What is the treatment for scalp skin infections?

Treatment of Scalp Skin Infections

The treatment of scalp skin infections depends entirely on the causative organism—bacterial infections require systemic antibiotics targeting Gram-positive organisms (particularly Staphylococcus and Streptococcus), fungal infections (tinea capitis) require systemic antifungal therapy, and abscesses require incision and drainage as primary treatment.

Initial Diagnostic Approach

The first critical step is identifying the type of infection based on clinical presentation:

• Bacterial infections present with purulent drainage, crusting, erythema, warmth, and tenderness 1
• Fungal infections (tinea capitis) present with scaling, hair loss (alopecia), and broken-off hairs at the scalp surface 2, 3, 4
• Seborrheic dermatitis presents with yellowish greasy scales and is related to Malassezia species overgrowth 5
• Abscesses present as fluctuant, localized collections requiring drainage 1

Culture specimens before initiating therapy when possible to guide antibiotic selection and identify resistance patterns 1.

Bacterial Scalp Infections

Mild Superficial Infections (Impetigo, Folliculitis)

For localized bacterial infections without systemic signs:

• First-line therapy: Oral antibiotics targeting Gram-positive organisms, particularly beta-hemolytic Streptococcus and Staphylococcus aureus 1
• Consider MRSA coverage if the patient is at risk (prior MRSA infection, IV drug use, failure of initial therapy, or high local MRSA prevalence) 1, 6
• MRSA-directed options: Trimethoprim-sulfamethoxazole 160-800 mg twice daily or clindamycin 6

Moderate to Severe Infections with Systemic Signs

When fever, elevated heart rate, or signs of deeper infection are present:

• Empiric broad-spectrum IV therapy: Vancomycin 15-20 mg/kg IV every 8-12 hours PLUS either piperacillin-tazobactam, a carbapenem, or ceftriaxone plus metronidazole 6
• Duration: 7-14 days based on clinical response 6
• Reassess within 48-72 hours to evaluate response and consider switching to oral therapy once improving 6

Special Consideration: Gonococcal Scalp Abscesses in Newborns

This rare complication results from fetal scalp electrode monitoring:

• Treatment: Ceftriaxone 25-50 mg/kg/day IV or IM daily for 7 days 1
• If meningitis documented: Extend duration to 10-14 days 1
• Alternative: Cefotaxime 25 mg/kg IV or IM every 12 hours for same duration 1
• Workup required: Blood, CSF, and joint aspirate cultures on chocolate agar 1

Fungal Scalp Infections (Tinea Capitis)

Systemic antifungal therapy is mandatory—topical therapy alone is inadequate for tinea capitis 2:

• Systemic treatment required because the infection involves hair follicles that topical agents cannot adequately penetrate 2, 3, 4
• Topical adjunctive therapy may be added to systemic treatment to reduce spore shedding 2
• Treatment duration is typically prolonged (weeks to months) 2

The evidence provided does not specify exact antifungal regimens, but the principle of systemic therapy is clearly established 2.

Scalp Abscesses

Incision and drainage is the primary and essential treatment:

• Drainage alone is sufficient for simple, well-localized abscesses without systemic signs 1, 6
• Antibiotics are NOT recommended for simple abscesses after adequate drainage 1
• Add antibiotics when: Systemic signs present, immunocompromised host, severe surrounding cellulitis, or inability to achieve complete drainage 1
• Multiple counter-incisions are preferred over single long incisions to prevent step-off deformities and promote healing 1

High-Risk Populations (IV Drug Users)

For scalp abscesses in IV drug users, special considerations apply:

• Higher MRSA risk necessitates empiric MRSA coverage 6
• Consider polymicrobial infection including anaerobes 6
• Evaluate for complications: Endocarditis, septic thrombophlebitis, osteomyelitis 6
• Rule out foreign bodies with radiography 1
• Screen for viral infections: HIV, HCV, HBV 1
• Broad-spectrum coverage: Vancomycin plus piperacillin-tazobactam or carbapenem 6

Viral Infections (Herpes Zoster of Scalp)

For immunocompromised patients with suspected or confirmed HSV or VZV scalp infection:

• High-dose IV acyclovir is the treatment of choice 1
• Oral antivirals (acyclovir, famciclovir, valacyclovir) may be used for mild cases or to complete therapy after IV treatment 1
• Prophylaxis with oral acyclovir or valacyclovir during periods of maximum immunosuppression 1

Critical Pitfalls to Avoid

• Never rely on topical antibiotics alone for bacterial scalp infections—systemic therapy is required 1
• Never use topical therapy alone for tinea capitis—systemic antifungals are mandatory 2
• Never prescribe antibiotics for simple abscesses—drainage is the definitive treatment 1
• Never miss MRSA coverage in high-risk patients (IV drug users, prior MRSA, treatment failure) 6
• Never delay surgical consultation when necrotizing infection is suspected 6
• Never forget to culture before starting antibiotics when feasible 1