What is the treatment for ringworm?

Treatment of Ringworm (Tinea Infections)

For most cases of ringworm on the body (tinea corporis) or groin (tinea cruris), topical antifungal therapy with clotrimazole 1% cream or miconazole 2% cream applied twice daily for 2-4 weeks is the recommended first-line treatment. 1

Location-Specific Treatment Approach

Body and Groin Infections (Tinea Corporis/Cruris)

Topical therapy is first-line for localized disease:

• Clotrimazole 1% cream applied twice daily for 2-4 weeks is highly effective 1, 2
• Miconazole 2% cream applied twice daily for 2-4 weeks is an equally effective alternative 1
• Terbinafine cream demonstrates superior efficacy compared to placebo (NNT = 3) and may require shorter treatment duration 2
• Naftifine 1% cream shows strong mycological cure rates (NNT = 3) with a favorable therapeutic reservoir effect 3, 2

When to escalate to oral therapy:

• Extensive disease involving multiple body sites 4
• Lack of response after 2 weeks of appropriate topical therapy 1
• Hair follicle involvement 4
• Immunocompromised patients 4
• Oral fluconazole 150-200 mg weekly for 2-4 weeks is recommended for these situations 1

Scalp Infections (Tinea Capitis)

Oral antifungal therapy is mandatory—topical agents alone are inadequate: 5, 6

• Oral terbinafine is considered first-line therapy due to excellent tolerability, efficacy, and low cost 4
• Griseofulvin 10 mg/kg daily remains the only FDA-approved agent for pediatric tinea capitis, typically requiring 4-6 weeks of treatment 5
  • Children 30-50 lbs: 125-250 mg daily
  • Children >50 lbs: 250-500 mg daily 5
• Itraconazole and fluconazole offer shorter treatment intervals with acceptable safety profiles 6, 7
• Treatment must continue until the organism is completely eradicated; premature discontinuation leads to relapse 5

Nail Infections (Tinea Unguium/Onychomycosis)

Oral therapy is required:

• Oral terbinafine is first-line due to superior efficacy and tolerability 4
• Griseofulvin requires prolonged treatment: fingernails minimum 4 months, toenails minimum 6 months 5

Foot Infections (Tinea Pedis)

• Topical antifungals for 4-8 weeks are typically effective 5
• Concomitant topical therapy is usually required alongside systemic treatment when oral agents are used 5
• Note that yeasts and bacteria may co-exist; griseofulvin does not eradicate these organisms 5

Critical Clinical Caveats

Diagnosis confirmation is essential before treatment:

• Clinical diagnosis alone is unreliable—tinea corporis mimics eczema, onychomycosis mimics psoriatic nails or trauma-related dystrophy 4
• Obtain KOH preparation, fungal culture, or nail biopsy before initiating therapy 5
• Direct microscopic examination or culture on appropriate medium is mandatory 5

Avoid combination antifungal-corticosteroid products:

• While azole-steroid combinations show higher clinical cure rates at end of treatment, they are not recommended in clinical guidelines due to concerns about resistance and long-term outcomes 2
• Antifungal stewardship emphasizes avoiding these combinations 4

Emerging resistant tinea infections:

• May present with more severe disease that fails first-line topicals and oral agents 4
• Require prolonged oral therapy and specialized diagnostic testing 4

Treatment Duration and Monitoring

• Tinea corporis: 2-4 weeks 5
• Tinea pedis: 4-8 weeks 5
• Tinea capitis: 4-6 weeks 5
• Fingernail infections: Minimum 4 months 5
• Toenail infections: Minimum 6 months 5

If no improvement after 2 weeks of appropriate therapy, switch to a different antifungal class 1

Adjunctive Measures

• General hygiene measures to control sources of infection and reinfection 5
• Topical agents are usually required as adjuncts, particularly for tinea pedis 5
• Treatment must continue until complete eradication is confirmed by clinical or laboratory examination 5