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% cream or miconazole 2% cream applied twice daily for 2-4 weeks is the recommended first-line treatment. 1, 2

Site-Specific Treatment Approach

Tinea Corporis and Tinea Cruris (Body and Groin)

Topical therapy is first-line for localized disease:

• Clotrimazole 1% cream applied twice daily for 2-4 weeks 1, 3
• Miconazole 2% cream applied twice daily for 2-4 weeks 1
• Terbinafine cream is highly effective with significantly higher cure rates than placebo (4.5 times more likely to achieve clinical cure) 3
• Naftifine 1% is also effective, with 2.4 times higher mycological cure rates compared to placebo 3

Treatment duration: Continue for at least 2 weeks for tinea corporis/cruris, and for at least one week after clinical clearing 4

Oral therapy is indicated when:

• Extensive disease is present 2
• Topical treatment fails after 2 weeks 1
• Hair follicles are involved 2
• Patient is immunocompromised 2

For these situations, oral fluconazole 150-200 mg weekly for 2-4 weeks is recommended 1

Tinea Capitis (Scalp Ringworm)

Systemic therapy is mandatory - topical agents alone are ineffective for scalp infections 5, 6

First-line treatment:

• Oral terbinafine is considered first-line therapy due to excellent tolerability, effectiveness, and low cost 2
• Treatment duration: 6 weeks 5

Alternative FDA-approved option:

• Griseofulvin 0.5 g daily (or 10 mg/kg/day in children over 2 years) 7
• Treatment duration: 4-6 weeks 7
• Dosing: Adults can take 125 mg four times daily, 250 mg twice daily, or 500 mg once daily 7
• Pediatric dosing: 30-50 lbs: 125-250 mg daily; over 50 lbs: 250-500 mg daily 7

Tinea Pedis (Foot)

Topical therapy:

• Azole antifungals for 4 weeks 4
• Allylamine medications for 1-2 weeks 4
• Concomitant topical therapy is usually required alongside any systemic treatment 7

Note: Yeasts and bacteria may coexist with dermatophytes in tinea pedis; antifungal agents will not eradicate these co-infections 7

Tinea Unguium (Nail Infections/Onychomycosis)

Oral terbinafine is first-line therapy 2

Treatment duration with griseofulvin (if used):

• Fingernails: at least 4 months 7
• Toenails: at least 6 months 7

Critical Management Principles

Accurate diagnosis is essential before treatment:

• Clinical diagnosis alone is unreliable - tinea corporis can mimic eczema, and onychomycosis can resemble dystrophic nails from trauma or psoriasis 2
• Confirm diagnosis with direct microscopy using potassium hydroxide preparation or culture 7, 4

Treatment must continue until complete eradication:

• Medication must be continued until the organism is completely eradicated as confirmed by clinical or laboratory examination 7
• Clinical relapse will occur if treatment is stopped prematurely 7
• Continue treatment for at least one week after clinical clearing 4

Hygiene measures are essential:

• General hygiene measures must be observed to control sources of infection and reinfection 7

Important Caveats and Pitfalls

Avoid combination antifungal-corticosteroid products:

• While combination creams may show higher clinical cure rates at end of treatment, they carry risks of skin atrophy and other steroid complications 3, 4
• Antifungal stewardship emphasizes avoiding these combinations to prevent resistance 2
• Use combination products with caution and only when significant inflammation is present 4

Emerging resistant tinea infections:

• Some emerging tinea infections are more severe than classic presentations 2
• These generally do not improve with first-line topical or oral antifungals 2
• May require prolonged oral therapy and specialized diagnostic testing 2

When to switch therapy:

• If no improvement occurs after 2 weeks of appropriate topical therapy, switch to a different class of antifungal agent 1
• Consider oral therapy for treatment failures 1, 2