What is the first‑line treatment regimen for tinea corporis in an otherwise healthy adult?

Tinea Corporis Treatment Regimen

For otherwise healthy adults with tinea corporis, topical terbinafine 1% cream applied once daily for 1 week is the first-line treatment, achieving 84% mycological cure rates with excellent tolerability. 1

First-Line Topical Therapy

Topical antifungals are the standard of care for localized tinea corporis, with oral agents reserved for extensive disease, treatment failures, or immunocompromised patients. 2

Preferred Topical Regimens

• Terbinafine 1% cream once daily for 1 week provides superior efficacy with the shortest treatment duration, achieving 84.2% mycological cure versus 23.3% with placebo. 1

• Allylamine antifungals (terbinafine, naftifine) offer 1-2 week treatment courses, significantly shorter than azole alternatives. 2

• Butenafine cream once daily for 1-2 weeks is an effective alternative allylamine option. 3, 4

Alternative Topical Options

• Azole antifungals (clotrimazole, miconazole, ketoconazole) require twice-daily application for 2-4 weeks, making them less convenient but widely available over-the-counter. 3, 5

• Ketoconazole 2% cream once daily for 2 weeks is FDA-approved for tinea corporis, though it requires longer treatment than allylamines. 6

• Ciclopirox olamine 0.77% cream twice daily for 4 weeks achieves approximately 60% cure rates at end of treatment. 7

Oral Therapy for Extensive or Resistant Disease

Oral antifungals are indicated when infection is extensive, topical therapy fails, deep tissue involvement exists, or onychomycosis coexists as a reservoir for reinfection. 8, 2

Oral Treatment Regimens

• Itraconazole 100 mg once daily for 15 days achieves 87% mycological cure, superior to griseofulvin's 57% cure rate. 9, 2

• Terbinafine 250 mg once daily for 1-2 weeks is particularly effective against Trichophyton tonsurans, the most common cause of tinea corporis gladiatorum. 9, 2

• Fluconazole 150 mg once weekly for 2-4 weeks reduces symptom severity scores from 7.1 to 1.5 (p=0.001), though it is less effective than terbinafine or itraconazole. 10

Oral Terbinafine Considerations

• Terbinafine achieves >80% mycological cure in tinea corporis/cruris with predictable side effects including gastrointestinal disturbances (49%) and taste disturbance. 2

• Contraindications include active or chronic liver disease and lupus erythematosus. 2

• Baseline liver function tests and complete blood count are recommended in adults with hepatotoxicity history or hematologic abnormalities before initiating oral terbinafine. 8

• Rare serious adverse events (0.04% incidence) include Stevens-Johnson syndrome and toxic epidermal necrolysis. 2

Diagnostic Confirmation

Confirm dermatophyte infection via potassium hydroxide (KOH) preparation or fungal culture before initiating therapy, as tinea corporis mimics eczema and other inflammatory conditions. 2, 4

Treatment Monitoring and Endpoints

• Mycological cure, not just clinical response, is the definitive treatment endpoint. 2

• Continue treatment for at least 1 week after clinical clearing to prevent recurrence. 3

• If clinical improvement occurs but mycology remains positive, continue therapy for an additional 2-4 weeks. 2

• Follow-up with repeat mycology sampling is recommended until clearance is documented. 2

Prevention of Recurrence

• Screen and treat all family members, as over 50% of household contacts may be affected with anthropophilic species like T. tonsurans. 2

• Clean all fomites (combs, brushes, towels) with disinfectant or 2% sodium hypochlorite solution. 2

• Avoid skin-to-skin contact with infected individuals and do not share towels or personal items. 2

• Athletes require minimum 72 hours of antifungal therapy before return to contact sports, with lesions covered by gas-permeable dressing. 8

Common Pitfalls to Avoid

• Failing to treat concomitant onychomycosis allows the nail to serve as a reservoir for reinfection, requiring extended oral therapy (12-16 weeks). 8

• Treating only the index patient without addressing subclinical infections in household contacts leads to repeated episodes. 8

• Using topical corticosteroid-antifungal combinations without caution risks skin atrophy and other steroid-associated complications. 3

• Misdiagnosing tinea corporis as eczema leads to inappropriate corticosteroid monotherapy, which exacerbates fungal infection. 4