What is the treatment for ringworm?

Treatment for Ringworm

For ringworm (tinea corporis), topical antifungal agents are the first-line treatment, with oral therapy reserved for extensive, resistant, or complicated cases. 1

First-Line Treatment

Topical Therapy

• Preferred agents:

  • Azole antifungals (clotrimazole 1%, miconazole)
  • Allylamine antifungals (terbinafine 1%, naftifine 1%)
  • Apply once or twice daily for 2-4 weeks 1, 2
  • Continue treatment for at least 1 week after clinical improvement to prevent relapse

• Evidence of efficacy:

  • Clotrimazole 1% shows significantly higher mycological cure rates compared to placebo (RR 2.87) 1
  • Terbinafine shows significantly higher clinical cure rates compared to placebo (RR 4.51) 1
  • Naftifine 1% demonstrates superior mycological cure (RR 2.38) and clinical cure (RR 2.42) compared to placebo 1

Second-Line/Extensive Disease Treatment

Oral Therapy

For extensive disease, multiple lesions, immunocompromised patients, or treatment failures:

• Fluconazole:

  • 50-100 mg daily or 150 mg once weekly for 2-3 weeks 3

• Itraconazole:

  • 100 mg daily for 2 weeks or 200 mg daily for 7 days 3

• Terbinafine:

  • 250 mg daily for 1-2 weeks 3

• Griseofulvin (ultramicrosize):

  • Adults: 375 mg daily (single dose or divided doses) 4
  • Children: 7.3 mg/kg/day 4
  • Duration: 2-4 weeks for tinea corporis 4

Special Considerations

Tinea Capitis (Scalp Ringworm)

Requires systemic therapy:

• First-line options:

  • Griseofulvin:

    • <50 kg: 15-20 mg/kg/day for 6-8 weeks

    • 50 kg: 1 g/day for 6-8 weeks 5

  • Terbinafine:

    • <20 kg: 62.5 mg/day for 2-4 weeks
    • 20-40 kg: 125 mg/day for 2-4 weeks

    • 40 kg: 250 mg/day for 2-4 weeks 5

• Second-line option:

  • Itraconazole: 50-100 mg/day for 4 weeks, or 5 mg/kg/day for 2-4 weeks 5

Tinea Cruris (Groin)

• Similar treatment approach as tinea corporis
• Topical therapy is first-line 1
• Keep area dry and wear loose-fitting clothing

Tinea Pedis (Athlete's Foot)

• Topical therapy for 4-8 weeks 4
• Consider oral therapy for chronic or extensive cases

Important Clinical Pearls

1. Diagnosis confirmation: While treatment can be initiated based on clinical appearance, consider microscopy with potassium hydroxide (KOH) preparation or culture for confirmation in atypical or resistant cases 4

2. General hygiene measures:

   • Keep affected areas clean and dry
   • Avoid sharing personal items (towels, clothing, combs)
   • Treat family members or close contacts if infected 5

3. Treatment failures:

   • Consider poor compliance
   • Evaluate for incorrect diagnosis
   • Consider fungal resistance
   • Check for ongoing sources of reinfection

4. Combination therapy:

   • Some evidence suggests azole-steroid combinations may provide faster symptomatic relief but should be used cautiously as they may mask symptoms while infection persists 1

5. Duration of therapy:

   • Continue treatment until clinical and mycological cure
   • Extend treatment for 1-2 weeks beyond clinical resolution to prevent relapse

By following this treatment algorithm, most cases of ringworm will resolve completely with minimal risk of recurrence or complications.