What is the treatment for a 10-year-old with a fungal (fungus) infection of the skin and scalp?

Treatment of Fungal Infections of the Skin and Scalp in a 10-Year-Old Child

The treatment for a 10-year-old with fungal infections of the skin and scalp requires systemic antifungal therapy, with terbinafine being the first-line treatment for dermatophyte infections, dosed according to weight (62.5 mg daily if <20 kg, 125 mg daily for 20-40 kg, and 250 mg daily if >40 kg). 1

Diagnostic Approach

• Confirm the diagnosis through laboratory testing before initiating treatment, including skin scrapings, hair plucking, or scalp brushings for microscopy and culture 1
• Wood's lamp examination may help identify certain fungal species, particularly Microsporum canis which shows fluorescence 1
• Dermoscopy can be a useful adjunctive tool in diagnosing tinea capitis, showing characteristic findings like "comma-shaped" hairs in white children or corkscrew hairs in Afro-Caribbean children 1

Systemic Treatment Options for Tinea Capitis

• First-line therapy: Terbinafine

  • Dosage based on weight: 62.5 mg daily if <20 kg, 125 mg daily for 20-40 kg, 250 mg daily if >40 kg 1
  • Duration: 6 weeks for fingernail infection, 12 weeks for toenail infection 1
  • Particularly effective against Trichophyton species 2

• Alternative options:

  • Itraconazole: 5 mg/kg/day for 1 week per month (pulse therapy) for 2 months (fingernails) or 3 months (toenails) 1
  • Fluconazole: 3-6 mg/kg once weekly for 12-16 weeks (fingernails) or 18-26 weeks (toenails) 1
  • Griseofulvin: No longer first-line due to longer treatment duration and lower efficacy 1, 2

Treatment Considerations Based on Fungal Species

• For Trichophyton species infections: Terbinafine, itraconazole, and fluconazole show similar efficacy to traditional griseofulvin but with shorter treatment durations 2
• For Microsporum infections: Evidence is limited, but griseofulvin may be more effective than newer antifungals 2
• For Candida infections: Azole drugs are generally preferred over allylamines 3

Topical Therapy

• Topical antifungals alone are generally insufficient for tinea capitis but may be used as adjunctive therapy 4, 5
• Topical therapy is appropriate for limited cutaneous fungal infections without scalp or nail involvement 3, 6
• Options include:
  • Allylamines (terbinafine, naftifine): Fungicidal, requiring shorter treatment courses 4, 3
  • Azoles (miconazole, clotrimazole, ketoconazole): Fungistatic, may require longer treatment 3

Duration of Treatment

• Treatment should continue until both clinical and mycological cure is achieved 1, 7
• Post-treatment samples should be sent to ensure clearance 1
• Shorter treatment durations with newer antifungals may improve treatment adherence compared to traditional griseofulvin 2

Additional Measures

• Examine family members for concomitant infections, particularly parents and siblings 1
• Clean contaminated combs and brushes properly to prevent reinfection 7
• Be aware that inflammatory reactions may occur at the beginning of effective therapy, which should not be confused with drug reactions 1

Special Considerations

• Children with tinea capitis should be examined for concomitant tinea pedis 1
• Topical therapy alone is insufficient for tinea capitis due to the need to penetrate the hair follicle 2, 3
• Systemic therapy has a reasonable safety profile in children when properly dosed 2