What is the treatment for ringworm?

Treatment for Ringworm

For ringworm (tinea corporis, tinea cruris, tinea pedis), topical antifungal therapy is the first-line treatment for localized infections, with systemic therapy reserved for extensive disease, scalp involvement, or treatment failures. 1, 2

Topical Therapy for Localized Infections

Topical antifungals are highly effective for limited skin infections and should be applied for 2-4 weeks depending on the site. 2, 3

• Terbinafine cream is one of the most effective topical agents, requiring only 1-2 weeks of treatment compared to 2-4 weeks for azoles 2, 3
• Azole antifungals (clotrimazole, miconazole, ketoconazole) applied twice daily are effective alternatives, with clotrimazole showing significantly higher cure rates than placebo (NNT 2) 3
• Naftifine 1% demonstrates strong efficacy with mycological cure rates significantly better than placebo (NNT 3) 3

Treatment Duration by Site

• Tinea corporis and tinea cruris: 2 weeks of topical therapy 2
• Tinea pedis: 4 weeks with azoles or 1-2 weeks with allylamines (terbinafine, naftifine) 2
• Continue treatment for at least 1 week after clinical clearing to prevent relapse 2

Systemic Therapy Indications

Oral antifungal therapy is required when topical treatment fails, infection is extensive, or specific sites are involved (scalp, nails, beard). 1, 4

When to Use Systemic Therapy

• Tinea capitis (scalp ringworm) - topical therapy alone is inadequate 4, 5
• Tinea barbae (beard area) - requires systemic treatment 6, 1
• Tinea unguium (nail infections) 1
• Extensive or widespread skin involvement not responding to topical agents 1
• Immunocompromised patients 7

Systemic Treatment Options

Griseofulvin is the only FDA-approved systemic agent for dermatophyte infections in children and remains first-line for tinea capitis. 1, 4

• Adult dosing: 500 mg daily (can give as 125 mg four times daily, 250 mg twice daily, or 500 mg once daily) 1
• Pediatric dosing (>2 years): 10 mg/kg daily (children 30-50 lbs: 125-250 mg daily; >50 lbs: 250-500 mg daily) 1
• Duration: Tinea corporis 2-4 weeks, tinea capitis 4-6 weeks, tinea pedis 4-8 weeks, fingernails ≥4 months, toenails ≥6 months 1

Terbinafine oral is an effective alternative with shorter treatment duration (6 weeks for tinea capitis vs 6-8 weeks for griseofulvin), though used off-label in children 4, 5

Fluconazole 150-200 mg once daily for 2-4 weeks is recommended for extensive or severe fungal infections of the beard area 6

Important Caveats and Pitfalls

Avoid These Common Mistakes

• Do not use topical corticosteroid-antifungal combinations for >2 weeks (tinea cruris) or >4 weeks (tinea pedis/corporis), as prolonged steroid use can worsen infection and cause cutaneous adverse effects 7
• Never use combination steroid products in children <12 years, on the face, or in occluded areas (including diaper regions) 7
• Do not stop systemic therapy prematurely - continue until the infecting organism is completely eradicated by clinical or laboratory examination, as early discontinuation leads to relapse 1
• Griseofulvin is ineffective against Candida, bacteria, and other non-dermatophyte fungi - confirm dermatophyte infection with KOH prep or culture before initiating therapy 1

Adjunctive Measures

• Concomitant topical therapy is usually required with systemic treatment, particularly for tinea pedis 1
• Address hygiene and moisture control to prevent reinfection 1, 2
• For tinea pedis, treat concurrent bacterial or yeast infections separately, as griseofulvin does not eradicate these organisms 1

When Combination Steroid-Antifungal Products May Be Considered

If using a corticosteroid-antifungal combination, limit to low-potency nonfluorinated steroids in healthy adults with heavily inflamed lesions only. 7

• Use only for initial symptom relief in acute, inflamed tinea pedis, corporis, or cruris 7
• Switch to pure antifungal once symptoms improve 7
• Contraindicated in immunosuppressed patients 7