Ringworm (Tinea) Treatment
Immediate Treatment Recommendations by Location
For tinea corporis (body) and tinea cruris (groin), start with topical antifungal therapy using clotrimazole or miconazole cream twice daily for 2-4 weeks for localized disease in otherwise healthy individuals 1. Alternatively, terbinafine 1% cream applied twice daily for 1 week is highly effective and superior to 4 weeks of clotrimazole 2.
For tinea capitis (scalp), oral systemic therapy is always required—topical treatment alone is insufficient 3, 1.
Topical Therapy for Tinea Corporis/Cruris/Pedis
- Clotrimazole 1% cream twice daily for 2 weeks (tinea corporis/cruris) or 4 weeks (tinea pedis) 1, 4
- Miconazole cream twice daily for 2-4 weeks 1
- Terbinafine 1% cream twice daily for 1 week provides superior mycological cure (93.5%) compared to 4 weeks of clotrimazole (73.1%) 2
- Ketoconazole 2% cream once daily for 2 weeks (tinea corporis/cruris) or 6 weeks (tinea pedis) 4
Treatment should continue for at least one week after clinical clearing to prevent recurrence 5.
When to Switch to Oral Therapy
Oral antifungals are indicated when 1, 6:
- Topical treatment fails after 2-4 weeks
- Extensive disease covering large body surface area
- Hair follicle involvement (folliculitis)
- Immunocompromised patients
- Patient preference for shorter treatment duration
Oral terbinafine 250 mg daily for 1-2 weeks is the preferred systemic option for tinea corporis/cruris resistant to topical therapy 1.
Tinea Capitis: Oral Therapy Required
First-Line Treatment Based on Organism
For Trichophyton species (most common in many regions):
For Microsporum species:
Second-Line Therapy for Tinea Capitis
If first-line therapy fails after 2-4 weeks of clinical improvement but ongoing positive mycology, continue current therapy for an additional 2-4 weeks 3. If no initial clinical improvement occurs:
- Itraconazole 50-100 mg daily for 4 weeks, or 5 mg/kg daily for 2-4 weeks 3
- Switch from terbinafine to griseofulvin for Microsporum, or vice versa for Trichophyton 3
Critical Management Considerations
- Start treatment immediately if kerion (inflammatory mass), scaling, lymphadenopathy, or alopecia are present—do not wait for mycology results 1
- Obtain baseline liver function tests before starting terbinafine or itraconazole 1
- The endpoint is mycological cure, not just clinical improvement—repeat mycology sampling until clearance is documented 3, 1
Adjunctive Measures to Prevent Transmission
- Use antifungal shampoos (ketoconazole 2%, selenium sulfide 1%, or povidone-iodine) to reduce spore transmission 1, 8
- Screen and treat all family members for T. tonsurans infections, as >50% may be affected 1
- Clean contaminated items (combs, brushes, towels) with disinfectant or 2% sodium hypochlorite 1
- Children on appropriate therapy can attend school or nursery—isolation is not necessary 3
Common Pitfalls and How to Avoid Them
Diagnostic Confirmation
- Always confirm diagnosis with potassium hydroxide (KOH) preparation or culture rather than relying on clinical appearance alone, as eczema can mimic tinea corporis 1, 6
Treatment Failure
If treatment fails, consider 3, 1:
- Non-compliance with medication regimen
- Suboptimal drug absorption (griseofulvin not taken with fatty food)
- Reinfection from untreated household contacts
- Emerging resistant strains that may require prolonged therapy and specialized testing 6
Avoid Combination Steroid-Antifungal Products
- While combination antifungal-corticosteroid creams show higher short-term clinical cure rates, they are not recommended in clinical guidelines due to risk of skin atrophy and potential for promoting resistance 6, 9
- Use these only in exceptional circumstances with significant inflammation, and for limited duration 5
Asymptomatic Carriers
- Treat asymptomatic carriers with high spore load (culture positive but no clinical infection) to prevent transmission, particularly in T. tonsurans outbreaks 3