What is the treatment for ringworm?

Treatment for Ringworm

For ringworm of the body or groin, apply topical terbinafine 1% cream twice daily for 2-4 weeks as first-line treatment, which achieves mycological cure in over 80% of cases. 1

Treatment Based on Location

Tinea Corporis (Body) and Tinea Cruris (Groin)

Topical therapy is the standard approach:

• Terbinafine 1% cream applied twice daily for 2-4 weeks is the preferred first-line agent, with mycological cure rates exceeding 80% and significantly superior efficacy compared to placebo (RR 4.51, NNT 3) 1, 2

• Clotrimazole 1% cream applied twice daily for 2-4 weeks is an effective alternative, achieving mycological cure rates nearly 3 times higher than placebo (RR 2.87, NNT 2) 1, 2

• Naftifine 1% applied twice daily for 2-4 weeks is another effective option with mycological cure rates more than double that of placebo (RR 2.38, NNT 3) 2

• Miconazole 2% cream applied twice daily for 2-4 weeks can also be used 3

Continue treatment for at least one week after clinical clearing to prevent relapse 1, 4

Tinea Capitis (Scalp)

Oral antifungal therapy is mandatory—topical treatment alone will fail because it cannot penetrate the hair shaft adequately: 1

For Trichophyton species (most common):

• Terbinafine is first-line 1
  • <20 kg: 62.5 mg daily for 2-4 weeks 1
  • 20-40 kg: 125 mg daily for 2-4 weeks 1

  • 40 kg: 250 mg daily for 2-4 weeks 1

For Microsporum species:

• Griseofulvin is first-line 1, 5
  • <50 kg: 15-20 mg/kg/day for 6-8 weeks 1

  • 50 kg: 1 g daily for 6-8 weeks 1

  • Pediatric dosing (>2 years): 10 mg/kg daily (30-50 lbs: 125-250 mg daily; >50 lbs: 250-500 mg daily) 5
  • Treatment duration: 4-6 weeks for tinea capitis 5

The shorter treatment duration with terbinafine (2-4 weeks vs 6-8 weeks for griseofulvin) improves compliance 1

Tinea Pedis (Feet)

• Topical therapy for 4 weeks with azoles or 1-2 weeks with allylamines 4
• For hyperkeratotic tinea pedis unresponsive to topical monotherapy, combine oral and topical antifungals 6

Special Situations Requiring Oral Therapy

Oral antifungals are indicated when: 6

• Extensive or widespread lesions where topical application to all areas is impractical 6
• Tinea facialis near eyes, ears, or mouth 6
• Tinea cruris involving complex skin folds of external genitalia 6
• Resistance to topical therapy after 2 weeks 3

Oral fluconazole 150-200 mg weekly for 2-4 weeks may be used for extensive or resistant cases 3, 7

Important Clinical Considerations

Diagnosis Confirmation

Confirm dermatophyte infection before initiating treatment with KOH preparation, fungal culture, or nail biopsy 5

Common Pitfalls to Avoid

• Never use topical antifungals alone for scalp ringworm—they cannot penetrate hair shafts and will fail 1
• Do not stop treatment when lesions appear clinically clear—continue until mycological cure is achieved to prevent relapse 1
• Avoid premature discontinuation—medication must continue until the organism is completely eradicated 5

When to Switch Therapy

If no improvement occurs after 2 weeks of appropriate therapy, switch to a different class of antifungal agent 3

Adjunctive Measures

• Address exacerbating factors such as skin moisture 4
• Implement general hygiene measures to control sources of infection or reinfection 5
• Concomitant topical agents are usually required, particularly for tinea pedis 5

Adverse Effects

All examined treatments have minimal adverse effects, primarily limited to mild irritation and burning 2