What is the recommended treatment for tinea capitis?

Treatment for Tinea Capitis

The first-line treatment for tinea capitis should be oral antifungal therapy with the choice guided by the causative organism: terbinafine for Trichophyton species infections and griseofulvin for Microsporum species infections. 1, 2

Diagnostic Approach

• Obtain scalp samples via scalpel scraping, hair pluck, brush, or swab
• Process all specimens for microscopy and culture
• Treatment can be initiated while awaiting confirmatory mycology if clinical signs are present (scale, lymphadenopathy, alopecia, or kerion) 1

First-Line Treatment Options

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

• Terbinafine (oral) for 2-4 weeks 1, 2
  • Dosing by weight:
    • < 20 kg: 62.5 mg daily
    • 20-40 kg: 125 mg daily

    • 40 kg: 250 mg daily

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

• Griseofulvin (oral) for 6-8 weeks 1, 2, 3
  • Dosing by weight:
    • < 50 kg: 15-20 mg/kg/day (single or divided doses)

    • 50 kg: 1 g/day (single or divided doses)

Adjunctive Therapy

• Ketoconazole 2% shampoo or selenium sulfide shampoo to reduce spore transmission 2, 4
• Apply 2-3 times weekly during treatment

Second-Line Treatment

• Itraconazole: 5 mg/kg/day for 4 weeks 1, 2
  • Effective against both Trichophyton and Microsporum species
  • Consider when first-line treatment fails

Treatment Considerations

• Duration: Continue treatment until mycological cure is achieved 2, 3
• Follow-up: Clinical improvement expected within 1-2 weeks; mycological cure is the definitive endpoint 2
• Treatment failure: Consider compliance issues, suboptimal absorption, organism insensitivity, or reinfection 1

Important Clinical Pearls

1. Topical therapy alone is not effective for tinea capitis; oral therapy is required 1, 2, 4
2. Medication choice should be guided by the causative organism when possible 1, 2
3. Prevention of reinfection:
   • Screen and treat family members for anthropophilic infections
   • Avoid sharing personal items (combs, brushes, hats)
   • Clean shared items with disinfectant 2

Special Considerations

• Terbinafine is less effective against Microsporum species and may require higher doses or longer treatment periods for Trichophyton infections 1
• Griseofulvin is generally well-tolerated with extensive safety data in children; side effects include gastrointestinal disturbances and rashes in <8% of patients 1, 2
• Terbinafine is generally well-tolerated but can cause gastrointestinal and dermatological side effects; rare serious reactions include Stevens-Johnson syndrome and hepatic toxicity 2

Treatment Algorithm

1. Identify causative organism through mycology when possible
2. Select oral antifungal based on organism:
   • Trichophyton → Terbinafine
   • Microsporum → Griseofulvin
3. Add adjunctive antifungal shampoo
4. Continue treatment until mycological cure
5. If treatment fails after 4-8 weeks, switch to second-line therapy (itraconazole)