What is the treatment for fungal scalp infection?

Treatment for Fungal Scalp Infection

For fungal scalp infections (tinea capitis), oral antifungal therapy is required with the choice of medication determined by the causative organism - terbinafine is recommended for Trichophyton species infections (2-4 weeks) while griseofulvin is recommended for Microsporum species infections (6-8 weeks). 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Scalp scraping, hair pluck, brush or swab samples should be collected
• All specimens should be processed for microscopy and culture
• Identification of the causative organism guides treatment selection

Treatment Algorithm

First-Line Therapy

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

   • Terbinafine (oral) for 2-4 weeks:
     • <20 kg: 62.5 mg daily
     • 20-40 kg: 125 mg daily

     • 40 kg: 250 mg daily

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

   • Griseofulvin (oral) for 6-8 weeks:
     • <50 kg: 15-20 mg/kg/day (single or divided dose)

     • 50 kg: 1 g daily (single or divided dose)

Adjunctive Therapy

• Antifungal shampoo (2-3 times weekly) to reduce spore shedding and prevent transmission:
  • Ketoconazole 2% shampoo
  • Selenium sulfide 1% shampoo
  • Povidone-iodine shampoo

Second-Line Therapy (for treatment failures)

If treatment fails after 2-4 weeks, consider:

1. Itraconazole: Safe and effective against both Trichophyton and Microsporum species 1
2. Fluconazole: Alternative option for resistant cases 2

Management of Treatment Failure

When initial treatment fails, consider:

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

If there is clinical improvement but persistent positive mycology, continue current therapy for an additional 2-4 weeks. If no clinical improvement occurs, switch to second-line therapy 1.

Special Considerations

• Kerion (inflammatory tinea capitis): Begin treatment immediately while awaiting confirmatory mycology 1
• Immunocompromised patients: May require longer treatment duration and closer follow-up 2
• Drug interactions: Azole antifungals have significant drug interactions that should be evaluated before prescribing 2

Prevention of Recurrence

• Prophylactic antifungal shampoo (ketoconazole 2%) used once weekly can significantly reduce recurrence rates 3, 4
• Examine and potentially treat family members to prevent reinfection
• Wash bedding, towels, and headwear in hot water
• Avoid sharing combs, brushes, hats, or other hair accessories

Follow-up

• Assess clinical response within 3-5 weeks of treatment initiation
• Continue treatment until clinical and mycological cure is achieved
• Monitor for side effects, particularly with prolonged treatment

Important Caveats

• Topical therapy alone is not recommended for tinea capitis and will not achieve cure 1
• Treatment duration must be adequate to prevent relapse
• The causative organism significantly impacts treatment choice and duration
• Terbinafine is more effective for Trichophyton while griseofulvin is more effective for Microsporum infections 1