What is the treatment for tinea capitis?

Treatment of Tinea Capitis

Oral antifungal therapy is absolutely required for tinea capitis, as topical treatment alone never penetrates the hair follicle and must never be used as monotherapy. 1, 2

Immediate Treatment Initiation

• Start treatment empirically without waiting for culture results if clinical signs are strongly suggestive, including scaling, lymphadenopathy, alopecia, or kerion presentation 1, 2
• Culture results may take 2-4 weeks, and delaying therapy increases transmission risk and disease progression 1
• Obtain specimens for microscopy and culture (using scalpel scraping, hair pluck, or brush) to confirm diagnosis and identify the causative organism, but do not delay treatment in clinically evident cases 1, 2

First-Line Oral Antifungal Selection Based on Organism

The optimal treatment regimen varies according to the dermatophyte species involved, so treatment protocols should reflect local epidemiology 1:

For Trichophyton Species (including T. tonsurans)

Terbinafine is superior and preferred 2, 3:

• <20 kg body weight: 62.5 mg daily for 2-4 weeks 2
• 20-40 kg body weight: 125 mg daily for 2-4 weeks 2
• >40 kg body weight: 250 mg daily for 2-4 weeks 2

For Microsporum Species (including M. canis)

Griseofulvin is more effective and preferred 2, 3:

• <50 kg body weight: 15-20 mg/kg/day for 6-8 weeks 1, 2
• >50 kg body weight: 1 g/day for 6-8 weeks 2
• Take with fatty food to increase absorption and bioavailability 1
• Griseofulvin remains the only licensed product for tinea capitis in children in the UK 1

Alternative Agent (Broad Spectrum)

Itraconazole has activity against both Trichophyton and Microsporum species 2:

• 50-100 mg daily for 4 weeks, or 5 mg/kg/day for 2-4 weeks 2
• Licensed for children over 12 years in the UK, though used off-label in younger children in some countries 4
• Important drug interactions: enhanced toxicity with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin 4

Essential Adjunctive Measures to Reduce Transmission

Topical antifungal shampoos reduce spore transmission but are never sufficient as monotherapy 1:

• Use ketoconazole 2%, selenium sulfide 1%, or povidone-iodine shampoo 1
• Screen all family members and close contacts for T. tonsurans infections, as over 50% may be affected 4, 2
• Treat asymptomatic carriers with high spore loads systemically 2
• Clean all fomites (hairbrushes, combs, towels) with disinfectant or 2% sodium hypochlorite solution 4, 2

Management of Treatment Failure

If treatment fails, assess for non-compliance, suboptimal drug absorption, organism resistance, or reinfection 2:

• If clinical improvement is seen but mycology remains positive: continue current therapy for an additional 2-4 weeks 2
• If no clinical improvement is seen: switch agents (e.g., from terbinafine to griseofulvin for Microsporum, or to itraconazole) 2
• Consider fluconazole as a third-line option, though it is not licensed for tinea in children under 10 years in the UK and has limited comparative efficacy data 4

Treatment Endpoint and Monitoring

The definitive endpoint for treatment is mycological cure, not clinical cure 4, 2:

• Repeat mycology sampling (microscopy and culture) until clearance is documented 4, 2
• Clinical improvement alone is insufficient to stop therapy 2
• Continue medication until the infecting organism is completely eradicated as indicated by laboratory examination 5

Critical Pitfalls to Avoid

• Never use topical antifungals alone, as they do not penetrate hair follicles 2
• Never use terbinafine for Microsporum infections, as it has inferior efficacy compared to griseofulvin 2, 3
• Never stop treatment based on clinical appearance alone—mycological cure must be confirmed 2
• Never forget to screen household contacts, especially with T. tonsurans, as transmission rates exceed 50% 4, 2
• Do not use griseofulvin as first-line for Trichophyton infections, as it requires longer treatment duration and is less effective than terbinafine 4