What is the recommended treatment for ringworm?

Treatment of Ringworm

For ringworm (tinea corporis), apply topical terbinafine cream once daily for 1 week as the first-line treatment. 1

Treatment Options Based on Location

Tinea Corporis (Ringworm on Body)

• First-line treatment: Topical terbinafine applied once daily for 1 week 1
• Alternative options:
  • Topical azoles (clotrimazole, miconazole) applied twice daily for 2-4 weeks
  • For extensive or resistant cases: oral terbinafine 250 mg daily for 2 weeks 2

Tinea Cruris (Groin)

• First-line treatment: Topical terbinafine applied once daily for 1 week 1
• Alternative options: Topical azoles applied twice daily for 2-4 weeks

Tinea Pedis (Feet)

• Between toes: Topical terbinafine twice daily for 1 week 1
• On bottom/sides of foot: Topical terbinafine twice daily for 2 weeks 1

Evidence Strength and Treatment Selection

Topical antifungal treatments have demonstrated high efficacy for localized ringworm infections. The FDA-approved labeling for terbinafine cream specifically recommends once daily application for ringworm for 1 week 1, which offers better compliance compared to longer treatment regimens with other agents.

A Cochrane systematic review found that terbinafine showed significantly higher clinical cure rates compared to placebo (RR 4.51,95% CI 3.10 to 6.56) with a number needed to treat of only 3 patients 3. This review rated terbinafine as one of the most effective topical treatments for tinea corporis.

Special Considerations

Extensive or Resistant Infection

For widespread, inflammatory, or treatment-resistant infections, consider oral therapy:

• Terbinafine 250 mg daily for 1-2 weeks (adults) 2
• Fluconazole 150 mg once weekly for 2-3 weeks 2
• Itraconazole 100 mg daily for 2 weeks or 200 mg daily for 7 days 2

Children

• Children ≥12 years: Same as adult dosing 1
• Children <12 years: Consult a physician for appropriate dosing 1
• For tinea capitis (scalp ringworm): Oral therapy is required (not topical) 4

Important Clinical Pearls

1. Avoid combination products with corticosteroids for initial treatment. While they may provide faster symptom relief, they can potentially mask symptoms while allowing the infection to spread or worsen 5.

2. Continue treatment for the full recommended duration even if symptoms improve earlier to ensure complete eradication of the fungus and prevent recurrence.

3. Implement preventive measures alongside treatment:

   • Keep affected areas clean and dry
   • Wear loose-fitting, breathable clothing
   • Change socks and underwear daily
   • Avoid sharing personal items like towels or clothing

4. Treatment failure considerations:

   • Poor adherence to treatment regimen
   • Incorrect diagnosis
   • Reinfection from untreated contacts or fomites
   • Resistant fungal strain

5. When to consider oral therapy:

   • Extensive skin involvement
   • Failure of topical therapy
   • Immunocompromised patients
   • Deep or inflammatory lesions

Topical terbinafine offers the advantage of shorter treatment duration (1 week) compared to azoles (2-4 weeks), which may improve patient compliance while maintaining excellent efficacy against dermatophyte infections.