Treatment of Ringworm (Tinea Infection)
For otherwise healthy individuals with ringworm (tinea corporis or tinea cruris), topical antifungal therapy applied once to twice daily for 2-4 weeks is the best first-line treatment, with oral therapy reserved for extensive disease, treatment failure, or scalp involvement.
Location-Specific Treatment Approach
Tinea Corporis and Tinea Cruris (Body and Groin)
Topical therapy is first-line for localized disease:
- Apply econazole cream 1% once daily for 2 weeks for tinea corporis and cruris 1
- Alternative topical options include clotrimazole cream twice daily for 2-4 weeks 2 or miconazole cream twice daily for 2-4 weeks 2
- Terbinafine cream is highly effective, with significantly higher clinical cure rates compared to placebo (RR 4.51, NNT 3) 3
- Naftifine 1% demonstrates strong mycological cure rates (RR 2.38, NNT 3) 3
Oral therapy is indicated when:
- Infection is resistant to topical treatment 2
- Extensive disease is present 4
- Patient is immunocompromised 4
- Hair follicle involvement exists 4
For oral therapy when needed:
- Terbinafine 250 mg daily for 1-2 weeks is particularly effective against Trichophyton tonsurans 2
- Itraconazole 100 mg daily for 15 days achieves 87% mycological cure rate 2
- Terbinafine shows superior efficacy for Trichophyton species infections 2
Tinea Capitis (Scalp Ringworm)
Oral therapy is always required - topical therapy alone is ineffective:
- Topical therapy alone is not recommended for tinea capitis 5
- Treatment choice depends on the causative organism 5
For Trichophyton species (T. tonsurans, T. violaceum, T. soudanense):
- Terbinafine is first-line:
- Terbinafine requires shorter treatment duration, improving compliance 5
For Microsporum species (M. canis, M. audouinii):
- Griseofulvin is first-line:
- Take with fatty food to enhance absorption 5
- Griseofulvin achieves 88.5% response rates for Microsporum species 5
Second-line therapy for treatment failure:
- Itraconazole 50-100 mg daily for 4 weeks or 5 mg/kg daily for 2-4 weeks 5
- Itraconazole is effective against both Trichophyton and Microsporum species 5
Critical Management Considerations
When to start treatment:
- In the presence of kerion, scaling, lymphadenopathy, or alopecia, start treatment immediately while awaiting mycology results 5
- For less severe cases, confirm diagnosis with microscopy or culture before initiating therapy 5
Monitoring and follow-up:
- The endpoint is mycological cure, not just clinical improvement 2
- Repeat mycology sampling until clearance is documented 5, 2
- Baseline liver function tests are recommended before starting terbinafine or itraconazole 2
Prevention of transmission and recurrence:
- Use antifungal shampoos (ketoconazole 2%, selenium sulfide 1%, or povidone-iodine) to reduce spore transmission 5
- Screen and treat all family members for T. tonsurans infections, as >50% may be affected 2
- Clean contaminated combs, brushes, and towels with disinfectant or 2% sodium hypochlorite 2
- Avoid skin-to-skin contact with infected individuals and do not share personal items 2
Common Pitfalls to Avoid
Do not use combination antifungal-corticosteroid creams as first-line therapy - while they may provide faster symptom relief, they are not recommended in clinical guidelines and may mask the infection 4, 3. Although some studies show higher clinical cure rates at end of treatment, the evidence quality is very low 3.
Do not rely on clinical diagnosis alone - other conditions like eczema, psoriasis, and dystrophic nails can mimic tinea infections 4. Confirm diagnosis with potassium hydroxide preparation or culture 2.
For treatment failure, consider:
- Non-compliance with medication regimen 5
- Suboptimal drug absorption 5
- Reinfection from untreated contacts 5
- If clinical improvement occurs but mycology remains positive, continue current therapy for 2-4 weeks 5
- If no clinical improvement, switch to second-line therapy 5
Children receiving appropriate therapy for tinea capitis should be allowed to attend school or nursery 5.