Ringworm (Tinea) Treatment
For most ringworm infections of the body (tinea corporis), tinea cruris, and tinea pedis, start with topical antifungal therapy using azoles, allylamines, or ciclopiroxolamine for 2-4 weeks, but for scalp ringworm (tinea capitis) or nail infections (tinea unguium), oral systemic antifungals are mandatory. 1, 2
Treatment by Location
Tinea Corporis, Tinea Cruris, and Tinea Pedis (Body, Groin, Feet)
Topical therapy is first-line for localized disease:
- Apply topical azoles (clotrimazole, miconazole), allylamines (terbinafine), amorolfine, ciclopiroxolamine, or tolnaftate for 2-4 weeks 2, 3
- These infections generally respond well to inexpensive topical agents 2
Switch to oral therapy if:
- Extensive disease is present 2
- No response to topical treatment after appropriate duration 2
- Patient is immunocompromised 2
- Hair follicle involvement is present 2
Tinea Capitis (Scalp Ringworm)
Oral systemic antifungal therapy is absolutely required—topical therapy alone is inadequate. 1
First-line treatment depends on the causative organism:
For Trichophyton species (most common in many regions):
For Microsporum species:
- Griseofulvin is the treatment of choice: 1, 4
- Children: 20-25 mg/kg/day for 6-8 weeks (can divide into single or multiple doses) 1, 5
- Adults: 500 mg daily (can give as 125 mg four times daily, 250 mg twice daily, or 500 mg once daily) 5
- Take with fatty food to enhance absorption 1, 5
- This is the only FDA-approved and licensed treatment for tinea capitis in children in the UK 1
Adjunctive measures:
- Add antifungal shampoo (ketoconazole 2%, selenium sulfide 1%, or povidone-iodine) to reduce spore transmission 1
- Children can attend school/nursery while on appropriate therapy 1
- Screen and treat family members and close contacts, especially for T. tonsurans infections 1
When to start treatment:
- If kerion present or diagnosis strongly suspected clinically (scaling, lymphadenopathy, alopecia), start treatment immediately without waiting for culture results 1
- Culture results take 2-4 weeks and delaying increases spread risk 1
Treatment failure management:
- First assess compliance, drug absorption, and possibility of reinfection 1
- If clinical improvement but positive mycology persists, continue current therapy 2-4 weeks longer 1
- If no clinical improvement, switch agents: 1
- If on terbinafine for Trichophyton, switch to griseofulvin
- If on griseofulvin for Microsporum, continue or increase dose
- Consider itraconazole 50-100 mg daily or 5 mg/kg/day for 2-4 weeks as second-line 1
Tinea Unguium (Onychomycosis/Nail Infections)
Oral systemic therapy is required:
Alternative: Itraconazole 3
- Particularly important if terbinafine resistance suspected (T. rubrum resistance or T. mentagrophytes ITS genotype VIII) 3
Important considerations:
- Always combine oral therapy with topical antifungal treatment 3
- Treatment duration depends on nail growth rate: fingernails minimum 4 months, toenails minimum 6 months 5
Emerging Resistant Infections
Critical warning about T. mentagrophytes ITS genotype VIII (T. indotineae):
- This emerging pathogen shows terbinafine resistance 3
- Causes more severe tinea corporis and tinea cruris that doesn't respond to standard topical or oral terbinafine 2, 3
- Requires species identification, genotype testing, and resistance testing 3
- Itraconazole is the drug of choice for this organism 3
- May require prolonged oral antifungal therapy 2
Key Pitfalls to Avoid
- Never use topical therapy alone for tinea capitis or tinea unguium—systemic therapy is mandatory 1
- Avoid combination antifungal-corticosteroid products—this promotes resistance and worsens outcomes 2
- Don't stop treatment based on clinical appearance alone—continue until mycological cure is confirmed 1, 5
- Don't assume all ringworm responds to the same treatment—optimal regimens vary by causative organism 1
- Consider emerging resistant organisms if standard therapy fails—obtain culture, species identification, and resistance testing 2, 3