What is the recommended treatment for Tinea (ringworm of the scalp) capitis in children?

Treatment of Tinea Capitis in Children

Oral antifungal therapy is required for tinea capitis in children, with the choice of medication determined by the causative dermatophyte species, with griseofulvin being the first-line treatment for Microsporum species and terbinafine for Trichophyton species. 1

Diagnosis

• Laboratory diagnosis should be obtained via scalp lesions sampling through scalpel scraping, hair pluck, brush, or swab, with specimens processed for microscopy and culture 1
• Treatment can be initiated while awaiting confirmatory mycology if a kerion is present or when cardinal clinical signs (scale, lymphadenopathy, alopecia) are evident 1

First-Line Treatment

Griseofulvin

• Remains the only licensed treatment for tinea capitis in children in the UK 1
• Dosing by body weight:
  • <50 kg: 15-20 mg/kg/day (single or divided dose) for 6-8 weeks 1

  • 50 kg: 1 g/day (single or divided dose) for 6-8 weeks 1

• FDA recommends 10 mg/kg daily for pediatric patients (>2 years) 2
• More effective against Microsporum species (88.5% response rate) 1
• May require higher doses (20-25 mg/kg/day) for 8 weeks due to increasing treatment failures 3

Terbinafine

• More effective against Trichophyton species (T. tonsurans, T. violaceum, T. soudanense) 1
• Requires shorter treatment course (2-4 weeks), which may increase compliance 1
• Dosing by body weight:
  • <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

• Less effective against Microsporum species (67.9% response rate) 1

Second-Line Treatment

Itraconazole

• Safe and effective with activity against both Trichophyton and Microsporum species 1
• Dosing: 50-100 mg/day for 4 weeks, or 5 mg/kg/day for 2-4 weeks 1
• Superior to conventional treatment in griseofulvin-resistant Microsporum canis cases 4

Treatment Selection Algorithm

1. Identify causative organism through laboratory diagnosis 1
2. For Trichophyton species (especially T. tonsurans):
   • First choice: Terbinafine (dosage based on weight) for 2-4 weeks 1, 5
   • Alternative: Griseofulvin for 6-8 weeks if terbinafine is contraindicated 1
3. For Microsporum species (M. canis, M. audouinii):
   • First choice: Griseofulvin for 6-8 weeks 1, 6
   • Alternative: Itraconazole if griseofulvin fails 4
4. For unknown species or while awaiting culture results:
   • Start with griseofulvin as it has broader coverage 6

Treatment Failure Management

• Consider lack of compliance, suboptimal absorption, organism insensitivity, or reinfection 1
• If clinical improvement but ongoing positive mycology: continue current therapy for 2-4 more weeks 1
• If no clinical improvement: switch to second-line therapy 1
• For griseofulvin failure with Trichophyton: switch to terbinafine 1
• For terbinafine failure with Microsporum: switch to griseofulvin 1

Additional Measures

• Children receiving appropriate therapy can attend school or nursery 1
• Screen family members and close contacts for T. tonsurans cases and treat positive cases 1
• Clean contaminated combs and brushes with disinfectant 7
• Topical antifungal shampoos (e.g., selenium sulfide) may be used as adjunctive therapy to reduce spore burden 3

Monitoring and Follow-up

• Follow-up should include both clinical and mycological assessment until clearance is documented 7
• Mycological cure is the definitive endpoint for treatment, not just clinical response 7
• Treatment must continue until the infecting organism is completely eradicated 2

Important Considerations

• Topical therapy alone is not recommended for tinea capitis; oral therapy is required for clinical and mycological cure 1
• The long treatment course required for griseofulvin may affect compliance 1, 3
• Griseofulvin has the longest track record of safety in children 8
• Terbinafine appears well tolerated in children with side effects (gastrointestinal disturbances, rashes) in <8% of cases 1