What are the oral and topical treatments for ringworm?

Treatment of Ringworm (Tinea)

For ringworm infections, oral griseofulvin (10 mg/kg/day for children or 500 mg/day for adults) is recommended for extensive or resistant cases, while topical antifungal agents like azoles or allylamines are effective first-line treatments for localized infections. 1, 2

Topical Treatment Options

First-Line Topical Treatments

• Azoles (clotrimazole, miconazole, econazole)
  • Apply 1-2 times daily for 2-4 weeks for tinea corporis/cruris 3
  • Continue treatment for 1-2 weeks after clinical clearing
  • Clotrimazole 1% has demonstrated superior efficacy compared to placebo (NNT = 2) 3

Alternative Topical Treatments

• Allylamines (terbinafine, naftifine)
  • Apply once daily for 1-2 weeks for tinea corporis/cruris 3, 4
  • Terbinafine shows significantly higher clinical cure rates compared to placebo (NNT = 3) 3
  • Naftifine 1% is more effective than placebo for both mycological and clinical cure 3
  • May require fewer applications and shorter treatment duration than azoles

Treatment Duration

• Tinea corporis/cruris: 2-4 weeks 1, 4
• Tinea pedis: 4-8 weeks 1, 4
• Continue treatment for 1-2 weeks after symptoms resolve to prevent recurrence 4

Oral Treatment Options

Indications for Oral Therapy

• Extensive infection not adequately treated by topical therapy
• Resistant cases
• Tinea capitis (always requires oral therapy) 2
• Hair or nail involvement 1

Recommended Oral Medications

1. Griseofulvin:

   • Adults: 500 mg daily (can start with 750 mg-1g/day for widespread lesions)
   • Children (>2 years): 10 mg/kg daily
   • Treatment duration:
     • Tinea corporis: 2-4 weeks
     • Tinea cruris: 2-4 weeks
     • Tinea pedis: 4-8 weeks 1

2. Alternative Oral Agents (for resistant cases):

   • Terbinafine: 250 mg daily for 1-2 weeks 5
   • Fluconazole: 150 mg once weekly for 2-3 weeks 5
   • Itraconazole: 100 mg daily for 2 weeks or 200 mg daily for 7 days 5

Special Considerations

Combination Therapy

• Concomitant use of appropriate topical agents is usually required with oral therapy, particularly for tinea pedis 1
• For inflammatory lesions, short-term use of combination antifungal/steroid agents may be considered, but use with caution due to potential for atrophy 4

Prevention of Recurrence

• General hygiene measures should be observed to control sources of infection or reinfection 1
• For athletes or contact sports players, extra vigilance is needed as T. tonsurans infections may require longer treatment (2-3 months) 6
• Complete drying after bathing, especially in skin folds 2
• Use separate clean towels for different body parts 2
• For tinea cruris, covering active foot lesions with socks before wearing undershorts may reduce direct contamination 2

Diagnostic Confirmation

• Accurate diagnosis is essential before starting treatment 1
• Identification should be made by direct microscopic examination of infected tissue in potassium hydroxide solution or by culture 1, 4

Treatment Monitoring

• Continue medication until the infecting organism is completely eradicated as indicated by appropriate clinical or laboratory examination 1
• Clinical relapse will occur if medication is not continued until eradication 1

Caution

• Griseofulvin is not effective against bacterial infections, candidiasis, or other non-dermatophyte fungal infections 1
• Minor or trivial dermatophyte infections will respond to topical agents alone 1
• Be aware that steroid-modified tinea ("tinea incognito") may present atypically and require longer treatment 7