What is the treatment for Tinea capitis?

Treatment of Tinea Capitis

Oral antifungal therapy is essential for the treatment of tinea capitis, with the choice of agent determined by the causative dermatophyte species. 1

First-Line Treatment Options

Causative Organism Identification

• Laboratory diagnosis via scalpel scraping, hair pluck, brush, or swab is recommended
• All specimens should be processed for microscopy and culture 1
• Treatment can be initiated while awaiting confirmatory mycology if clinical signs (scale, lymphadenopathy, alopecia) or kerion are present 1

Systemic Therapy Selection

1. For Trichophyton species infections (T. tonsurans, T. violaceum, T. soudanense):

   • Terbinafine is the preferred treatment 1
   • Dosing by weight:
     • < 20 kg: 62.5 mg daily for 2-4 weeks
     • 20-40 kg: 125 mg daily for 2-4 weeks

     • 40 kg: 250 mg daily for 2-4 weeks

2. For Microsporum species infections (M. canis, M. audouinii):

   • Griseofulvin is more effective 1, 2
   • Dosing by weight:
     • < 50 kg: 15-20 mg/kg/day (single or divided dose) for 6-8 weeks

     • 50 kg: 1 g daily (single or divided dose) for 6-8 weeks

Important Treatment Principles

• Topical therapy alone is not recommended as it does not penetrate the hair follicle 1, 2
• Medication must be continued until the infecting organism is completely eradicated 3
• The goal of treatment should be mycological cure, not just clinical improvement 4

Adjunctive Measures

• Sporicidal shampoos (selenium sulfide 1-2%) help remove scales and reduce spore viability 4, 5
• Children receiving appropriate therapy can attend school or nursery 1
• Screen family members and close contacts for T. tonsurans infections and treat positive cases 1
• Asymptomatic carriers with high spore load generally warrant systemic treatment 1

Second-Line Treatment

If treatment failure occurs (consider compliance issues, suboptimal absorption, organism insensitivity, or reinfection):

• Itraconazole: 50-100 mg daily for 4 weeks, or 5 mg/kg/day for 2-4 weeks 1

  • Effective against both Trichophyton and Microsporum species
  • Weight-adapted dosing (50 mg daily for < 20 kg; 100 mg daily for ≥ 20 kg) 6

• Fluconazole: Can be considered as an alternative, especially for younger children who cannot take tablets 5

Monitoring and Follow-up

• Repeat mycology sampling until mycological clearance is achieved 1, 4
• Clinical improvement should be seen within 1-2 weeks 4
• Complete resolution typically takes 2-4 weeks 4

Pitfalls and Caveats

• Terbinafine is less effective against Microsporum species as it cannot be incorporated into the hair shaft in prepubertal children 1
• Griseofulvin requires longer treatment duration (6-8 weeks), which may affect compliance 1, 5
• Treatment failure can result from inadequate duration, misdiagnosis, or concurrent steroid use 4
• Some antifungals (terbinafine, itraconazole, fluconazole) are used off-label in some countries 7
• Monitoring for liver enzyme elevations is generally unnecessary if therapy is limited to ≤4 weeks 5