Treatment of Ringworm (Tinea Infections)
For tinea corporis and tinea cruris (body and groin ringworm), topical terbinafine 1% cream applied once or twice daily for 1-2 weeks is the most effective first-line treatment, providing superior cure rates compared to other topical agents. 1, 2
Topical Treatment Approach
First-Line Topical Agents
- Terbinafine 1% cream is the preferred topical agent, applied once or twice daily for 1-2 weeks for tinea corporis and tinea cruris 1, 2, 3
- Terbinafine demonstrates significantly higher mycological cure rates (93.5%) compared to clotrimazole (73.1%) and requires only 1 week of treatment versus 4 weeks for azoles 2
- Naftifine 1% cream is an effective alternative, showing mycological cure rates 2.38 times higher than placebo 1
Alternative Topical Agents
- Azole antifungals (clotrimazole, miconazole, ketoconazole) applied twice daily for 2-4 weeks are effective but require longer treatment duration 1, 3
- Clotrimazole 1% demonstrates mycological cure rates 2.87 times higher than placebo 1
- Butenafine cream is another inexpensive and effective option 4
Important Topical Treatment Considerations
- Treatment should continue for at least 1 week after clinical clearing to prevent relapse 3
- Topical therapy alone is not recommended for tinea capitis (scalp ringworm), which requires oral treatment 5
- For tinea pedis (foot), treat for 4 weeks with azoles or 1-2 weeks with allylamines 3
Oral Treatment Approach
When to Use Oral Therapy
Oral antifungals are indicated for: 3, 4
- Extensive disease covering large body surface areas
- Failed topical treatment after 2-4 weeks
- Tinea capitis (scalp infections) - always requires oral therapy
- Immunocompromised patients
- Severe or widespread infections
Oral Treatment Options
For Trichophyton species (most common): 5, 6
- Terbinafine is first-line oral therapy
- Terbinafine is fungicidal with higher efficacy against Trichophyton species 6
- Griseofulvin is the treatment of choice and the only licensed product for tinea capitis in children in the UK 5
- Taking griseofulvin with fatty food increases absorption 5
- Itraconazole: 100 mg daily for 2-4 weeks, or 200 mg daily for 7 days 5, 8
- Fluconazole: 50-100 mg daily or 150 mg once weekly for 2-3 weeks 5, 8
Treatment Failure Management
If initial treatment fails, consider: 5, 6
- Lack of compliance with medication regimen
- Suboptimal drug absorption
- Organism resistance (rare)
- Reinfection from contaminated sources
For clinical improvement but persistent positive mycology: Continue current therapy for an additional 2-4 weeks 5, 6
For no clinical improvement: Switch to second-line therapy 5, 6
- If terbinafine failed for Trichophyton: switch to itraconazole 100 mg daily for 4 weeks 5
- If griseofulvin failed for Microsporum: consider alternative agents 5
Prevention and Adjunctive Measures
- Complete drying of affected areas after bathing is essential to prevent recurrence 9
- Use separate towels for affected areas to reduce contamination 9
- For anthropophilic species (human-to-human transmission), screen and treat family members and close contacts 5, 6
- Antifungal shampoos (ketoconazole 2%, selenium sulfide 1%, or povidone-iodine) reduce spore transmission for scalp infections 5
- Clean contaminated personal items with disinfectant 6
- Avoid sharing personal items and skin-to-skin contact with infected individuals 6
Common Pitfalls to Avoid
- Do not use topical therapy alone for tinea capitis - oral treatment is mandatory 5
- Do not use terbinafine for tinea versicolor - it is ineffective for this condition 8
- Griseofulvin is not effective for tinea versicolor, candidiasis, or other non-dermatophyte infections 7
- Avoid premature discontinuation - treatment must continue until mycological cure is achieved, not just clinical improvement 7
- Combination steroid-antifungal creams may provide faster symptom relief but are not recommended in guidelines due to potential steroid complications 1, 3