From the Guidelines
Terbinafine is generally preferred over itraconazole as first-line therapy for tinea capitis, especially for Trichophyton species infections, due to its higher efficacy and shorter treatment duration. According to the British Association of Dermatologists' guidelines for the management of tinea capitis 2014 1, terbinafine is more efficacious against Trichophyton species, which are the most common cause of tinea capitis. The recommended dose of terbinafine is 250 mg per day for 2-4 weeks for children over 40 kg, and 125 mg per day for 2-4 weeks for children between 20-40 kg 1.
Key Considerations
- Itraconazole is an effective alternative, particularly for Microsporum infections, and can be administered at 50-100 mg per day for 4 weeks, or 5 mg kg−1 per day for 2-4 weeks 1.
- Both medications require monitoring for side effects, with terbinafine potentially causing gastrointestinal upset, taste disturbances, and rarely liver issues, while itraconazole may cause similar side effects and has more drug interactions 1.
- Treatment should be accompanied by antifungal shampoo (such as ketoconazole or selenium sulfide) 2-3 times weekly to reduce spore shedding.
- Family members should be screened for infection, and personal items like combs and hats should not be shared.
Treatment Failure and Second-Line Therapy
- In cases of treatment failure, itraconazole can be considered as second-line therapy, especially for Trichophyton infections, while griseofulvin can be used for Microsporum species 1.
- The choice of systemic therapy should be directed by the causative dermatophyte and/or local epidemiology, and oral therapy is generally indicated to achieve both clinical and mycological cure 1.
From the Research
Comparison of Itraconazole and Terbinafine for Tinea Capitis
- Itraconazole and terbinafine are both used as alternative treatments for tinea capitis, although griseofulvin is still considered the first-line therapy 2, 3.
- Several studies have shown that short-term terbinafine, itraconazole, or fluconazole are comparable in efficacy and safety to griseofulvin 2.
- A systematic review found that terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy in treating Trichophyton species infections, and itraconazole and griseofulvin for six weeks also showed similar cure rates 4.
- Another study found that itraconazole seems to be more effective than terbinafine in treating tinea infections, with higher cure rates at 4 and 8 weeks 5.
- A meta-analysis of randomized clinical trials comparing terbinafine and griseofulvin found that a 2- to 4-week course of terbinafine is at least as effective as a 6- to 8-week course of griseofulvin for treating Trichophyton infections of the scalp 6.
Efficacy and Safety
- The efficacy and safety of itraconazole and terbinafine for tinea capitis have been documented in several studies, with both agents showing comparable results to griseofulvin 2, 3, 4.
- Itraconazole and terbinafine have been used off-label in the United States and United Kingdom for tinea capitis, and guidelines for therapy with each of these agents have been summarized 2.
- The use of antifungal shampoos is recommended as an adjuvant therapy to decrease the viability of fungal spores present on the hair and to prevent infection or eliminate the carrier state 2.
Treatment Duration and Outcome
- The treatment duration for tinea capitis with itraconazole and terbinafine can be shorter than with griseofulvin, which may improve treatment adherence 4.
- Prolonged duration of treatment is required for complete cure, with cure rates at 8 weeks being higher than at 4 weeks for all groups 5.
- The outcomes between itraconazole and terbinafine were not significantly different when used for 2 to 3 weeks, but itraconazole showed higher cure rates when used for longer treatment durations 4, 5.