the common presentation - interdigital tinea pedis, based on previous work which suggests that toe separation can reduce the incidence by lowering interdigital humidity.
The authors suggest that toe socks (socks with individual toes - sometimes referred to as finger socks or glove socks) can improve outcomes for patients with the infection. To test this hypothesis, they enrolled patients diagnosed with interdigital tinea pedis (using a diagnosis based on microscopy). All patients were issued with a topical azole to use for 4 weeks, twice a day interdigitally. The test group also received five pairs of toe socks and were instructed to wear these socks exclusively throughout the four-week study period.
A total of 54 patients completed the study (31 using socks, 23 in the control [no socks] group). At 6 weeks (two weeks after conclusion of treatment), in the treatment group 74% were completely cured, 16% improved and 10% were deemed a treatment failure. Whilst the no finger socks groups showed 22% cure, 26% improved, 52% treatment failure, which was statistically significant. The term cure in this study was defined by visual assessment by a dermatologist where the toe space had no visual appearance suggestive of fungal infection. The most commonly identified organism was T rubrum.
What does this mean?
The study suggests that wearing toe socks rather than ordinary socks can improve outcomes for patients with interdigital tinea pedis. The explanation for this effect from the authors is that the sock fibre worn in between toes can reduce interdigital humidity and improve outcomes. I would also add that it may hold antifungal cream more effectively after application, preventing evaporation and so may potentiate its effect.
Examining the protocol, it would appear that this is probably a correct finding as other factors were examined comparing the two groups in terms of frequency of socks changes, foot washing and daily time spent in socks. A larger sample size would confirm this finding and mycological data would strengthen the result.
Previous antifungal sock research
This is not the first study looking at toe web separation to reduce infection. The current work was based on previous research that showed a sock that had 3rd/4th toe separation seam had increased efficacy at preventing athletes’ foot versus standard socks [3]. Other sock related research has focussed on impregnating the material with various chemicals to inhibit or prevent fungal growth – including zinc oxide and copper compounds [4-7]
Are toe socks a recommendation for all our tinea patients? Probably not, as much of the tinea pedis we see is moccasin (plantar) infection and exclusively interdigital infection only makes up a small proportion of cases.
The future
Of course, all good research furthers knowledge a little and then generates further questions. In a future blog I will also be looking to try and answer what is the best way to disinfect socks in patients with tinea pedis.
References
1. Bristow, I. and Y. Mak, Fungal foot infection - the hidden enemy. Wounds UK Journal, 2009. 5(4): p. 72-78.
2. Aksoy, H., et al., Effect of Finger Socks on Clinical Cure in Interdigital Tinea Pedis. Journal of the American Academy of Dermatology, 2025. (in press)
3. Du, L., et al., Interdigital-type antifungal socks for prevention and treatment of tinea pedis. J Infect Public Health, 2024. 17(7): p. 102455.
4. Bristow, I. and A. Turner, Antifungal socks as part of a regime to prevent recurrence of tinea pedis and onychomycosis. Podiatry Now, 2009. 12(10): p. 27.
5. Leeyaphan, C., et al., Randomized controlled trial and cost-effectiveness analysis: Comparing chlorhexidine scrub, ZnO-nanoparticle socks, and their combination in pitted keratolysis treatment. The Journal of Dermatology, 2023. 50(11): p. 1427-1432.
6. Yuen, C.-W.M., et al., Treatment of interdigital-type tinea pedis with a 2-week regimen of wearing hygienic socks loaded with antifungal microcapsules: A randomized, double-blind, placebo-controlled study. Journal of the American Academy of Dermatology, 2013. 69(3): p. 495-496.
7. Zatcoff, R., M.S. Smith, and G. Borkow, Treatment of tinea pedis with socks containing copper impregnated fibers. The Foot, 2007. 18(3): p. 136-141.