Ringworm (Tinea) Medications
For localized tinea corporis or tinea cruris, start with topical terbinafine or naftifine applied once or twice daily for 1-2 weeks, as these are the most effective topical agents with the shortest treatment duration.
Topical Therapy for Localized Skin Infections
First-Line Topical Agents
Terbinafine 1% cream is highly effective for tinea corporis and tinea cruris, requiring only 1-2 weeks of treatment with once or twice daily application 1, 2.
Naftifine 1% cream demonstrates superior efficacy compared to placebo (mycological cure RR 2.38, clinical cure RR 2.42) and requires shorter treatment duration than azoles 3.
Azole antifungals (clotrimazole, miconazole, ketoconazole) are effective alternatives applied twice daily for 2-4 weeks, though they require longer treatment duration than allylamines 2, 3.
Treatment Duration by Site
Tinea corporis and tinea cruris: Treat for 2 weeks with azoles or 1-2 weeks with allylamines, continuing at least 1 week after clinical clearing 2.
Tinea pedis: Treat for 4 weeks with azoles or 1-2 weeks with allylamines 2, 4.
Important Caveat About Combination Products
- Avoid antifungal-corticosteroid combinations as routine therapy, as they may cause skin atrophy and promote resistance 1. These should only be considered when significant inflammation is present, and only for short-term use 2.
Oral Therapy Indications
When to Use Systemic Treatment
Oral antifungals are required for:
Tinea capitis (scalp ringworm) - topical therapy alone is ineffective as the infection involves hair follicles 1, 5.
Onychomycosis (nail infections) - topical agents cannot adequately penetrate the nail 6, 7.
Extensive disease covering large body surface areas where topical application is impractical 1, 5.
Failed topical therapy after appropriate duration of treatment 1.
Immunocompromised patients who may not respond adequately to topical treatment 1.
Hyperkeratotic tinea pedis unresponsive to topical monotherapy 5.
First-Line Oral Agents
Terbinafine 250 mg daily is first-line for tinea capitis and onychomycosis due to excellent efficacy, tolerability, and low cost 1.
Griseofulvin is an alternative for tinea capitis when terbinafine cannot be used 6.
Alternative Oral Agents
Fluconazole: 50-100 mg daily or 150 mg weekly for 2-3 weeks for tinea corporis/cruris; 150 mg weekly for tinea pedis 4.
Itraconazole: 100 mg daily for 2 weeks or 200 mg daily for 7 days for tinea corporis/cruris; 100 mg daily for 2 weeks or 400 mg daily for 1 week for tinea pedis 4.
Critical Diagnostic Requirement
Always confirm diagnosis with laboratory testing (KOH preparation, fungal culture, or nail biopsy) before initiating systemic therapy 6, 7, 1. Clinical diagnosis alone is unreliable as many conditions mimic tinea infections (eczema, psoriasis, dystrophic nails from trauma) 1.
Common Pitfalls to Avoid
Do not use griseofulvin or terbinafine for Candida infections - these agents are only effective against dermatophytes, not yeasts 6.
Do not stop treatment when lesions clear clinically - continue for at least 1 week after clinical resolution to prevent relapse 2.
Do not use topical therapy alone for tinea capitis - this will fail and may worsen inflammation 5.
Address hygiene and moisture control concurrently with antifungal therapy to prevent reinfection 6, 2.