What is the recommended antifungal treatment for a 10-year-old patient with tinea (ringworm) of the face, specifically around the mouth and cheeks?

Treatment of Facial Tinea in a 10-Year-Old Child

For a 10-year-old with tinea of the face around the mouth and cheeks, oral antifungal therapy is mandatory—topical therapy alone is insufficient for facial dermatophyte infections. 1, 2

Why Oral Therapy is Required

Facial tinea (tinea faciei) behaves similarly to tinea capitis in requiring systemic treatment for complete eradication. Topical antifungals cannot adequately penetrate to eliminate the dermatophyte infection in these areas and should never be used as monotherapy. 2

First-Line Oral Treatment Options

Terbinafine (Preferred for Most Cases)

• Dosing for a 10-year-old: 125 mg daily for 2-4 weeks if the child weighs 20-40 kg, or 250 mg daily for 2-4 weeks if over 40 kg 2
• Advantages: Fungicidal activity, shorter treatment duration (improves compliance), and superior efficacy against Trichophyton species (the most common cause of facial tinea) 2
• Side effects: Gastrointestinal disturbances and rashes occur in less than 8% of children 2
• Important caveat: Terbinafine fails against Microsporum species, so if this organism is suspected or confirmed, switch to griseofulvin 2

Griseofulvin (If Microsporum is Confirmed or Suspected)

• Dosing: 10 mg/kg/day for 2-4 weeks for tinea corporis (facial tinea follows similar duration) 3
• This is the only FDA-approved treatment for pediatric dermatophyte infections and has the longest safety track record 3, 4
• Treatment duration: 2-4 weeks for tinea corporis/faciei, which is shorter than the 6-8 weeks required for tinea capitis 3

Diagnostic Confirmation Before or During Treatment

While treatment can be started empirically if clinical signs are clear (scale, erythema, characteristic annular lesions), obtain specimens via scalpel scraping for microscopy and culture to confirm the diagnosis and identify the causative organism. 1 This allows you to optimize therapy if the initial choice proves ineffective.

Adjunctive Topical Therapy

Add topical antifungal cream (clotrimazole or miconazole twice daily) as adjunctive treatment only—never as monotherapy. 1, 2 This helps reduce surface fungal load and may speed clinical improvement, but oral therapy remains essential for cure.

Monitoring and Treatment Endpoint

• The endpoint is mycological cure, not just clinical improvement. 1, 2 Clinical lesions may resolve while viable organisms persist.
• Baseline liver function tests are recommended before starting terbinafine or itraconazole, especially if any pre-existing hepatic concerns exist. 1
• Follow-up with repeat mycology sampling until clearance is documented 1
• If clinical improvement occurs but mycology remains positive, continue current therapy for an additional 2-4 weeks 2

Prevention of Recurrence and Spread

• Screen and treat all family members, as over 50% may be affected with anthropophilic species like Trichophyton tonsurans 1
• Clean contaminated items (towels, pillowcases) with disinfectant or 2% sodium hypochlorite solution 1, 2
• Avoid skin-to-skin contact with infected individuals and do not share personal items 1
• Cover lesions until treatment is underway 1

Second-Line Options for Treatment Failure

If initial therapy fails after 4 weeks, consider:

• Poor compliance (most common cause)
• Suboptimal drug absorption
• Organism insensitivity (wrong drug for the species)
• Reinfection from untreated contacts or fomites 2

Switch to itraconazole 5 mg/kg/day for 2-4 weeks (effective against both Trichophyton and Microsporum species) if first-line therapy fails. 2 Note that itraconazole is used off-label in children under 12 years in many countries and has important drug interactions with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin. 1

Common Pitfalls to Avoid

• Never use topical therapy alone for facial tinea—it will fail 2
• Do not use terbinafine if Microsporum is confirmed or strongly suspected—it has poor efficacy against this organism 2
• Do not stop treatment when lesions clear clinically—continue until mycological cure is confirmed 1, 2
• Do not forget to screen household contacts—they are a major source of reinfection 1