What is the treatment for ringworm?

Treatment for Ringworm

Topical antifungal medications are the first-line treatment for most ringworm infections (tinea), with oral antifungals reserved for extensive disease, hair/nail involvement, or treatment failures. 1

Diagnosis Confirmation

• Diagnosis should be confirmed through:
  • Direct microscopic examination with potassium hydroxide (KOH) preparation
  • Fungal culture when diagnosis is uncertain
  • Nail biopsy for suspected onychomycosis 2

Treatment Algorithm Based on Infection Site

Tinea Corporis (Body) and Tinea Cruris (Groin)

1. First-line treatment: Topical antifungal agents

   • Terbinafine 1% cream applied twice daily for 1-2 weeks 3, 4
   • Clotrimazole 1% cream applied twice daily for 2-4 weeks 5, 4
   • Other azole creams (miconazole, econazole) applied for 2-4 weeks 4

2. For extensive or resistant disease:

   • Oral terbinafine 250 mg daily for 2-4 weeks
   • Oral fluconazole 400 mg weekly for 2-4 weeks 6

Tinea Pedis (Feet)

1. First-line treatment: Topical antifungal agents

   • Terbinafine 1% cream twice daily for 1-2 weeks 3
   • Clotrimazole 1% cream twice daily for 4 weeks 5

2. For moccasin-type or resistant infections:

   • Oral terbinafine 250 mg daily for 2-4 weeks 1

Tinea Capitis (Scalp)

1. Requires oral therapy:

   • Griseofulvin 10 mg/kg/day for 6-8 weeks (FDA-approved) 2, 7
   • For children >2 years: 10 mg/kg daily (typically 125-250 mg for 30-50 lbs; 250-500 mg for >50 lbs) 2
   • For adults: 500 mg daily (125 mg four times daily, 250 mg twice daily, or 500 mg once daily) 2
   • Oral terbinafine is an alternative (weight-based dosing for 6 weeks) 1

2. Adjunctive therapy:

   • Antifungal shampoo (ketoconazole 2%) to reduce spore shedding 1

Tinea Unguium (Onychomycosis)

1. Requires oral therapy:
   • Oral terbinafine 250 mg daily (6 weeks for fingernails, 12 weeks for toenails) 1
   • Griseofulvin 500 mg daily for at least 4 months (fingernails) or 6 months (toenails) 2

Treatment Duration and Monitoring

• Continue treatment for at least 1 week after clinical clearing of infection 5
• For tinea capitis, continue for full 6-8 weeks even if symptoms improve earlier 2, 7
• For tinea unguium, treatment duration depends on nail growth rate 2
• Monitor for:
  • Clinical response within 1-2 weeks
  • Complete resolution of lesions
  • Potential adverse effects (irritation, burning with topicals; hepatotoxicity with oral agents) 4

Important Considerations and Pitfalls

1. Confirm diagnosis before treatment

   • Many skin conditions mimic tinea (eczema, psoriasis, seborrheic dermatitis) 1
   • Failure to confirm diagnosis can lead to inappropriate treatment and steroid use

2. Address exacerbating factors

   • Keep affected areas dry
   • Wear loose-fitting clothing for tinea cruris
   • Wear breathable footwear for tinea pedis 5

3. Avoid common pitfalls

   • Using topical treatment for tinea capitis (will not penetrate hair shaft) 7
   • Discontinuing treatment prematurely when symptoms improve
   • Using combination antifungal/steroid products for prolonged periods 5
   • Failing to treat all infected family members/close contacts (especially for tinea capitis) 1

4. When to consider oral therapy

   • Extensive skin involvement
   • Hair or nail involvement
   • Failed topical treatment
   • Immunocompromised patients 1

Proper diagnosis and appropriate antifungal selection based on the infection site are essential for effective treatment of ringworm infections, with particular attention to completing the full treatment course to prevent recurrence.