What is the treatment for ringworm?

Treatment of Ringworm (Tinea Corporis/Cruris)

For uncomplicated ringworm of the body or groin, topical antifungal therapy with azoles (clotrimazole 1% or miconazole 2%) applied twice daily for 2-4 weeks is the first-line treatment, with oral therapy reserved for extensive, resistant, or scalp/nail involvement. 1

Topical Therapy (First-Line for Body/Groin)

Topical antifungals are highly effective for localized tinea corporis and tinea cruris:

• Clotrimazole 1% cream applied twice daily for 2-4 weeks is an effective first-line option 1
• Miconazole 2% cream applied twice daily for 2-4 weeks is equally effective 1
• Terbinafine cream demonstrates superior efficacy compared to placebo (RR 4.51, NNT 3) and requires only 1-2 weeks of treatment 2
• Naftifine 1% shows strong efficacy for both mycological cure (RR 2.38, NNT 3) and clinical cure (RR 2.42, NNT 3) 2

Treatment duration: Continue for 2-4 weeks, even after lesions appear resolved, to prevent relapse 1, 2

Oral Therapy (For Extensive or Resistant Cases)

Systemic antifungals are indicated when:

• Topical therapy fails after 2 weeks 1
• Extensive body surface area involvement
• Scalp (tinea capitis) or nail (tinea unguium) involvement 3
• Patient preference for shorter treatment duration

Oral Treatment Options:

For tinea corporis/cruris:

• Fluconazole 150-200 mg weekly for 2-4 weeks for extensive or resistant cases 1, 4
• Terbinafine 250 mg daily for 1-2 weeks is highly effective 4
• Itraconazole 100 mg daily for 2 weeks or 200 mg daily for 7 days 4

For tinea capitis (scalp ringworm):

• Griseofulvin is the only FDA-approved treatment for children: 10 mg/kg daily (typically 125-500 mg daily depending on weight) for 4-6 weeks 3, 5
• Terbinafine (off-label) requires 6 weeks of treatment and shows similar cure rates 5
• Topical antifungals must be added to oral therapy for tinea capitis to eradicate contagious spores 6

For tinea pedis (foot):

• Treatment duration is longer: 4-8 weeks with griseofulvin 3
• Concomitant topical therapy is usually required 3

Critical Management Points

Diagnosis confirmation is essential before treatment:

• Obtain KOH preparation, fungal culture, or tissue biopsy to confirm dermatophyte infection 3
• This prevents inappropriate treatment of conditions that mimic ringworm (seborrheic dermatitis, psoriasis, eczema) 7

When to switch therapy:

• If no improvement after 2 weeks of appropriate topical therapy, switch to a different class of antifungal or consider oral therapy 1
• Griseofulvin is ineffective against Candida, bacteria, and other non-dermatophyte fungi 3

Common Pitfalls to Avoid

• Do not stop treatment when lesions appear resolved - continue for full 2-4 week course to prevent relapse 1, 2
• Do not use topical therapy alone for tinea capitis - systemic treatment is mandatory for scalp infections 3, 6, 7
• Do not use terbinafine for pityriasis versicolor - it is ineffective for this condition 4
• Address hygiene and environmental sources to prevent reinfection 3
• Look for other sites of infection that may serve as reservoirs 6

Comparative Effectiveness

No significant difference exists between azoles and benzylamines for mycological cure (RR 1.01) 2. However, allylamines (terbinafine, naftifine) may offer advantages with shorter treatment duration (1-2 weeks vs 2-4 weeks) and fewer daily applications 2, 4.

Azole-steroid combinations show higher clinical cure rates at end of treatment but are not recommended in guidelines due to concerns about steroid effects and similar mycological cure rates 2.

Adverse Effects

All topical and oral antifungals are generally well-tolerated:

• Topical agents: minimal irritation and burning 2
• Oral agents: adverse effects within acceptable limits 7
• Griseofulvin safety is established at recommended doses 3