What is the appropriate treatment for a 6-year-old child with a round rash that has a white center, suggestive of a fungal infection, such as ringworm (tinea corporis)?

Treatment of Tinea Corporis (Ringworm) in a 6-Year-Old Child

For a 6-year-old child with a round, spreading rash with a white center consistent with tinea corporis (ringworm), topical antifungal therapy with clotrimazole or miconazole cream applied twice daily for 2-4 weeks is the appropriate first-line treatment for localized disease. 1, 2

Diagnostic Confirmation Before Treatment

• Obtain potassium hydroxide (KOH) preparation or fungal culture before initiating prolonged treatment to confirm dermatophyte infection and visualize hyphae. 1, 3
• Collect specimens using scalpel scraping or swab of the active border of the lesion where fungal elements are most concentrated. 2
• In cases with highly typical clinical features (annular lesion with central clearing and raised scaly border), it is reasonable to start topical therapy immediately while awaiting confirmation. 2

First-Line Topical Treatment Regimen

• Apply clotrimazole 1% cream or miconazole 2% cream twice daily to the affected area and extend 2-3 cm beyond the visible border of the lesion. 2
• Continue treatment for 2-4 weeks until both clinical and mycological clearance is achieved, not just until visible improvement occurs. 1, 2
• Keep the affected area clean and dry, as moisture promotes fungal growth. 1

When to Escalate to Oral Systemic Therapy

Oral antifungal therapy is indicated when:

• The infection is widespread or involves multiple body sites. 1, 3
• There is failure to respond to adequate topical treatment after 2-4 weeks. 1, 2
• The child has difficulty with compliance to topical application. 3

Oral Treatment Options for Extensive Disease

• Griseofulvin is the only FDA-licensed systemic treatment for tinea corporis in children and should be dosed at 10 mg/kg/day (typically 125-250 mg daily for a child weighing 30-50 lbs) for 2-4 weeks. 4
• Griseofulvin should be taken with fatty food to increase absorption and bioavailability. 1
• Terbinafine is the preferred alternative for widespread dermatophyte infections due to its fungicidal properties and high cure rates, dosed at 62.5-125 mg daily for children weighing 20-40 kg. 1, 2
• Itraconazole 100 mg daily for 15 days (approximately 5 mg/kg/day) can be used in children ≥2 years, though it requires therapeutic drug monitoring with target trough concentration ≥0.5 mg/L. 1, 2

Critical Prevention and Management Points

• Screen and treat all family members, as anthropophilic dermatophytes like Trichophyton tonsurans can affect over 50% of household contacts. 1, 2
• Clean all contaminated items (towels, clothing, bedding) with bleach or 2% sodium hypochlorite solution to prevent reinfection. 1, 2
• Avoid skin-to-skin contact with infected individuals and cover lesions appropriately during treatment. 2, 3
• Do not share personal items such as towels, clothing, or sports equipment. 2

Common Pitfalls to Avoid

• Do not stop treatment when the rash appears to be improving clinically—continue until mycological cure is documented, as premature discontinuation leads to relapse. 1, 2
• Do not use topical corticosteroids alone, as this will worsen the infection by suppressing local immunity. 2
• Baseline liver function tests are recommended before initiating oral terbinafine or itraconazole, especially if there are pre-existing hepatic concerns. 2
• Ensure proper application technique—topical antifungals must extend beyond the visible lesion border to treat subclinical infection. 2

Follow-Up and Treatment Endpoints

• The definitive endpoint is mycological cure confirmed by repeat KOH preparation or culture, not just clinical resolution of the rash. 2, 3
• Follow-up with repeat mycology sampling is recommended 2-4 weeks after completing treatment to document clearance. 2
• Clinical relapse will occur if medication is not continued until the infecting organism is completely eradicated. 4