What is the best treatment for topical ringworm?

From the Guidelines

Topical therapy alone is not recommended for the treatment of tinea capitis, and oral therapy is generally indicated to achieve both clinical and mycological cure. However, for topical ringworm (tinea corporis), the best treatment is an over-the-counter antifungal cream such as clotrimazole 1% (Lotrimin), miconazole 2% (Micatin), or terbinafine 1% (Lamisil) 1.

Key Points to Consider

• Apply the cream to the affected area and about 1-2 cm beyond the border of the rash twice daily for 2-4 weeks, even if the rash appears to clear sooner.
• For more severe or extensive infections, prescription-strength topical medications like ketoconazole 2% cream or oral antifungal medications such as fluconazole (150mg once weekly for 2-4 weeks) or terbinafine (250mg daily for 2-4 weeks) may be necessary.
• While treating ringworm, keep the affected area clean and dry, avoid sharing personal items like towels or clothing, and wash bedding and clothes in hot water to prevent reinfection.
• These antifungal medications work by disrupting the fungal cell membrane or inhibiting ergosterol synthesis, which is essential for fungal cell survival.
• Most cases resolve completely with proper treatment, though recurrence is possible if treatment is stopped too early or if there is reexposure to the fungus.

Additional Measures

• Children receiving appropriate therapy should be allowed to attend school or nursery 1.
• Index cases due to T. tonsurans warrant screening of all family members and close contacts and treatment for those positive cases 1.
• In asymptomatic carriers (no clinical infection, culture positive) with a high spore load, systemic treatment is generally justified 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Sufficient Econazole Nitrate Cream, 1% should be applied to cover affected areas once daily in patients with tinea pedis, tinea cruris, tinea corporis, and tinea versicolor, and twice daily (morning and evening) in patients with cutaneous candidiasis INDICATIONS AND USAGE Econazole Nitrate Cream is indicated for topical application in the treatment of tinea pedis, tinea cruris, and tinea corporis caused by Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans, Microsporum canis, Microsporum audouini, Microsporum gypseum, and Epidermophyton floccosum, in the treatment of cutaneous candidiasis, and in the treatment of tinea versicolor.

The best treatment for topical ringworm is Econazole Nitrate Cream, 1% applied once daily to cover affected areas, as it is indicated for the treatment of tinea corporis, which is another term for ringworm. The treatment should be continued for two weeks to reduce the possibility of recurrence 2. It is effective against various fungi that cause ringworm, including Trichophyton rubrum, Trichophyton mentagrophytes, and Microsporum canis 2.

• Key points:
  • Apply Econazole Nitrate Cream, 1% once daily
  • Treat for two weeks
  • Effective against Trichophyton rubrum, Trichophyton mentagrophytes, and Microsporum canis

From the Research

Topical Ringworm Treatment Options

• The most effective topical antifungal treatments for ringworm (tinea corporis) include terbinafine, naftifine, and clotrimazole 3.
• Terbinafine has been shown to have significantly higher clinical cure rates compared to placebo, with a risk ratio (RR) of 4.51 and a number needed to treat (NNT) of 3 3.
• Naftifine 1% has also been found to be effective in achieving mycological and clinical cure, with a RR of 2.38 and 2.42, respectively, and a NNT of 3 3.
• Clotrimazole 1% has been shown to be effective in achieving mycological cure, with a RR of 2.87 and a NNT of 2 3.

Comparison of Topical Antifungal Treatments

• Azoles, such as miconazole, clotrimazole, and ketoconazole, are fungistatic and limit fungal growth, while allylamines and benzylamines, such as terbinafine and naftifine, are fungicidal and kill the fungal organisms 4.
• Fungicidal drugs, such as terbinafine and naftifine, are often preferred over fungistatic drugs for the treatment of dermatophytic fungal infections, as they can provide shorter treatment durations and higher cure rates 4.

Treatment Duration and Patient Preference

• Treatment duration for topical antifungal treatments can vary from one week to two months, but most studies have used treatment durations of two to four weeks 3.
• Patients often prefer to treat weeping infections with spray formulations, while most physicians prescribe branded products in cream or lotion bases 4.
• Cost is a factor in dictating prescription choice, especially for large areas of the body surface 4.

Limitations of Current Evidence

• Many studies on topical antifungal treatments are of unclear or high risk of bias, and there is a need for further high-quality, adequately powered trials focusing on patient-centered outcomes 3.
• There is insufficient evidence to determine the effectiveness of some topical antifungal treatments, such as Whitfield's ointment 3.