What is the treatment for tinea capitis?

Treatment of Tinea Capitis

Oral griseofulvin 15-20 mg/kg/day for 6-8 weeks is the first-line treatment for tinea capitis, though terbinafine offers a shorter 2-4 week course and is superior for Trichophyton species infections. 1

Mandatory Oral Therapy

• Topical therapy alone is completely ineffective for tinea capitis and should never be used as monotherapy. 1, 2
• Oral antifungal therapy is absolutely required because the infection involves the hair shaft, which topical agents cannot adequately penetrate. 1

First-Line Treatment Selection Based on Organism

For Microsporum Species (M. canis, M. audouinii, M. gypseum)

• Griseofulvin is the preferred agent with an 88.5% response rate. 2
• Dosing: 1, 2
  • <50 kg: 15-20 mg/kg/day for 6-8 weeks
  • >50 kg: 1 g/day for 6-8 weeks
• Can be given as a single daily dose or divided doses. 3
• Griseofulvin is the only licensed treatment for tinea capitis in children in the UK. 2

For Trichophyton Species (T. tonsurans, T. violaceum, T. soudanense)

• Terbinafine is more effective than griseofulvin for these organisms and requires a shorter treatment duration. 1, 2
• Dosing for 2-4 weeks: 1, 2
  • <20 kg: 62.5 mg/day
  • 20-40 kg: 125 mg/day
  • >40 kg: 250 mg/day
• Terbinafine has only a 67.9% response rate against Microsporum species and should be avoided for these infections. 2

Critical Diagnostic Step

• Obtain specimens via scalp scraping, hair pluck, brush, or swab for microscopy and culture before initiating treatment. 1, 2
• Treatment can be started empirically if a kerion is present or cardinal signs (scale, lymphadenopathy, alopecia) are evident while awaiting culture results. 2
• Organism identification is essential because treatment efficacy is highly species-dependent. 1, 2

Second-Line Treatment Options

Itraconazole

• Effective against both Trichophyton and Microsporum species. 2
• Dosing: 50-100 mg/day or 5 mg/kg/day for 2-4 weeks. 2
• Licensed only for children over 12 years in the UK, though used off-label in younger children. 4
• Important drug interactions: Enhanced toxicity with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin. 4

Fluconazole

• Third-line option with limited comparative efficacy data. 4
• Not licensed for tinea in children under 10 years in the UK. 4
• Less cost-effective than terbinafine. 4

Treatment Failure Management Algorithm

Step 1: Assess the following factors: 1, 2

• Medication compliance
• Drug absorption issues
• Organism sensitivity
• Potential reinfection from household contacts or fomites

Step 2: If clinical improvement but positive mycology: 1, 2

• Continue current therapy for an additional 2-4 weeks

Step 3: If no clinical improvement: 1, 2

• For griseofulvin failure with Trichophyton: Switch to terbinafine
• For terbinafine failure with Microsporum: Switch to griseofulvin
• Consider itraconazole as a second-line alternative for either organism

Essential Adjunctive Measures

Household Contact Management

• Screen and treat all family members for anthropophilic species like T. tonsurans, as over 50% of household contacts may be carriers. 1, 2
• This is critical to prevent reinfection cycles. 1

Environmental Decontamination

• Clean all fomites (hairbrushes, combs, towels, hats) with disinfectant or 2% sodium hypochlorite solution. 1, 4

School Attendance

• Children receiving appropriate oral antifungal therapy should be allowed to attend school or nursery. 1, 2

Monitoring and Treatment Endpoint

• Mycological cure, not just clinical response, is the definitive treatment endpoint. 1, 2
• Follow-up should include repeat mycological sampling until clearance is documented. 1, 2
• Clinical improvement may occur before mycological clearance. 1

Important Contraindications and Caveats

Griseofulvin Contraindications

• Lupus erythematosus, porphyria, and severe liver disease. 1
• The longer treatment course (6-8 weeks) may reduce compliance compared to terbinafine. 2

Terbinafine Limitations

• Relatively ineffective against Microsporum species—avoid for these infections. 1, 2
• Well tolerated in children with side effects (gastrointestinal disturbances, rashes) in <8% of cases. 2

Monitoring

• Liver enzyme monitoring is generally unnecessary if therapy is limited to ≤4 weeks. 5