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Tinea treatement regime harrison

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tinea corporis cruris pedis treatment guideline topical terbinafine oral regimen

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PMID: 40053133

Tinea treatment regimen - Harrison's Principles of Internal Medicine, 22e

Treatment depends on the anatomical site. Confirm with KOH microscopy or fungal culture, especially before oral therapy.

1. Tinea corporis, cruris, and limited pedis

First line: topical antifungal
  • Topical azole: clotrimazole, miconazole, ketoconazole, etc.
  • Topical allylamine: terbinafine, naftifine, or butenafine.
Apply to the lesion plus a small surrounding margin, usually twice daily, and continue for 1 week after apparent clinical clearing.
  • Tinea corporis / cruris: commonly 2-4 weeks, depending on the product and response.
  • Tinea pedis: often needs a longer course and has frequent relapses.
Harrison's states that topical treatment is generally effective for uncomplicated tinea corporis, cruris, and limited pedis, but nystatin is inactive against dermatophytes.
Harrison's Principles of Internal Medicine, 22e, pp. 432-433.

2. When to use oral treatment

Use systemic therapy for:
  • Tinea capitis
  • Onychomycosis
  • Extensive tinea corporis/cruris
  • Recurrent or treatment-resistant tinea pedis/corporis
  • Failure of correctly used topical treatment
  • Immunocompromised patients or severe hyperkeratotic ("moccasin") tinea pedis
Harrison's lists terbinafine, itraconazole, and griseofulvin as systemic options. It notes that terbinafine has fewer drug interactions than itraconazole and is generally the preferred systemic drug for extensive dermatophyte infection.
Harrison's Principles of Internal Medicine, 22e, p. 1778-1784; p. 1767.
Common adult regimens used clinically:
ConditionUsual regimen
Extensive/refractory corporis or crurisTerbinafine 250 mg orally once daily for 2 weeks, sometimes 2-4 weeks depending on response
Severe/refractory tinea pedisTerbinafine 250 mg orally once daily for 2 weeks, often longer for hyperkeratotic disease
Tinea capitisOral terbinafine or griseofulvin, usually 4-8 weeks depending on organism and formulation
Fingernail onychomycosisTerbinafine 250 mg once daily for 6 weeks
Toenail onychomycosisTerbinafine 250 mg once daily for 12 weeks
For oral azoles, drug interactions are important. All oral antifungals can cause hepatotoxicity. Obtain medication history, consider baseline liver tests, and avoid oral therapy in pregnancy or breastfeeding unless specialist-directed.

3. Prevent recurrence

  • Keep skin folds and feet dry.
  • Dry carefully between toes after bathing.
  • Use loose, breathable clothing and change socks/underwear daily.
  • Treat coexisting tinea pedis and onychomycosis, which commonly reinfect the groin or body.
  • Do not use topical steroid alone on a suspected fungal rash. It can mask and worsen infection, producing tinea incognito.

Important distinction

Tinea versicolor is not dermatophyte tinea. Harrison's recommends topical selenium sulfide or topical azoles, generally for 2 weeks; extensive cases may receive oral itraconazole or fluconazole for 5-7 days.
Harrison's Principles of Internal Medicine, 22e, p. 1766.
Recent evidence supports topical allylamines: a 2025 systematic review found topical naftifine effective for tinea pedis, corporis, and cruris (systematic review, PMID 40053133).
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