Treatment of Ringworm (Tinea Infections)
For ringworm of the body (tinea corporis) and groin (tinea cruris), topical antifungal therapy with clotrimazole 1% or miconazole 2% cream applied twice daily for 2-4 weeks is first-line treatment, while scalp ringworm (tinea capitis) and nail infections (tinea unguium) require oral griseofulvin or terbinafine. 1, 2
Treatment by Body Site
Tinea Corporis (Body) and Tinea Cruris (Groin)
Topical therapy is the standard approach:
- Clotrimazole 1% cream applied twice daily for 2-4 weeks is highly effective for localized infections 1, 3
- Miconazole 2% cream applied twice daily for 2-4 weeks provides equivalent efficacy 1
- Terbinafine cream demonstrates superior efficacy compared to placebo (RR 4.51, NNT 3) and may require shorter treatment duration (1-2 weeks) 3, 4
- Naftifine 1% shows strong mycological cure rates (RR 2.38, NNT 3) 3
When to escalate to oral therapy:
- Extensive disease covering large body surface areas 5
- Failure to respond after 2 weeks of appropriate topical treatment 1
- Immunocompromised patients 5
- Hair follicle involvement 5
For extensive or resistant cases requiring oral therapy:
- Oral fluconazole 150-200 mg weekly for 2-4 weeks 1
- Continue treatment for at least one week after clinical clearing 4
Tinea Capitis (Scalp)
Oral systemic therapy is mandatory—topical agents alone are ineffective:
Griseofulvin is FDA-approved and remains first-line: 2
Oral terbinafine is considered first-line by many experts due to better tolerability, efficacy, and lower cost, though used off-label in children 5, 6
- Duration: 6 weeks 7
Alternative agents (off-label): itraconazole and fluconazole offer shorter treatment intervals with acceptable safety profiles 6, 7
Critical point: Medication must be continued until the organism is completely eradicated as confirmed by clinical or laboratory examination—premature discontinuation leads to relapse 2
Tinea Pedis (Feet)
- Topical azoles for 4 weeks (longer than body/groin infections) 4
- Allylamine medications for 1-2 weeks (shorter duration due to superior efficacy) 4
- Concomitant topical therapy is usually required as yeasts and bacteria may co-exist with dermatophytes 2
Tinea Unguium (Nails/Onychomycosis)
Oral therapy is required:
- Oral terbinafine is first-line due to efficacy, tolerability, and cost 5
- Griseofulvin alternative dosing: 2
- Fingernails: minimum 4 months
- Toenails: minimum 6 months (depends on rate of nail growth)
Key Clinical Considerations
Diagnosis confirmation is essential before treatment:
- Direct microscopic examination with KOH preparation 2
- Fungal culture on appropriate medium 2
- Nail biopsy for onychomycosis 2
Common pitfall: Clinical diagnosis without laboratory confirmation is unreliable—tinea corporis mimics eczema, and onychomycosis resembles dystrophic nails from trauma or psoriasis 5
Hygiene measures must accompany pharmacotherapy:
- Control sources of infection and reinfection 2
- Address exacerbating factors, particularly skin moisture 4
Monitoring for treatment failure:
- If no improvement after 2 weeks of appropriate therapy, switch to a different antifungal class 1
- Emerging resistant tinea infections may require prolonged oral therapy and specialized diagnostic testing 5
Avoid combination antifungal-corticosteroid products as part of antifungal stewardship to prevent resistance, despite some evidence showing higher short-term clinical cure rates 5, 3
Griseofulvin is NOT effective for: bacterial infections, candidiasis, histoplasmosis, or other non-dermatophyte fungal infections 2