What is the first‑line treatment for uncomplicated ringworm (tinea corporis, tinea cruris, tinea pedis) in children?

Treatment of Ringworm in Children

First-Line Treatment: Topical Terbinafine

For uncomplicated ringworm (tinea corporis, tinea cruris, tinea pedis) in children, topical terbinafine 1% cream applied once to twice daily for 1-2 weeks is the first-line treatment. 1, 2, 3

Why Terbinafine is Superior

• Terbinafine achieves approximately 94% mycological cure rates with significantly shorter treatment duration (1 week) compared to azole antifungals (4 weeks), which dramatically improves adherence in pediatric patients. 3, 4
• The fungicidal mechanism of action allows for shorter courses and continued improvement after treatment cessation due to residual tissue effects. 4, 5
• Terbinafine 1% is approved for children 12 years and older, though it is commonly used off-label in younger children. 3

Alternative Topical Agents

If terbinafine is unavailable or not tolerated:

• Ciclopirox olamine 0.77% cream/gel applied twice daily for 4 weeks achieves approximately 60% cure at end of treatment and 85% two weeks post-treatment. 1
• Clotrimazole 1% cream applied twice daily for 2-4 weeks is less effective than terbinafine but widely available over-the-counter. 1, 2
• Miconazole cream applied twice daily for 2-4 weeks is another reasonable alternative for mild to moderate infections. 2
• Naftifine 1% gel is FDA-approved for tinea pedis, cruris, and corporis caused by common dermatophytes. 6

When to Use Oral Therapy

Reserve oral antifungals for: 2, 3, 7

• Extensive or multiple lesions covering large body surface areas
• Failed topical therapy after 4 weeks
• Chronic or deep tissue involvement
• Concomitant nail infection (onychomycosis)
• Immunocompromised patients
• Tinea capitis (always requires systemic therapy)

Oral Treatment Options

Oral terbinafine 250 mg once daily for 1-2 weeks is the preferred systemic agent for dermatophyte infections in children who can swallow tablets, achieving >80% mycological cure rates. 2, 4, 8

• Particularly effective against Trichophyton tonsurans, the most common cause of tinea corporis in children. 2, 3
• Well-tolerated with low drug interaction potential compared to azoles. 4
• Obtain baseline liver function tests before initiating oral terbinafine, especially if pre-existing hepatic abnormalities are suspected. 2

Itraconazole 100 mg daily for 15 days is an effective alternative with 87% mycological cure rates. 2, 3

• Licensed for children over 12 years in the UK; used off-label in younger children in some countries. 2
• Important drug interactions: Enhanced toxicity with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin. 2
• Broader antifungal spectrum than terbinafine, covering Candida and non-dermatophyte moulds. 1

Fluconazole is a third-line option due to weaker efficacy against dermatophytes compared to terbinafine and itraconazole. 1

• May be useful when other agents are contraindicated due to fewer cytochrome P450 interactions. 1
• Not licensed for tinea in children under 10 years in the UK. 2

Critical Diagnostic and Management Points

Confirm the Diagnosis

Obtain potassium hydroxide (KOH) preparation or fungal culture before treatment when diagnosis is uncertain, especially in atypical presentations. 2, 3, 7

• Specimens should be collected via scalpel scraping from the active border of lesions. 2

Treatment Endpoint

The definitive endpoint is mycological cure, not just clinical improvement. 2, 3

• Continue treatment for at least one week after clinical clearing to ensure eradication. 5
• Consider follow-up mycology sampling to document clearance in recurrent or resistant cases. 2

Prevention of Recurrence

Address these factors to prevent reinfection: 1, 2, 3

• Screen and treat all family members simultaneously, as >50% may be subclinically infected with anthropophilic species like T. tonsurans. 2, 3
• Decontaminate fomites: Clean combs, brushes, and towels with 2% sodium hypochlorite solution or disinfectant. 2, 3
• Examine for concomitant onychomycosis, which serves as a reservoir requiring 12-16 weeks of oral terbinafine. 1
• Treat concurrent tinea pedis if present, as dermatophytes spread between body sites via direct contact or contaminated hands. 1, 3
• Ensure complete drying of skin folds after bathing and use separate towels for different body parts. 3

Common Pitfalls to Avoid

• Do not use topical corticosteroid-antifungal combinations in children <12 years due to risk of cutaneous atrophy, especially in occluded areas like the diaper region. 9
• If combination products are used in adolescents for heavily inflamed lesions, limit to 2 weeks maximum and switch to pure antifungal once symptoms improve. 9
• Griseofulvin is not recommended as first-line therapy due to lower efficacy (30-40% cure rates), longer treatment duration, and inferior outcomes compared to terbinafine. 1, 2, 4
• Failing to address contaminated footwear leads to recurrence; decontaminate shoes with naphthalene mothballs sealed in plastic bags for ≥3 days or spray with terbinafine solution. 1