What is the diagnosis and treatment for tinea capitis (ringworm of the scalp)?

From the Guidelines

Tinea capitis should be treated with oral antifungal medication, with griseofulvin and terbinafine being the most widely used first-line treatments, as recommended by the British Association of Dermatologists' guidelines 1. The choice of systemic therapy should be directed by the causative dermatophyte and/or local epidemiology 1.

• Griseofulvin is more effective against Microsporum species, while terbinafine is more efficacious against Trichophyton species 1.
• The dosage of griseofulvin is 15-20 mg/kg/day for children weighing less than 50 kg, and 1 g/day for children weighing more than 50 kg, for 6-8 weeks 1.
• The dosage of terbinafine is 625 mg/day for children weighing less than 20 kg, 125 mg/day for children weighing 20-40 kg, and 250 mg/day for children weighing more than 40 kg, for 2-4 weeks 1. In cases of treatment failure, it is essential to consider lack of compliance, suboptimal absorption of the drug, relative insensitivity of the organism, and reinfection 1.
• Second-line therapy includes itraconazole, which is safe and effective against both Trichophyton and Microsporum species 1. Additional measures, such as using antifungal shampoo and screening family members, are also crucial in managing tinea capitis 1.
• Children receiving appropriate therapy should be allowed to attend school or nursery, and asymptomatic carriers with a high spore load may require systemic treatment 1. The end point of treatment is mycological rather than clinical cure, and repeat mycology sampling is recommended until mycological clearance is achieved 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Representative treatment periods are tinea capitis, 4 to 6 weeks; The recommended treatment period for tinea capitis with griseofulvin is 4 to 6 weeks 2.

• The treatment should be continued until the infecting organism is completely eradicated.
• Medication must be continued until the infecting organism is completely eradicated as indicated by appropriate clinical or laboratory examination.

From the Research

Definition and Causes of Tinea Capitis

• Tinea capitis is a dermatophyte infection involving the hair shaft on the scalp, primarily affecting preadolescent children 3.
• The predominant pathogen varies according to geographical location, with Trichophyton tonsurans and Microsporum canis being the most common causes in North America and certain parts of Europe 3, 4.

Treatment Options

• The current standard of care for the treatment of tinea capitis is oral griseofulvin, which remains the only medication approved by the US FDA for this condition 3, 4.
• Newer oral antifungal agents, such as terbinafine, itraconazole, and fluconazole, have been shown to be effective, safe, and have the advantage of a shorter treatment duration 3, 5, 6, 4, 7.
• Adjuvant topical therapy with 2% ketoconazole or 1% selenium sulfide shampoos is often recommended to reduce surface colony counts of dermatophytes 3, 4, 7.

Efficacy and Safety of Treatment Options

• Griseofulvin has been shown to have a high cure rate, with 92.0% of patients achieving effective treatment in one study 6.
• Terbinafine, itraconazole, and fluconazole have also been shown to be effective, with cure rates ranging from 84.0% to 96.0% in various studies 5, 6.
• The safety profiles of these agents have been shown to be favorable, with few adverse effects reported 6, 7.

Guidelines for Therapy

• Griseofulvin is currently considered the drug of choice for tinea capitis, but terbinafine, itraconazole, and fluconazole may be used as alternative treatments, especially in patients who have failed griseofulvin or developed adverse reactions 7.
• Guidelines for therapy with each of these agents have been summarized, and families should be informed that these alternative agents are not FDA-approved for this indication 7.