What is the treatment for tinea capitis (ringworm of the scalp)?

Treatment of Tinea Capitis

Oral griseofulvin at 20-25 mg/kg/day for 6-8 weeks remains the gold standard first-line treatment for tinea capitis in children, though terbinafine offers an effective alternative with shorter treatment duration for Trichophyton species. 1, 2

Diagnostic Confirmation Required Before Treatment

• Always obtain laboratory confirmation through scalp scrapings, hair pluck, brush samples, or swabs for microscopy and culture before initiating therapy 3, 1
• Potassium hydroxide (10-30%) microscopy provides rapid preliminary diagnosis within hours 1
• Culture on Sabouraud agar identifies the specific dermatophyte species, which is critical for selecting optimal antifungal therapy 1
• Wood's lamp examination can identify Microsporum canis infections through fluorescence, allowing targeted hair plucking for specimens 3

First-Line Systemic Treatment Options

Griseofulvin (Licensed Treatment)

• Dosing for children: 20-25 mg/kg/day for 6-8 weeks (higher than older recommendations due to increased treatment failures) 1, 4
• FDA-approved dosing: 10 mg/kg/day, though clinical guidelines recommend higher doses 5
• Adults: 500 mg daily, may increase to 750 mg-1 g/day for extensive infections 5
• Preferred for Microsporum species infections 2
• Requires longer treatment duration (6-8 weeks) but has decades of safety data 1, 4

Terbinafine (Preferred for Trichophyton)

• Weight-based dosing for 2-4 weeks: 2
  • <20 kg: 62.5 mg/day
  • 20-40 kg: 125 mg/day

  • 40 kg: 250 mg/day

• Preferred first-line for Trichophyton tonsurans and T. violaceum (the most common causative organisms in North America and urban areas) 2, 6
• Advantage: Shorter treatment course (2-4 weeks vs 6-8 weeks) improves compliance 4, 6
• Available in tablet form, best for older children who can swallow pills 4

Second-Line Treatment Options

Itraconazole

• Dosing: 5 mg/kg/day for 2-4 weeks or 50-100 mg/day for 4 weeks 2
• Effective against both Trichophyton and Microsporum species 2
• Reserve for treatment failures or when first-line agents are unavailable 2

Fluconazole

• Favorable for young children due to liquid formulation availability 2, 4
• Excellent tolerability profile 2
• Use for refractory cases or when compliance with other agents is problematic 2, 4

Treatment Algorithm Based on Organism

1. Identify causative organism through culture (treatment endpoint is mycological cure, not just clinical improvement) 2
2. For Trichophyton species: Terbinafine first-line (2-4 weeks) 2
3. For Microsporum species: Griseofulvin first-line (6-8 weeks) 2
4. If organism unknown pending culture: Start griseofulvin empirically as it covers both genera 1

Essential Adjunctive Measures

• Antifungal shampoos (selenium sulfide 1% or ketoconazole 2%) used twice weekly reduce spore shedding and transmission risk 4, 6
• Screen and treat household contacts and close contacts, especially for anthropophilic infections like T. tonsurans 1, 2
• Disinfect fomites: Cleanse combs, brushes, hats, and pillowcases with disinfectant 1
• Avoid sharing personal items to prevent transmission 1

Special Clinical Scenarios

Kerion (Inflammatory Mass)

• Continue systemic antifungal therapy as primary treatment 3
• Consider short course of oral or topical corticosteroids for severe inflammatory response, though evidence is mixed 4
• Do not mistake for bacterial abscess, but rule out secondary bacterial infection 3
• Commonly caused by zoophilic species (T. mentagrophytes, T. verrucosum) but increasingly seen with T. tonsurans 3, 1

"Id" Reaction (Dermatophytid)

• Pruritic papular eruption around ear helix may occur after treatment initiation 3
• Represents cell-mediated immune response to effective therapy 3
• Do not discontinue antifungal therapy 3
• Treat symptomatically with topical corticosteroids if needed 3

Monitoring and Treatment Endpoint

• Treatment endpoint is mycological clearance, not clinical improvement alone 1, 2
• Repeat mycology sampling at end of standard treatment period to document clearance 1, 2
• Continue treatment until mycological cure is confirmed 1, 5
• Clinical relapse occurs if medication stopped before organism eradication 5
• Liver enzyme monitoring generally unnecessary for treatment courses ≤4 weeks 4

Critical Pitfalls to Avoid

• Never use topical antifungals alone—systemic therapy is mandatory for tinea capitis 7
• Do not treat empirically without attempting diagnostic confirmation—organism identification guides optimal drug selection 1, 2
• Do not stop treatment based on clinical improvement alone—mycological cure must be documented 1, 2
• Do not overlook asymptomatic carriers in household—they serve as persistent reservoirs for reinfection 8
• Delayed diagnosis or inadequate treatment can result in permanent scarring alopecia 7