What is the first line treatment for Tinea capitis?

First-Line Treatment for Tinea Capitis

The first-line treatment for tinea capitis depends on the causative organism: terbinafine is preferred for Trichophyton species infections, while griseofulvin is preferred for Microsporum species infections. 1

Diagnostic Confirmation Required Before Treatment

• Collect scalp samples via scrapings, hair pluck, brush, or swab for microscopy and culture to confirm infection and identify the causative organism before initiating therapy. 1
• Potassium hydroxide microscopy provides rapid preliminary diagnosis while awaiting culture results. 1

First-Line Treatment Options

Terbinafine (Preferred for Trichophyton species)

• Weight-based dosing for 2-4 weeks: 1
  • Children <20 kg: 62.5 mg/day
  • Children 20-40 kg: 125 mg/day
  • Children >40 kg and adults: 250 mg/day
• Terbinafine is particularly effective against T. tonsurans, the most common pathogen in North America. 2, 3
• Offers the advantage of shorter treatment duration (2-4 weeks) compared to griseofulvin. 1, 4

Griseofulvin (Preferred for Microsporum species; only licensed option in many countries)

• Dosing for 6-8 weeks: 1, 5
  • Children <50 kg: 15-20 mg/kg/day (higher end of range recommended due to increasing treatment failures at lower doses) 1, 3
  • Children >50 kg and adults: 1 g/day
• Griseofulvin remains the only FDA-approved and licensed treatment for tinea capitis in children in many countries. 1, 6
• Common pitfall: Using inadequate dosing (10 mg/kg/day) leads to treatment failures; current recommendations favor 20-25 mg/kg/day. 3

Treatment Algorithm Based on Organism

• If Trichophyton species identified: Use terbinafine as first choice. 1
• If Microsporum species identified: Use griseofulvin as first choice. 1
• If organism unknown pending culture: Consider starting empiric therapy based on local epidemiology (T. tonsurans predominates in North America; M. canis more common in Europe). 4, 7

Second-Line Options for Treatment Failures or Refractory Cases

• Itraconazole: 5 mg/kg/day for 2-4 weeks, effective against both Trichophyton and Microsporum species. 1
• Fluconazole: Alternative for refractory cases with favorable tolerability profile and liquid formulation available for younger children. 1, 3

Essential Adjunctive Measures

• Topical sporicidal shampoos (selenium sulfide or ketoconazole) should be used as adjunctive therapy to reduce spore transmission. 1, 3, 4
• Screen and treat all family members and close contacts, especially for anthropophilic species like T. tonsurans, as over 50% of household members may be affected. 1, 2
• Clean all fomites (hairbrushes, combs, towels) with disinfectant or 2% sodium hypochlorite solution. 2

Critical Monitoring Points

• Treatment endpoint is mycological cure, not just clinical improvement. 1
• Repeat mycology sampling until clearance is documented to prevent relapse. 1, 2
• Common pitfall: Discontinuing treatment when hair regrows or symptoms improve clinically, before achieving mycological cure, leads to relapse. 5
• Monitor for treatment side effects, though liver enzyme monitoring is generally unnecessary for treatment courses ≤4 weeks. 3

Special Considerations for Inflammatory Presentations (Kerion)

• Consider short burst of oral or topical corticosteroids for severe kerion presentations to reduce inflammation and prevent scarring alopecia, though evidence is mixed. 3
• Systemic antifungal therapy remains the primary treatment even in inflammatory cases. 3