What is the recommended treatment for tinea cruris?

Treatment for Tinea Cruris

The recommended first-line treatment for tinea cruris is terbinafine 1% cream applied once daily for 1-2 weeks, which has demonstrated superior efficacy with mycological cure rates of 84.2% compared to 23.3% for placebo. 1, 2

Diagnosis Confirmation

Before initiating treatment:

• Confirm diagnosis through microscopic examination (KOH preparation) or fungal culture 1, 3
• Treatment can begin while awaiting confirmatory mycology if clinical signs are present (scale, erythema, pruritus) 1

Treatment Algorithm

Step 1: Topical Therapy for Localized Infections

• First-line: Terbinafine 1% cream once daily for 1-2 weeks 1, 2
• Alternatives:
  • Clotrimazole 1% cream twice daily for 2 weeks 1
  • Miconazole 2% cream twice daily for 2 weeks 1

Step 2: Systemic Therapy for Extensive, Recurrent, or Resistant Cases

• First-line: Itraconazole 100 mg daily for 15 days (87% mycological cure rate) 1
• Alternatives:
  • Terbinafine 250 mg daily for 1-2 weeks (particularly effective for Trichophyton species) 1, 4
  • Griseofulvin 0.5 g daily (125 mg four times daily, 250 mg twice daily, or 500 mg once daily) for 2-4 weeks 1, 3
  • Fluconazole 150 mg once weekly for 2-4 weeks 5

Duration of Treatment

• Continue treatment for at least one week after clinical resolution 1, 6
• For topical treatments: typically 1-2 weeks 1, 2
• For systemic treatments: 2-4 weeks for tinea cruris 1, 3

Evidence Quality and Considerations

The American Academy of Dermatology recommends terbinafine 1% cream as first-line topical treatment based on high-quality evidence showing superior efficacy 1. A randomized controlled trial demonstrated that once-daily application for just one week achieved 84.2% mycological cure rate 2.

For extensive or resistant cases, itraconazole has shown superior efficacy (66% cure rate) compared to fluconazole (42%), terbinafine (28%), and griseofulvin (14%) 1.

Prevention and Management of Recurrence

• Examine and treat all household members for anthropophilic infections 1
• Clean personal items with disinfectant and avoid sharing 1
• Apply antifungal powders containing miconazole or clotrimazole to prevent reinfection 1
• Practice good personal hygiene; keep the skin dry and cool 7

Important Caveats

• Avoid combination antifungal/steroid agents for long-term use due to potential for skin atrophy and other steroid-associated complications 6
• Griseofulvin is not effective against non-dermatophyte infections such as candidiasis 3
• Treatment should target mycological cure, not just clinical improvement 1
• Systemic antifungals may have side effects:
  • Itraconazole: primarily gastrointestinal side effects, cutaneous eruptions, occasional headache 1
  • Terbinafine: gastrointestinal and dermatological events; rare serious adverse reactions include Stevens-Johnson syndrome and hepatic toxicity 1
  • Griseofulvin: gastrointestinal disturbances and rashes in <8% of patients 1