What is the recommended treatment for ringworm?

Ringworm Treatment

For ringworm (tinea corporis), topical antifungal therapy with clotrimazole 1% or miconazole 2% cream applied twice daily for 2-4 weeks is the recommended first-line treatment, with oral therapy reserved for extensive disease, treatment failure, or scalp/nail involvement. 1

First-Line Topical Therapy

Topical antifungals are the standard treatment for localized tinea corporis:

• Clotrimazole 1% cream applied twice daily for 2-4 weeks is highly effective for ringworm 1
• 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), requiring only 1-2 weeks of treatment versus 2-4 weeks for azoles 2, 3
• Naftifine 1% cream shows strong mycological cure rates (RR 2.38, NNT 3) and clinical cure (RR 2.42, NNT 3) 2

Treatment duration: Continue for at least one week after clinical clearing to prevent relapse 3

When to Use Oral Therapy

Oral antifungals are indicated when:

• Extensive or widespread lesions covering large body surface areas 4, 5
• Failure to respond to appropriate topical therapy after 2 weeks 1
• Immunocompromised patients 4
• Hair follicle involvement (tinea capitis requires oral therapy) 6, 7, 4
• Lesions near eyes, ears, or mouth where topical application is difficult 5
• Hyperkeratotic lesions unresponsive to topical monotherapy 5

Oral fluconazole 150-200 mg weekly for 2-4 weeks is the recommended systemic option for extensive or resistant cases 1

Alternative Oral Therapy for Specific Sites

For tinea capitis (scalp ringworm):

• Griseofulvin remains FDA-approved: 10 mg/kg daily for children (125-500 mg based on weight), 500 mg daily for adults, continued for 4-6 weeks 6
• Oral terbinafine is considered first-line by many experts due to better tolerability, efficacy, and lower cost, requiring only 6 weeks of treatment 7, 4
• Topical therapy alone is inadequate for tinea capitis as it cannot penetrate the hair shaft 6, 7

Critical Pitfalls to Avoid

Avoid combination antifungal-corticosteroid creams as routine first-line therapy:

• While azole-steroid combinations show higher immediate clinical cure rates (RR 0.67 for azoles alone), they carry risks of skin atrophy and should only be used when significant inflammation is present 2
• Mycological cure rates are identical between azoles alone and combination products (RR 0.99) 2
• Antifungal stewardship emphasizes avoiding these combinations to prevent resistance 4

Confirm diagnosis before treatment:

• Clinical diagnosis alone is unreliable—tinea corporis mimics eczema, psoriasis, and other conditions 4
• Obtain KOH preparation, fungal culture, or skin biopsy to confirm dermatophyte infection before initiating therapy 6, 4

Address exacerbating factors:

• Control skin moisture and humidity 3
• Implement hygiene measures to prevent reinfection 6
• In tinea pedis with erosion or contact dermatitis, start with oral antifungals plus topical corticosteroids, then add topical antifungals after complications resolve 5

Monitoring and Treatment Failure

If no improvement after 2 weeks of appropriate topical therapy:

• Switch to a different class of antifungal agent 1
• Consider oral therapy for extensive disease 1, 4
• Re-evaluate diagnosis—emerging resistant tinea infections may require prolonged oral therapy and specialized testing 4

Adverse Effects

Topical antifungals are generally well-tolerated:

• Minimal adverse effects, primarily mild irritation and burning 2
• No significant difference in adverse effects between active treatments and placebo 2

Oral griseofulvin considerations:

• Medication must continue until organism is completely eradicated to prevent relapse 6
• Not effective for bacterial, yeast, or non-dermatophyte fungal infections 6