What is the treatment for tinea capitis?

Treatment of Tinea Capitis

Oral antifungal therapy is the mainstay of treatment for tinea capitis, with the choice of agent determined by the causative dermatophyte species. 1

Diagnostic Approach

• Collect scalp samples via scrapings, hair pluck, brush or swab for microscopy and culture to confirm infection and identify the causative organism 2
• Microscopy using potassium hydroxide provides rapid preliminary diagnosis 2
• Culture on appropriate medium is essential for species identification and guiding treatment selection 3

First-Line Treatment Options

Griseofulvin

• The only licensed treatment for tinea capitis in children in many countries 1, 2
• Dosing:
  • Children <50 kg: 15-20 mg/kg/day for 6-8 weeks 1
  • Children >50 kg and adults: 1 g/day for 6-8 weeks 1
  • FDA recommends 10 mg/kg/day for pediatric patients, but higher doses (20-25 mg/kg/day) are now recommended due to increasing treatment failures 3, 4
• Most effective against Microsporum species (M. canis, M. audouinii) 1
• Advantages: extensive clinical experience, suspension formulation allows accurate dosing 1
• Disadvantages: prolonged treatment duration affecting compliance 1
• Contraindications: lupus erythematosus, porphyria, severe liver disease 1

Terbinafine

• Weight-based dosing:
  • <20 kg: 62.5 mg/day for 2-4 weeks 1
  • 20-40 kg: 125 mg/day for 2-4 weeks 1

  • 40 kg: 250 mg/day for 2-4 weeks 1

• More effective against Trichophyton species (T. tonsurans, T. violaceum, T. soudanense) 1
• Advantages: shorter treatment duration improving compliance 1, 5
• Less effective for Microsporum infections due to pharmacokinetic limitations in children 1

Second-Line Treatment

Itraconazole

• Dosing: 5 mg/kg/day for 2-4 weeks or 50-100 mg/day for 4 weeks 1
• Effective against both Trichophyton and Microsporum species 1
• Consider as second-line therapy when first-line treatments fail 1

Fluconazole

• Dosing: 6 mg/kg/day for 2-3 weeks 5
• Alternative for refractory cases 1
• Favorable tolerability profile and available in liquid form, making it suitable for younger children 4

Treatment Algorithm

1. Identify causative organism through microscopy and culture 2, 3
2. Select antifungal based on species:
   • For Trichophyton species: terbinafine as first choice 1
   • For Microsporum species: griseofulvin as first choice 1
3. If species identification is not possible, consider local epidemiology to guide treatment 1
4. For treatment failure:
   • Assess compliance, drug absorption, and possibility of reinfection 1
   • If clinical improvement with positive mycology, continue current therapy for 2-4 more weeks 1
   • If no clinical improvement, switch to second-line therapy 1

Adjunctive Measures

• Topical therapy alone is not recommended but can be used as adjunctive treatment 1
• Antifungal shampoos (2% ketoconazole or 1% selenium sulfide) help reduce spore load and transmission 4, 6
• Screen and treat family members and close contacts, especially for T. tonsurans infections 1
• Children receiving appropriate therapy can attend school 1

Monitoring and Follow-up

• Treatment endpoint is mycological cure, not just clinical improvement 1
• Repeat mycology sampling until clearance is achieved 1
• Monitor for treatment side effects, particularly gastrointestinal disturbances 1, 5

Special Considerations

• In adults, the same medications are used but with adult dosing; terbinafine and griseofulvin remain first-line options 7
• Emerging antifungal resistance necessitates appropriate stewardship of antifungal agents 7
• For kerion (inflammatory mass), some experts recommend short-term oral or topical corticosteroids, though this remains controversial 4