What is the treatment for Dermatophytosis (Ringworm)?

From the Guidelines

Dermatophytosis treatment should prioritize oral terbinafine as the first-line treatment, given its higher efficacy and tolerability compared to itraconazole, as demonstrated in recent guidelines 1. When considering treatment options for dermatophytosis, the location and severity of the infection are crucial factors. For localized skin infections, topical antifungals like terbinafine 1% cream, clotrimazole 1% cream, or miconazole 2% cream applied twice daily for 2-4 weeks are typically effective. However, for more extensive skin involvement or specific types of infections such as onychomycosis (nail infection) or tinea capitis (scalp ringworm), oral therapy is necessary.

Treatment Approaches

• For onychomycosis, oral terbinafine (250mg daily for 6 weeks for fingernails, 12 weeks for toenails) is recommended as the first-line treatment due to its superior efficacy compared to itraconazole, as shown in a multicentre, randomized trial 1.
• For tinea capitis, oral therapy with griseofulvin, terbinafine, or itraconazole is indicated, with the choice of systemic therapy directed by the causative dermatophyte and local epidemiology 2, 3.
• Good hygiene practices, keeping affected areas dry, avoiding sharing personal items, and completing the full treatment course are essential for successful eradication and preventing recurrence.

Medication Details

• Terbinafine: 250mg daily for 2-4 weeks for skin infections, 6 weeks for fingernail onychomycosis, and 12 weeks for toenail onychomycosis.
• Itraconazole: 200mg daily for 1-2 weeks for skin infections, or pulse therapy for onychomycosis.
• Griseofulvin: 10-20mg/kg/day for 6-8 weeks for tinea capitis.

Considerations

• Treatment should not commence before mycological confirmation of infection 4.
• The choice of treatment should consider the causative organism, local epidemiology, and the specific type of dermatophytosis 1, 2, 3.

From the FDA Drug Label

Terbinafine tablets, USP are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). Griseofulvin oral suspension, USP is indicated for the treatment of dermatophyte infections of the skin not adequately treated by topical therapy, hair and nails, namely: Tinea corporis Tinea pedis Tinea cruris Tinea barbae Tinea capitis Tinea unguium when caused by one or more of the following species of fungi:

Dermatophytosis treatment options include:

• Terbinafine (PO): for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) 5
• Griseofulvin (PO): for the treatment of dermatophyte infections of the skin, hair, and nails, including tinea unguium 6 Key considerations:
• Prior to initiating treatment, appropriate specimens for laboratory testing should be obtained to confirm the diagnosis
• Treatment should be discontinued if adverse effects occur, such as hepatotoxicity, taste disturbance, or depressive symptoms 5

From the Research

Treatment Options for Dermatophytosis

• Topical agents are available for the treatment of dermatophytosis, but they may be viewed as inconvenient by the patient, affecting compliance 7.
• Oral antifungals, such as griseofulvin or ketoconazole, can be used for more widespread infections or those involving hair or nails, but they have limitations and potential side effects 7, 8.
• New antimycotic agents, including itraconazole, fluconazole, and terbinafine, have been developed for systemic therapy of superficial fungal infections, offering improved safety profiles and efficacy 7, 9.

Efficacy of Specific Treatments

• Itraconazole has been shown to be effective against common dermatophytoses, with advantages including ease of use, affinity for keratinized tissues, and lack of toxicity 9.
• Terbinafine is an allylamine that has been found to be effective and safe in brief therapy of dermatophyte infections 7.
• Combination therapy of oral terbinafine and itraconazole may be an effective and safe therapeutic strategy in the management of dermatophytosis, with a high clinical and mycological cure rate 10.
• A study comparing the effectiveness of four oral antifungal drugs (fluconazole, griseofulvin, itraconazole, and terbinafine) found that itraconazole was the most effective, followed by fluconazole, terbinafine, and then griseofulvin, in chronic and chronic relapsing dermatophytosis in India 11.

Limitations and Considerations

• Certain types of dermatophyte infection, such as onychomycosis, infections of the sole caused by T. rubrum, and certain forms of tinea capitis or tinea corporis, may be clinically resistant to treatment 8.
• The optimum duration and frequency of treatment, as well as better methods of allowing penetration of drugs into nails and heavily keratinized sites, need to be considered in the treatment of dermatophytosis 8.
• The limited effectiveness of oral antifungal drugs in the current epidemic of altered dermatophytosis in India highlights the need for further research and consideration of alternative treatment strategies 11.