What is the treatment for tinea capitis?

Treatment of Tinea Capitis

Oral Antifungal Therapy is Absolutely Required

Tinea capitis requires oral antifungal therapy—topical treatment alone is completely ineffective and must never be used as monotherapy. 1 Topical antifungals cannot penetrate hair follicles adequately to eradicate the infection. 1

Start Treatment Immediately Without Waiting for Culture Results

• Begin empirical oral antifungal therapy immediately if clinical signs are present (scale, lymphadenopathy, alopecia, or kerion), while awaiting mycological confirmation. 1
• Do not delay treatment waiting for culture results when the clinical presentation is evident. 1
• Ideally confirm diagnosis through potassium hydroxide preparation or culture to identify the causative organism, but this should not delay initiation of therapy. 2

First-Line Agent Selection Based on Causative Organism

For Trichophyton Species (Including T. tonsurans):

Terbinafine is superior and the preferred first-line agent for Trichophyton infections. 1

• Dosing by weight: 1
  • Less than 20 kg: 62.5 mg daily
  • 20-40 kg: 125 mg daily
  • Over 40 kg: 250 mg daily
• Duration: 2-4 weeks 1
• Terbinafine has demonstrated 94% efficacy for Trichophyton species with excellent tolerability. 3

For Microsporum Species (Including M. canis):

Griseofulvin is more effective and the preferred first-line agent for Microsporum infections. 1

• Dosing by weight: 1
  • Less than 50 kg: 15-20 mg/kg/day
  • Over 50 kg: 1 g/day
• Duration: 6-8 weeks 1
• The FDA label confirms treatment periods of 4-6 weeks for tinea capitis, though current guidelines recommend longer durations for Microsporum. 2

When Organism is Unknown or Mixed:

Itraconazole has activity against both Trichophyton and Microsporum species and serves as a reasonable empiric choice. 1

• Dosing: 50-100 mg daily for 4 weeks, or 5 mg/kg/day for 2-4 weeks 1
• Itraconazole achieved 87% mycological cure rates in clinical trials. 4
• Important drug interactions exist with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin. 5

Critical Treatment Endpoint: Mycological Cure, Not Clinical Cure

The endpoint of treatment is mycological cure documented by negative microscopy and culture—not clinical appearance alone. 1

• Repeat mycology sampling until clearance is documented. 1
• Clinical improvement alone is insufficient to stop therapy, as clinical relapse will occur if the organism is not completely eradicated. 1, 2
• If clinical improvement is seen but mycology remains positive, continue current therapy for an additional 2-4 weeks. 1

Management of Treatment Failure

When treatment fails, assess systematically: 1

• Non-compliance with medication regimen
• Suboptimal drug absorption (consider taking griseofulvin with fatty foods)
• Organism resistance to the selected agent
• Reinfection from untreated contacts or contaminated fomites

If no clinical improvement is seen, switch agents: 1

• From terbinafine to griseofulvin for suspected Microsporum
• From griseofulvin to terbinafine for Trichophyton
• Consider itraconazole as an alternative

Essential Adjunctive Measures to Prevent Reinfection

Screen all family members and close contacts for infection, as more than 50% may be affected with T. tonsurans. 1

• Treat asymptomatic carriers with high spore loads systemically. 1
• Clean all fomites (hairbrushes, combs, towels, bedding) with disinfectant or 2% sodium hypochlorite solution. 1
• Consider sporicidal shampoos such as selenium sulfide to aid in removing adherent scales and decrease spread. 6

Critical Pitfalls to Avoid

• Never use topical antifungals alone—they do not penetrate hair follicles adequately. 1
• Never use terbinafine for Microsporum infections—it has inferior efficacy compared to griseofulvin. 1
• Never stop treatment based on clinical appearance alone—mycological cure must be confirmed. 1
• Never forget to screen household contacts, especially with T. tonsurans infections. 1
• Do not use griseofulvin as first-line for Trichophyton when terbinafine is available, as it requires longer treatment duration and has lower cure rates. 5