What is the best treatment for a 9-year-old boy with scalp fungal infection, hair loss, and scaling, who had temporary improvement with over-the-counter (OTC) terbinafine (antifungal) cream?

Treatment for Tinea Capitis in a 9-Year-Old Boy

Oral griseofulvin is the best treatment for this 9-year-old boy with tinea capitis presenting with hair loss, scaling, broken hairs, pustules, and trunk plaques. 1

Clinical Presentation Analysis

The clinical presentation strongly suggests tinea capitis (fungal infection of the scalp):

• 2 x 1-centimeter area of hair loss
• Scaling and broken hairs
• Pustules
• Nontender occipital lymphadenopathy
• Erythematous, well-demarcated plaques on trunk (suggesting possible tinea corporis as well)
• Previous temporary improvement with OTC terbinafine cream

Treatment Rationale

Why Oral Therapy is Necessary

• Topical therapy alone is not recommended for tinea capitis as it fails to penetrate the hair follicle adequately 1, 2
• Systemic oral therapy is required to achieve both clinical and mycological cure 1
• The temporary improvement with topical terbinafine confirms this principle, as it provided only transient relief without cure

Why Griseofulvin is the First Choice

1. Griseofulvin remains the only licensed product for tinea capitis in children in many countries 1
2. The British Association of Dermatologists guidelines specifically recommend griseofulvin as first-line therapy 1
3. The clinical presentation with pustules and occipital lymphadenopathy suggests a more inflammatory infection, which often responds well to griseofulvin

Dosing and Duration

• Standard dosing: 15-20 mg/kg/day for 6-8 weeks 1, 2
• May need up to 25 mg/kg/day in resistant cases 1
• Taking with fatty food improves absorption and bioavailability 1
• Treatment should continue until mycological cure is achieved, not just clinical improvement 2

Why Not the Other Options?

A. Topical nystatin

• Ineffective for tinea capitis as it does not penetrate the hair follicle 1
• Nystatin is primarily effective against Candida species, not dermatophytes 2

C. Oral amoxicillin/clavulanate

• Antibacterial agents are not effective against fungal infections
• No indication of bacterial superinfection requiring antibiotics

D. Ketoconazole shampoo

• While ketoconazole shampoo can help reduce spore transmission, it is not effective as monotherapy 1
• Should be used as an adjunct to oral therapy, not as the primary treatment 1

Adjunctive Therapy Considerations

• Consider adding ketoconazole 2% shampoo to reduce transmission of spores 1
• Selenium sulfide 1% or povidone-iodine shampoos are also effective adjuncts 1
• Examine and potentially treat household members to prevent reinfection 2

Important Clinical Considerations

• Follow-up is essential to ensure mycological cure 2
• If no improvement is seen after 2-4 weeks, consider:
  1. Confirming diagnosis with fungal culture
  2. Identifying specific dermatophyte species (Trichophyton vs. Microsporum)
  3. Adjusting treatment based on species identification 1, 3

Monitoring and Safety

• Griseofulvin is generally well-tolerated in children
• Side effects include gastrointestinal disturbances and rashes in <8% of patients 1
• Very few patients (0.8%) require discontinuation due to side effects 1
• Contraindications include lupus erythematosus, porphyria, and severe liver disease 1