Treatment of Ringworm (Tinea Infections)
Ringworm is the common term for tinea infections, which are superficial fungal infections of the skin caused by dermatophytes, and treatment depends on the location and severity of infection, with topical antifungals being first-line for most body and groin infections, while oral therapy is required for scalp infections and resistant cases. 1, 2, 3
Medical Terminology
- Tinea corporis: Ringworm of the body 1, 3
- Tinea cruris: Jock itch (groin infection) 3, 4
- Tinea pedis: Athlete's foot 5, 3
- Tinea capitis: Scalp ringworm 2, 6
Treatment Algorithm by Location
Tinea Corporis (Body Ringworm)
Topical Therapy (First-Line)
- Terbinafine 1% cream applied twice daily for 1-2 weeks is the most effective topical treatment 1, 3, 4
- Clotrimazole 1% cream applied twice daily for 2-4 weeks is a widely available alternative 4, 7
- Continue treatment for at least one week after clinical clearing 4
Oral Therapy (For Resistant or Extensive Disease)
- Terbinafine 250 mg daily for 1-2 weeks is first-line oral therapy 1
- Itraconazole 100 mg daily for 15 days achieves 87% mycological cure rate 1
- Griseofulvin 500 mg daily for 2-4 weeks is less effective and requires longer treatment 1, 6
Tinea Capitis (Scalp Ringworm)
Oral therapy is mandatory—topical treatment alone is ineffective 2, 8
Treatment Selection Based on Causative Organism:
For Trichophyton species (T. tonsurans, T. violaceum, T. soudanense):
For Microsporum species:
Itraconazole 50-100 mg daily (or 5 mg/kg/day) for 2-4 weeks is effective for both species when first-line agents fail 2
Tinea Pedis (Athlete's Foot)
Topical Therapy (First-Line)
- Terbinafine 1% cream applied twice daily for 1 week is more effective than longer courses of other agents 5, 3
- Ciclopirox olamine 0.77% cream/gel achieves approximately 60% cure at end of treatment and 85% two weeks after 5
- Clotrimazole 1% cream applied twice daily for 4 weeks is less effective but widely available 5
Oral Therapy (For Severe or Resistant Cases)
- Terbinafine 250 mg once daily for 1-2 weeks (extended to 2 weeks for extensive disease) 5
- Itraconazole 100 mg daily for 2 weeks or pulse dosing 200-400 mg daily for 1 week per month 5
- Reserve oral therapy for severe disease, failed topical treatment, concomitant nail infection, or immunocompromised patients 5
Tinea Cruris (Jock Itch)
- Treatment is identical to tinea corporis: terbinafine 1% cream twice daily for 1-2 weeks topically, or terbinafine 250 mg daily for 1-2 weeks orally for extensive disease 1, 3, 4
Critical Management Considerations
Diagnosis Confirmation
- Confirm diagnosis with potassium hydroxide preparation or culture before initiating treatment, especially for scalp infections and nail involvement 1, 2, 6
- Specimens should be collected via scalpel scraping, hair pluck, brush, or swab as appropriate 1, 2
Treatment Failure Management
- If clinical improvement occurs but mycology remains positive, continue current therapy for 2-4 more weeks 2
- If no clinical improvement, switch to second-line therapy 2
- For griseofulvin failure with Trichophyton, switch to terbinafine 2
- For terbinafine failure with Microsporum, switch to griseofulvin 2
Prevention of Recurrence
- Screen and treat all family members, especially with anthropophilic species like T. tonsurans, as over 50% may be affected 1
- Clean contaminated combs, brushes, and towels with disinfectant or 2% sodium hypochlorite solution 1, 2
- For tinea pedis, thoroughly dry between toes after showering, change socks daily, and apply foot powder after bathing 5
- Cover active foot lesions with socks before wearing underwear to prevent spread to groin 5
Common Pitfalls to Avoid
- Do not use topical therapy alone for tinea capitis—it will fail 2
- Do not stop treatment when lesions clear clinically; continue until mycological cure is documented 1, 2, 6
- Do not use griseofulvin as first-line for Trichophyton infections—terbinafine is superior 1, 2
- Do not use terbinafine as first-line for Microsporum infections—griseofulvin is more effective 2
- Failing to treat all infected family members simultaneously results in reinfection 5
Monitoring and Follow-Up
- Mycological cure, not just clinical response, is the definitive endpoint for treatment 1, 2
- Follow-up with repeat mycology sampling is recommended until clearance is documented 1, 2
- For athletes, require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered 5
Special Populations
- For diabetic patients, terbinafine is preferred over itraconazole due to lower risk of drug interactions and hypoglycemia 5
- Children receiving appropriate therapy for tinea capitis can attend school or nursery 2
- Itraconazole has important drug interactions with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin 1