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

From the Guidelines

Tinea capitis is best treated with oral antifungal medications, with terbinafine and griseofulvin 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, with terbinafine being more efficacious against Trichophyton species and griseofulvin more effective against Microsporum species 1. Some key points to consider when treating tinea capitis include:

• Topical therapy alone is not recommended for the treatment of tinea capitis, as it is insufficient to achieve both clinical and mycological cure 1.
• The dose of terbinafine and griseofulvin should be based on the patient's weight, with terbinafine dosing as follows: 625 mg per day for 2-4 weeks for children under 20 kg, 125 mg per day for 2-4 weeks for children 20-40 kg, and 250 mg per day for 2-4 weeks for those over 40 kg, and griseofulvin dosing as follows: 15-20 mg kg−1 per day for 6-8 weeks for children under 50 kg and 1 g per day for 6-8 weeks for those over 50 kg 1.
• Treatment failure should be initially considered due to lack of compliance, suboptimal absorption of the drug, relative insensitivity of the organism, and reinfection, and second-line therapy with itraconazole may be necessary 1.
• Children receiving appropriate therapy should be allowed to attend school or nursery, and index cases due to T. tonsurans warrant screening of all family members and close contacts and treatment for those positive cases 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Representative treatment periods are tinea capitis, 4 to 6 weeks; Medication must be continued until the infecting organism is completely eradicated as indicated by appropriate clinical or laboratory examination. Pediatric patients (older than 2 years): A dosage of 10 mg/kg daily is usually adequate

The treatment for tinea capitis with Griseofulvin (PO) typically lasts for 4 to 6 weeks. The dosage for pediatric patients (older than 2 years) is 10 mg/kg daily, while for adults it is 0.5 g daily. It is essential to continue the medication until the infecting organism is completely eradicated, as indicated by clinical or laboratory examination 2.

• The dosage should be individualized for each patient.
• Concomitant use of appropriate topical agents may be required.
• General measures in regard to hygiene should be observed to control sources of infection or reinfection.

From the Research

Tinea Capitis Treatment Options

• The current standard of care for the treatment of tinea capitis in the USA is oral griseofulvin, but evidence is accumulating that some of the newer antifungal agents may also be useful 3.
• Newer oral antifungal agents such as terbinafine, itraconazole, and fluconazole seem to be effective, safe, and have the advantage of a shorter treatment duration 3.
• Both 2% ketoconazole and 1% selenium sulfide shampoos are often recommended as adjuvant topical therapy 3.

Efficacy of Griseofulvin

• A meta-analysis of clinical trials of griseofulvin use in tinea capitis found that the overall mean effective cure rate was 73.4% +/- 7% 4.
• Higher efficacy rates appeared to be reported with the use of higher dosages of griseofulvin (> 18 mg/kg/d) 4.
• Griseofulvin remains an effective therapy for tinea capitis, with good efficacy against both Trichophyton and Microsporum species 4.

Comparison of Treatment Options

• A randomized comparison of 4 weeks of terbinafine vs. 8 weeks of griseofulvin for the treatment of tinea capitis found that there were no statistically significant differences between the two drugs in terms of overall outcome or tolerability 5.
• Terbinafine and griseofulvin have similar efficacy and safety profiles, with terbinafine requiring a shorter treatment duration 6, 5.
• The predictive value of symptoms for diagnosis of tinea capitis and the rate and timing of cure with high-dose griseofulvin treatment have been studied, with oral griseofulvin at 20 to 25 mg/kg/day with adjunctive shampooing for 6 weeks being moderately successful as treatment 7.