What is the recommended treatment for tinea capitis in a child?

Treatment of Tinea Capitis in Children

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

Diagnosis and Initial Assessment

• Treatment can be initiated while awaiting confirmatory mycology if clinical signs are present:

  • Scale
  • Lymphadenopathy
  • Alopecia
  • Kerion (inflammatory mass) 2, 1

• Obtain scalp samples via:

  • Scalpel scraping
  • Hair pluck
  • Brush or swab
  • Process all specimens for microscopy and culture to identify the causative organism 2, 1

Treatment Algorithm

First-line Treatment

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

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

     • 40 kg: 250 mg daily 2, 1

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

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

     • 50 kg: 1 g/day (single or divided dose) 2, 1, 3

3. When causative organism is unknown:

   • Begin with griseofulvin as it has broader coverage and a long track record of safety in children 2, 4, 5

Second-line Treatment (for treatment failures)

• Itraconazole: 5 mg/kg/day for 4 weeks (effective against both Trichophyton and Microsporum species) 2, 1

• Fluconazole: Can be considered, especially in younger children who may benefit from the liquid formulation 6

Important Clinical Considerations

Treatment Duration and Follow-up

• Continue treatment until mycological cure is achieved 1, 3
• Clinical improvement is typically expected within 1-2 weeks 1
• For Microsporum infections treated with griseofulvin, a full 6-8 weeks of treatment is necessary 2, 3
• Recent evidence shows that griseofulvin remains effective for Microsporum species infections even in cases where terbinafine and itraconazole have failed 7

Adjunctive Therapy

• Topical therapy alone is not effective for tinea capitis; oral therapy is required 2, 1
• Sporicidal shampoos (e.g., selenium sulfide) can help remove scales and reduce spore viability, potentially decreasing spread 6

Prevention of Spread and Recurrence

• Screen and treat all infected family members simultaneously 1
• Avoid sharing personal items such as combs, brushes, and hats 1
• Apply antifungal powders to prevent reinfection 1

Special Considerations

• Safety profile: Griseofulvin has the longest track record of safety in children and is FDA-approved specifically for tinea capitis in pediatric patients 3, 4

• Common side effects:

  • Griseofulvin: Gastrointestinal disturbances and rashes in <8% of patients 2
  • Terbinafine: Generally well-tolerated with occasional gastrointestinal and dermatological events 1

• Treatment failures: Consider:

  • Lack of compliance
  • Suboptimal absorption
  • Relative insensitivity of the organism
  • Reinfection 2

• For recalcitrant cases: If terbinafine or itraconazole fails in Microsporum infections, switching to griseofulvin often leads to successful outcomes 7