What is the treatment for Tinea (ringworm) infections?

Treatment of Tinea (Ringworm) Infections

Terbinafine 1% cream applied once daily for 1-2 weeks is the recommended first-line treatment for tinea corporis (ringworm) infections, with oral antifungals reserved for extensive or resistant cases. 1

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• Confirm diagnosis through microscopic examination (KOH preparation) or fungal culture 1
• Obtain appropriate samples via scalpel scraping, hair pluck, brush or swab for microscopy and culture 1
• Treatment can begin while awaiting confirmatory mycology if clinical signs are present 1

Treatment Algorithm

1. Localized Tinea Corporis (Ringworm)

• First-line: Terbinafine 1% cream once daily for 1-2 weeks 1
• Alternatives: Clotrimazole 1% cream or miconazole 2% cream twice daily for 2 weeks 1
• Continue treatment for at least one week after clinical resolution 1, 2

2. Extensive or Resistant Tinea Corporis

• Oral therapy options:
  • Terbinafine: 250mg daily for 1-2 weeks (especially for Trichophyton species) 1
  • Itraconazole: 100-200mg daily for 2-4 weeks (superior efficacy at 66% cure rate) 1
  • Griseofulvin: 0.5g daily for adults (or 10mg/kg for children) for 2-4 weeks 1, 3

3. Specific Tinea Types

• Tinea capitis: Requires 4-6 weeks of oral therapy 3
• Tinea pedis: Requires 4-8 weeks of oral therapy or topical treatment for 4 weeks with azoles or 1-2 weeks with allylamines 3, 2
• Tinea unguium (onychomycosis): Requires extended oral therapy (fingernails: at least 4 months; toenails: at least 6 months) 3

Medication Selection Based on Evidence

• Terbinafine has shown superior efficacy compared to clotrimazole in comparative studies, achieving 93.5% mycological cure with just 1 week of treatment versus 73.1% with 4 weeks of clotrimazole 4
• For systemic therapy, itraconazole has demonstrated superior efficacy (66%) compared to fluconazole (42%), terbinafine (28%), and griseofulvin (14%) in treatment-resistant cases 1

Safety Considerations

• Itraconazole: Generally well-tolerated; primarily gastrointestinal side effects, cutaneous eruptions, and occasional headache 1
• Griseofulvin: Generally well-tolerated with extensive safety data in children; side effects include gastrointestinal disturbances and rashes in <8% of patients 1
• Terbinafine: Generally well-tolerated but can cause gastrointestinal and dermatological events; rare serious adverse reactions include Stevens-Johnson syndrome and hepatic toxicity 1

Prevention of Reinfection

• Screen and treat all household members for anthropophilic infections 1
• Cleanse personal items (combs, brushes) with disinfectant and avoid sharing personal items 1
• Apply antifungal powders (containing miconazole, clotrimazole) to prevent reinfection 1
• For footwear-related infections, consider discarding heavily contaminated footwear, using antifungal powders inside shoes, and wearing cotton, absorbent socks 1

Important Clinical Pearls

• The endpoint of treatment should be mycological cure, not just clinical improvement 1
• Follow-up mycological examination is recommended until mycological clearance is achieved, especially in resistant or recurrent cases 1
• Accurate diagnosis is crucial - misdiagnosis between tinea corporis and conditions like pityriasis rosea can lead to inappropriate treatment 1
• Prior to therapy, a dermatophyte should be identified as responsible for the infection through appropriate laboratory testing 3