What is the treatment for ringworm?

Treatment for Ringworm (Tinea Infections)

For localized ringworm of the body (tinea corporis) or groin (tinea cruris), topical antifungal therapy with clotrimazole 1% or miconazole 2% cream applied twice daily for 2-4 weeks is first-line treatment, while scalp ringworm (tinea capitis) requires oral terbinafine as the preferred systemic therapy. 1, 2

Topical Treatment for Body and Groin Ringworm

First-line topical agents:

• Clotrimazole 1% cream applied twice daily for 2-4 weeks is highly effective for tinea corporis and tinea cruris 1, 3
• Miconazole 2% cream applied twice daily for 2-4 weeks provides similar efficacy 1
• Terbinafine cream demonstrates superior efficacy compared to placebo (RR 4.51, NNT 3) and requires only 1-2 weeks of treatment versus 2-4 weeks for azoles 4, 3
• Naftifine 1% is another effective option with proven mycological cure rates (RR 2.38, NNT 3) 3

Treatment duration specifics:

• Tinea corporis and cruris: 2 weeks minimum with azoles 4
• Tinea pedis (foot): 4 weeks with azoles or 1-2 weeks with allylamines 4
• Continue treatment for at least 1 week after clinical clearing to prevent relapse 4

Systemic Treatment Indications

Oral antifungals are required for:

• Tinea capitis (scalp ringworm) - topical therapy alone is ineffective as it cannot penetrate hair shafts 5, 6
• Extensive body surface area involvement 2
• Failed topical therapy 2
• Immunocompromised patients 2
• Hair follicle involvement 2

Oral Antifungal Therapy

For tinea capitis (scalp ringworm):

• Oral terbinafine is first-line therapy due to excellent tolerability, efficacy, and low cost 2
• Griseofulvin remains FDA-approved for pediatric tinea capitis: 10 mg/kg daily for children, with treatment duration of 4-6 weeks for tinea capitis 7, 6
• Griseofulvin dosing for adults: 500 mg daily (can be given as 125 mg four times daily or 250 mg twice daily), with severe infections potentially requiring 0.75-1.0 g daily initially 7

For extensive or resistant body/groin ringworm:

• Oral fluconazole 150-200 mg weekly for 2-4 weeks may be used for extensive or treatment-resistant cases 1

Critical Management Points

Diagnostic confirmation before treatment:

• Obtain KOH preparation, fungal culture, or nail biopsy to confirm dermatophyte infection before initiating therapy 7, 2
• Clinical diagnosis alone is unreliable - tinea corporis mimics eczema, and other conditions can appear similar 2

Important caveats:

• Avoid combination antifungal-corticosteroid creams as part of antifungal stewardship, despite some evidence showing higher short-term clinical cure rates (RR 0.67 for azoles alone vs combination) 2, 3
• If no improvement after 2 weeks of appropriate topical therapy, switch to a different antifungal class 1
• Griseofulvin is NOT effective against Candida, bacteria, or other non-dermatophyte fungi 7
• Continue medication until the organism is completely eradicated - premature discontinuation leads to relapse 7

Adjunctive measures:

• Implement general hygiene measures to control sources of reinfection 7
• Concomitant topical therapy is usually required with systemic treatment, particularly for tinea pedis 7

Emerging Resistant Infections

Be aware that emerging tinea infections may:

• Present more severely than classic infections 2
• Not respond to first-line topical or oral antifungals 2
• Require prolonged oral therapy and specialized diagnostic testing 2