Treatment of Ringworm (Tinea) Infections
For most ringworm infections of the body (tinea corporis) and groin (tinea cruris), topical terbinafine or other topical antifungals applied once or twice daily for 1-4 weeks are first-line therapy and cure most cases. 1, 2
Treatment Algorithm by Site and Severity
Tinea Corporis (Body) and Tinea Cruris (Groin)
Topical therapy is first-line for localized disease:
- Topical terbinafine applied to affected areas cures most athlete's foot, jock itch, and ringworm while relieving itching, burning, cracking, and scaling 1
- Alternative topical agents include miconazole, clotrimazole, or other azole formulations applied once or twice daily for 2-4 weeks 2, 3
- These are inexpensive and highly effective for limited disease 2
Oral therapy is indicated when:
- Disease is extensive or involves multiple body sites 2, 3
- Topical treatment has failed after 2-4 weeks 2
- Hair follicles are involved 2
- Patient is immunocompromised 2
For oral therapy:
- Fluconazole 150 mg once weekly for 2-4 weeks is highly effective, reducing symptom severity scores from 7.1 to 1.5 (p=0.001) 4
- Oral terbinafine is considered first-line oral therapy because it is well-tolerated, effective, and inexpensive 2
- Itraconazole 200 mg daily is an alternative oral option 5, 3
Tinea Capitis (Scalp)
Systemic therapy is mandatory—topical treatment alone is inadequate:
- Oral terbinafine is first-line therapy for tinea capitis due to superior tolerability, efficacy, and cost 2, 6
- Treatment duration is typically 6 weeks 6
- Griseofulvin is an alternative, requiring 6-8 weeks of treatment 6, 3
- Topical antifungals cannot penetrate the hair shaft adequately and should not be used as monotherapy 6
Tinea Pedis (Athlete's Foot)
Topical therapy for mild to moderate disease:
- Topical terbinafine or azole antifungals applied once or twice daily for 2-4 weeks 1, 2
- Tolnaftate is another topical option 3
Oral therapy for extensive or refractory disease:
Tinea Unguium (Onychomycosis/Nail Infections)
Oral therapy is required—topical agents have poor nail penetration:
- Oral terbinafine 250 mg daily for 12-16 weeks (toenails) or 6 weeks (fingernails) is first-line therapy 7, 2
- Itraconazole 200 mg daily for 12 weeks continuously, or pulse therapy at 400 mg daily for 1 week per month (2 pulses for fingernails, 3 pulses for toenails) 7
- Fluconazole 150-450 mg weekly for at least 6 months (toenails) or 3 months (fingernails) is a useful alternative for patients intolerant of terbinafine or itraconazole 7
Critical Management Considerations
Confirm diagnosis before treatment:
- Clinical diagnosis without laboratory confirmation is unreliable—tinea corporis can mimic eczema, and onychomycosis can resemble psoriatic nails or trauma-related dystrophy 2
- Obtain skin scrapings for microscopy and fungal culture when diagnosis is uncertain 2, 3
Avoid combination antifungal-corticosteroid products:
- These should be avoided as part of antifungal stewardship to prevent resistance and optimize outcomes 2
- Corticosteroids can worsen fungal infections and mask symptoms 2
Monitor for treatment failure:
- Emerging resistant tinea infections may not respond to first-line topical or oral antifungals and require prolonged oral therapy with specialized diagnostic testing 2
- If standard therapy fails, consider drug-resistant organisms or alternative diagnoses 2
Prevent reinfection:
- Good personal hygiene is essential as an adjunct to antifungal therapy 3
- For tinea pedis, use antifungal powders in shoes and wear absorbent cotton socks 7
- Discard contaminated footwear or treat with antifungal sprays 7
- Treat all infected family members simultaneously to prevent reinfection 7
Monitoring for oral therapy:
- Baseline liver function tests and complete blood count are recommended before starting oral terbinafine, especially in patients with hepatic history 7
- Monitor liver function during prolonged therapy (>1 month) 7
- For itraconazole, measure serum concentrations after 2 weeks to ensure adequate absorption 7