What is the treatment for tinea?

Treatment of Tinea Infections

For most tinea infections, topical antifungal therapy with azoles (clotrimazole or miconazole) applied twice daily for 2-4 weeks is first-line treatment, except for tinea capitis which always requires oral therapy. 1

Treatment Algorithm by Site of Infection

Tinea Corporis (Body) and Tinea Cruris (Groin)

Topical therapy (first-line):

• Clotrimazole cream twice daily for 2-4 weeks 1
• Miconazole cream twice daily for 2-4 weeks 1
• Treatment should continue for at least one week after clinical clearing 2

Oral therapy (when topical fails or extensive disease):

• Terbinafine 250 mg daily for 1-2 weeks is particularly effective against Trichophyton tonsurans 1
• Itraconazole 100 mg daily for 15 days achieves 87% mycological cure rate, superior to griseofulvin's 57% 1
• Fluconazole 50-100 mg daily for 2-3 weeks or 150 mg once weekly for 2-3 weeks 3

Tinea Pedis (Feet) and Tinea Manuum (Hands)

Topical therapy (first-line):

• Azole or allylamine antifungals applied once or twice daily for 4 weeks 2, 4
• Allylamines require only 1-2 weeks of treatment 2

Oral therapy (for hyperkeratotic or extensive disease):

• Terbinafine 250 mg daily for 2 weeks 3
• Itraconazole 100 mg daily for 2 weeks or 400 mg daily for 1 week 3
• Fluconazole 150 mg once weekly (pulse dosing) 3
• Combination topical plus oral therapy is effective for hyperkeratotic tinea pedis unresponsive to topical monotherapy alone 5

Tinea Capitis (Scalp)

Oral therapy is mandatory; topical therapy alone is inadequate: 6

• Griseofulvin 20 mg/kg daily for 6-8 weeks is first-line 6
• For resistant cases, increase griseofulvin to 25 mg/kg daily for prolonged periods 6
• Terbinafine is more effective for Trichophyton species 6
• Griseofulvin is more effective for Microsporum species (88.5% vs 67.9% response rate) 6
• Topical therapy should not be used as it enhances inflammation 5

Tinea Versicolor (Pityriasis Versicolor)

Topical therapy (first-line):

• Topical antifungal agents reduce spore transmission and are effective 7

Oral therapy (for extensive or resistant disease):

• Itraconazole 50-100 mg daily for 2-4 weeks 7
• Fluconazole 400 mg as a single dose or 200 mg daily for 5-7 days 3
• Note: Terbinafine is ineffective for tinea versicolor 3

Tinea Unguium (Onychomycosis)

Oral therapy is primary treatment:

• Griseofulvin for fingernails: at least 4 months; toenails: at least 6 months 8
• Itraconazole and terbinafine are standard treatments 4
• Topical amorolfine and ciclopirox are approved for milder cases 4

Critical Treatment Principles

Diagnostic confirmation before treatment:

• Accurate diagnosis through potassium hydroxide preparation microscopy or culture is essential 1, 6
• Specimens should be collected via scalpel scraping, hair pluck, brush, or swab as appropriate 1
• Treatment may be started immediately in high-risk populations or when clinical features strongly suggest tinea 6

Monitoring and follow-up:

• Mycological cure, not just clinical response, is the definitive endpoint 1
• Follow-up should include both clinical and mycological assessment until clearance is documented 7, 1, 6
• Repeat mycology sampling is recommended until mycological clearance 1

Baseline testing for oral therapy:

• Liver function tests are recommended before initiating terbinafine or itraconazole, especially with pre-existing hepatic abnormalities 1

Special Considerations and Drug Interactions

Itraconazole interactions:

• Enhanced toxicity with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin 1
• Licensed for children over 12 years in the UK, used off-label in younger children in some countries 1

Griseofulvin is not first-line for tinea corporis:

• Requires longer treatment duration, is less effective than terbinafine, and has lower cure rates 1

Fluconazole limitations:

• Not licensed for tinea in children under 10 years in the UK 1
• Less cost-effective than terbinafine with limited comparative efficacy data 1

Prevention of Recurrence

Essential preventive measures:

• Clean contaminated combs and brushes with disinfectant or 2% sodium hypochlorite solution 7, 1, 6
• Screen and treat all family members, especially with anthropophilic species like Trichophyton tonsurans (over 50% of family members may be affected) 1, 6
• Avoid skin-to-skin contact with infected individuals 1, 6
• Do not share towels and personal items 1
• Cover lesions during treatment 1
• Proper foot hygiene education is important for tinea pedis 4

Common Pitfalls to Avoid

Complicated presentations requiring modified approach:

• Interdigital tinea pedis with erosion or contact dermatitis: begin with topical corticosteroid plus oral antifungal, then add topical antifungal after complications resolve 5
• Tinea facialis near eyes, ears, or mouth: oral antifungals are necessary as topical application is difficult 5
• Widespread tinea corporis or tinea cruris involving complex skin folds: oral therapy is more practical 5
• Treatment failure may require extending treatment duration 1