When can a patient return to school after starting treatment for tinea capitis (ringworm of the scalp)?

School Attendance for Children with Tinea Capitis

Children with tinea capitis can return to school immediately after starting appropriate systemic and adjunctive topical therapy, as exclusion from school is considered impractical by most experts. 1

Treatment Protocol Before School Return

1. Systemic Antifungal Therapy (must be initiated):

   • First-line options based on causative organism:
     • For Trichophyton species: Terbinafine for 2-4 weeks
       • <20 kg: 62.5 mg daily
       • 20-40 kg: 125 mg daily

       • 40 kg: 250 mg daily

     • For Microsporum species: Griseofulvin for 6-8 weeks
       • <50 kg: 15-20 mg/kg/day

       • 50 kg: 1 g daily 1, 2

2. Adjunctive Topical Therapy:

   • Antifungal shampoo (selenium sulfide or ketoconazole) 2-3 times weekly
   • Helps reduce spore shedding and decrease risk of transmission 1, 3

Additional Infection Control Measures

• Family Screening: All household members should be screened and treated if positive, especially for T. tonsurans infections (>50% of family members may be affected) 1
• Fomite Cleaning: Disinfect hairbrushes, combs, and other personal items with bleach or 2% sodium hypochlorite solution 1
• Personal Items: Avoid sharing hats, pillows, combs, and brushes 4

Follow-Up Protocol

• The definitive endpoint for treatment is mycological cure, not just clinical improvement 1
• Follow-up with repeat mycology sampling is recommended:
  • At the end of standard treatment period
  • Monthly thereafter until mycological clearance is documented 1

Important Considerations

• Treatment Compliance: Ensure patients understand the importance of completing the full course of treatment even if symptoms improve 2, 3
• Treatment Failure: Consider lack of compliance, suboptimal drug absorption, organism insensitivity, or reinfection if treatment fails 1
• Second-line Therapy: If first-line treatment fails, consider itraconazole (50-100 mg daily for 4 weeks or 5 mg/kg/day for 2-4 weeks) 1, 4

Common Pitfalls to Avoid

• Premature Discontinuation: Stopping treatment based on clinical improvement alone rather than mycological cure 1
• Inadequate Family Treatment: Failing to screen and treat family members, leading to reinfection 1
• School Exclusion: Unnecessarily keeping children out of school, which disrupts education and is not recommended by experts 1
• Inadequate Follow-up: Not confirming mycological cure through appropriate testing 1

While some authorities have recommended school exclusion due to potential transmission risk, the British Association of Dermatologists' guidelines clearly state that children receiving appropriate systemic and adjunctive topical therapy should be allowed to attend school or nursery 1. This approach balances infection control with the child's educational needs.