What is the first line treatment for ringworm?

First-Line Treatment for Ringworm

For ringworm of the body (tinea corporis) or groin (tinea cruris), topical antifungal creams such as terbinafine 1% or clotrimazole 1% applied twice daily for 2-4 weeks are first-line treatment, while scalp ringworm (tinea capitis) requires oral therapy with either griseofulvin or terbinafine. 1, 2

Treatment Based on Location

Tinea Corporis and Tinea Cruris (Body and Groin)

Topical therapy is the standard approach:

• Terbinafine 1% cream applied twice daily for 2-4 weeks achieves mycological cure in >80% of patients and is significantly more effective than placebo (RR 4.51, NNT 3) 3, 4
• Clotrimazole 1% cream applied twice daily for 2-4 weeks is an effective alternative, with mycological cure rates approximately 3 times higher than placebo (RR 2.87, NNT 2) 1, 3
• Miconazole 2% cream applied twice daily for 2-4 weeks provides similar efficacy 1

When oral therapy is needed (extensive disease, failed topical treatment, immunocompromised patients, or follicular involvement):

• Oral terbinafine 250 mg daily for 2-4 weeks is first-line systemic therapy 4, 5
• Oral fluconazole 150-200 mg weekly for 2-4 weeks may be considered for extensive or resistant cases 1

Tinea Capitis (Scalp Ringworm)

Oral antifungal therapy is mandatory—topical treatment alone is ineffective: 2

The choice depends on the causative organism:

• For Trichophyton species (T. tonsurans, T. violaceum, T. soudanense): Terbinafine is more effective 2

  • <20 kg: 62.5 mg daily for 2-4 weeks
  • 20-40 kg: 125 mg daily for 2-4 weeks

  • 40 kg: 250 mg daily for 2-4 weeks 2

• For Microsporum species (M. canis, M. audouinii): Griseofulvin is more effective 2

  • <50 kg: 15-20 mg/kg/day for 6-8 weeks

  • 50 kg: 1 g daily for 6-8 weeks 2, 6

Important considerations for tinea capitis:

• In the UK, griseofulvin remains the only licensed treatment for tinea capitis in children, though terbinafine is widely used off-label 2, 7
• Terbinafine requires shorter treatment duration (2-4 weeks vs 6-8 weeks), which may improve compliance 2
• Treatment can be started empirically if cardinal signs are present (scale, lymphadenopathy, alopecia) while awaiting culture results 2

Common Pitfalls to Avoid

Do not use topical antifungals alone for scalp ringworm—they cannot penetrate the hair shaft adequately and will fail 2

Avoid combination antifungal-corticosteroid creams for initial treatment, as antifungal stewardship guidelines recommend against their routine use to prevent resistance 4. While some studies show higher clinical cure rates at end of treatment with azole-steroid combinations compared to azoles alone (RR 0.67 for clinical cure), mycological cure rates are equivalent (RR 0.99), and the quality of evidence is very low 3

Confirm the diagnosis before treatment when possible, especially for onychomycosis and tinea capitis, as clinical diagnosis can be unreliable—potassium hydroxide preparation or fungal culture should be obtained 6, 4, 5

If no improvement occurs after 2 weeks of appropriate topical therapy, consider switching to a different antifungal class or escalating to oral therapy 1

Continue treatment until mycological cure is achieved, not just clinical improvement—the endpoint should be negative mycology, as clinical relapse will occur if the organism is not fully eradicated 2, 6