What is the treatment for Tinea capitis?

Treatment of Tinea Capitis

Oral antifungal therapy is absolutely required for tinea capitis—topical treatment alone is ineffective and should never be used as monotherapy. 1, 2

Immediate Treatment Initiation

• Start treatment empirically if clinical signs are present (scale, lymphadenopathy, alopecia, or kerion) while awaiting mycological confirmation. 1
• Do not delay therapy waiting for culture results in clinically evident cases. 1

First-Line Oral Antifungal Selection

Your choice depends on the causative organism or local epidemiology:

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

• Terbinafine is superior and preferred 1, 3
  • < 20 kg: 62.5 mg daily for 2-4 weeks 1
  • 20-40 kg: 125 mg daily for 2-4 weeks 1
  • > 40 kg: 250 mg daily for 2-4 weeks 1
• Advantages: Shorter treatment duration improves compliance 1
• Note: Not licensed for tinea capitis in children in the UK, but widely used off-label 1

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

• Griseofulvin is more effective and preferred 1, 3
  • < 50 kg: 15-20 mg/kg/day for 6-8 weeks 1
  • > 50 kg: 1 g/day for 6-8 weeks 1
  • Can be given as single or divided doses 1, 4
• Griseofulvin remains the only licensed treatment for tinea capitis in children in the UK 1
• Take with fatty foods to enhance absorption 1

Alternative First-Line Option:

• Itraconazole has activity against both Trichophyton and Microsporum species 1
  • 50-100 mg daily for 4 weeks, or 5 mg/kg/day for 2-4 weeks 1
  • Licensed only for children > 12 years in the UK 5
  • Critical drug interactions: Enhanced toxicity with warfarin, terfenadine, astemizole, sertindole, midazolam, digoxin, cisapride, ciclosporin, and simvastatin 1, 5

Second-Line Therapy for Treatment Failure

First assess for: non-compliance, suboptimal drug absorption, organism resistance, or reinfection 1

• If clinical improvement but positive mycology: Continue current therapy for additional 2-4 weeks 1
• If no clinical improvement: Switch agents 1
  • If started on terbinafine → switch to griseofulvin for Microsporum or itraconazole 1
  • If started on griseofulvin → switch to terbinafine for Trichophyton 1
  • If started on itraconazole → switch to terbinafine for Trichophyton or griseofulvin for Microsporum 1

Third-Line Options for Refractory Cases

• Fluconazole 6 mg/kg/day for 2-3 weeks 6
  • Consider in exceptional circumstances only 1, 5
  • Not licensed for tinea in children < 10 years in the UK 5
  • Less cost-effective than terbinafine with limited comparative data 5
• Voriconazole may be considered in truly refractory cases 1

Essential Adjunctive Measures

Sporicidal Shampoo:

• Use selenium sulfide or 2% ketoconazole shampoo to reduce spore transmission 7, 8
• Helps remove adherent scales and decrease spread 7

Contact Screening and Treatment:

• Screen all family members and close contacts for T. tonsurans infections (>50% may be affected) 1, 5
• Treat asymptomatic carriers with high spore loads systemically 1

Environmental Decontamination:

• Clean all fomites (hairbrushes, combs, towels) with disinfectant or 2% sodium hypochlorite solution 5

School Attendance:

• Children on appropriate therapy should attend school/nursery—do not exclude 1

Treatment Endpoint and Monitoring

• The endpoint is mycological cure, not clinical cure 1, 5
• Repeat mycology sampling until clearance is documented 1, 5
• Clinical improvement alone is insufficient to stop therapy 1

Critical Pitfalls to Avoid

• Never use topical antifungals alone—they do not penetrate hair follicles 1, 3
• Do not use terbinafine for Microsporum infections—it has inferior efficacy compared to griseofulvin 1, 3
• Do not stop treatment based on clinical appearance alone—mycological cure must be confirmed 1, 5
• Do not forget to screen household contacts, especially with T. tonsurans 1, 5