What is the recommended treatment for a patient with ringworm?

Recommended Treatment for Ringworm (Tinea Corporis/Cruris)

For uncomplicated ringworm, apply topical terbinafine 1% cream once or twice daily for 1 week, which is superior to azole antifungals and achieves cure rates exceeding 90%. 1, 2

Topical Therapy (First-Line for Localized Infection)

Preferred Topical Agent

• Terbinafine 1% cream applied twice daily for 1 week is the most effective topical treatment, achieving mycological cure rates of 93.5% and effective treatment rates of 89.7% 1
• Terbinafine is fungicidal (kills fungi) rather than fungistatic (merely stops growth), which reduces recurrence when patients stop treatment early 3
• One week of terbinafine is significantly more effective than 4 weeks of clotrimazole (P = 0.0001) 1

Alternative Topical Agents

• Naftifine 1% cream is 2.4 times more effective than placebo for both mycological cure (RR 2.38, NNT 3) and clinical cure (RR 2.42, NNT 3) 2
• Clotrimazole 1% or miconazole 1% cream applied twice daily for 2-4 weeks are acceptable azole alternatives, achieving mycological cure rates 2.9 times higher than placebo (RR 2.87, NNT 2) 4, 2
• Azoles are fungistatic and require longer treatment duration (2-4 weeks) compared to allylamines like terbinafine 3

Important Caveat

• Avoid topical steroid-antifungal combination creams despite their higher short-term clinical cure rates, as they are not recommended in clinical guidelines and may mask infection or cause relapse 2

Oral Therapy (For Extensive or Treatment-Resistant Infection)

When to Escalate to Oral Treatment

• Extensive body surface area involvement 4
• Failure of topical therapy after 2-4 weeks 4
• Moderate to severe infection 4

Oral Treatment Options

• Terbinafine 250 mg daily for 1-2 weeks is highly effective for tinea corporis/cruris 5
• Fluconazole 150 mg once weekly for 2-3 weeks OR 50-100 mg daily for 2-3 weeks 5
• Itraconazole 100 mg daily for 2 weeks OR 200 mg daily for 7 days 5

Comparative Effectiveness

• No significant difference in mycological cure rates between azoles and benzylamines (RR 1.01) 2
• Terbinafine offers shorter treatment duration (1-2 weeks) compared to azoles (2-3 weeks) 5

Critical Adjunctive Measures

• Keep infected areas dry throughout treatment, as moisture promotes fungal growth 4
• Address predisposing factors including diabetes, immunosuppression, or excessive moisture to prevent recurrence 4
• Treatment duration should continue for the full prescribed course even if skin appears healed, as premature discontinuation leads to higher recurrence rates with fungistatic agents 3

Special Consideration: Scalp Ringworm (Tinea Capitis)

• Oral terbinafine is more effective than fluconazole for scalp infections, requiring 6 weeks of treatment 6, 7
• Topical therapy alone is inadequate for tinea capitis as it cannot penetrate the hair shaft 7