What's the next step for a 16-year-old female with ringworm (tinea corporis) on the neck, who has shown no improvement after 3 weeks of topical antifungal treatment?

From the Guidelines

The next step for a 16-year-old female with persistent tinea corporis on the neck despite 3 weeks of topical antifungal treatment would be to consult a healthcare provider for oral antifungal therapy, specifically itraconazole, 100 mg, given orally once a day, for 15 days, as it has shown a superior mycological cure rate of 87% compared to other treatments 1. When considering treatment options, it's essential to note that oral agents have proven efficacious in the treatment of most cases of T corporis, with different doses and durations of itraconazole being used in studies 1. Some key points to consider in the treatment of tinea corporis include:

• Confirming the diagnosis through skin scrapings and fungal culture to rule out other conditions that may mimic ringworm
• Ensuring good hygiene practices, such as avoiding sharing personal items and wearing loose clothing around the affected area
• Completing the full prescribed course of oral antifungal treatment, even if symptoms improve quickly
• Being aware that treatment failure with topical agents can occur due to inadequate application, insufficient treatment duration, or fungal resistance, and that oral antifungals can provide systemic treatment that reaches deeper skin layers that topical medications cannot effectively penetrate 1. It's also important to note that T corporis and T capitis infections have been reported more frequently among high school wrestlers and judo practitioners, and that the most common cause of T capitis gladiatorum is Trichophyton tonsurans, accounting for more than 80% of cases, but it may also be caused by Trichophyton rubrum and Trichophyton mentagrophytes 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... tinea corporis, 2 to 4 weeks; Medication must be continued until the infecting organism is completely eradicated as indicated by appropriate clinical or laboratory examination.

The patient has been treating with topical antifungal for 3 weeks with no improvement. Since the recommended treatment period for tinea corporis is 2 to 4 weeks, and the patient has not shown improvement, consideration of oral antifungal therapy such as griseofulvin may be necessary.

• The dosage for a pediatric patient over 50 lbs would be 250 mg to 500 mg daily, in divided doses 2. Clinical evaluation is necessary to determine the best course of action.

From the Research

Next Steps for Treatment

The patient has been treating ringworm on the neck with topical antifungal for 3 weeks with no improvement. Considering this, the next steps could involve:

• Re-evaluating the diagnosis to ensure it is indeed ringworm (tinea corporis) and not another skin condition 3.
• Assessing the patient's compliance with the current treatment regimen and ensuring proper application of the topical antifungal 3.
• Considering a change in treatment, such as switching to a different topical antifungal or adding a systemic antifungal agent, depending on the severity and extent of the infection 4, 5.

Systemic Antifungal Options

If the decision is made to add a systemic antifungal agent, options could include:

• Terbinafine: shown to be effective in treating tinea corporis, with a relatively favorable safety profile 6, 5.
• Itraconazole: demonstrated to be effective in treating various forms of dermatophytosis, including tinea corporis 6, 4, 5.
• Fluconazole: may be considered, although its effectiveness in treating tinea corporis is less well-established compared to terbinafine and itraconazole 4, 5.
• Griseofulvin: an older antifungal agent that may be considered, although it has a longer treatment duration and more side effects compared to newer agents 6, 4, 5.

Topical Antifungal Treatments

If the decision is made to continue with topical treatment, options could include:

• Terbinafine: shown to be effective in treating tinea corporis, with a relatively favorable safety profile 7.
• Naftifine: demonstrated to be effective in achieving mycological and clinical cure in tinea corporis 7.
• Clotrimazole: a widely used topical antifungal agent that may be effective in treating tinea corporis, although the evidence is less strong compared to terbinafine and naftifine 7.
• Azoles: a class of topical antifungal agents that may be effective in treating tinea corporis, although the evidence is generally less strong compared to terbinafine and naftifine 7.