What is the recommended treatment for scalp ringworm (tinea capitis) in pediatric patients?

Treatment of Scalp Ringworm (Tinea Capitis) in Pediatric Patients

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

Diagnostic Confirmation Before Treatment

• Obtain scalp samples via scraping, hair pluck, brush, or swab for microscopy and culture to identify the causative organism 2, 3
• Start treatment empirically if cardinal clinical signs are present (scale, lymphadenopathy, alopecia, or kerion) while awaiting culture results 3
• Potassium hydroxide microscopy provides rapid preliminary diagnosis 3

First-Line Treatment Selection Based on Organism

For Trichophyton Species (Most Common in Many Regions)

Terbinafine is the preferred first-line agent due to superior fungicidal activity and shorter treatment duration: 2, 3

• Weight-based dosing: 3
  • <20 kg: 62.5 mg daily for 2-4 weeks
  • 20-40 kg: 125 mg daily for 2-4 weeks

  • 40 kg: 250 mg daily for 2-4 weeks

• Advantages include shorter treatment duration (improving compliance) and gastrointestinal side effects occurring in <8% of children 3
• Critical caveat: Terbinafine fails against Microsporum species because it cannot be incorporated into hair shafts in prepubertal children 3

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

Griseofulvin is the preferred first-line agent with demonstrated superior efficacy: 2, 3

• Dosing: 15-20 mg/kg/day for 6-8 weeks (or 10 mg/kg daily per FDA labeling) 2, 4
• Griseofulvin achieves 88.5% response rate for Microsporum versus only 67.9% for Trichophyton 2
• Eight weeks of griseofulvin is significantly more effective than 4 weeks of terbinafine for confirmed Microsporum infection 3
• Griseofulvin is the only antifungal specifically licensed for tinea capitis in young children in many countries 2, 4

Second-Line Options for Treatment Failure

If initial therapy fails, consider these factors: poor compliance, suboptimal drug absorption, organism insensitivity, or reinfection 3

Management algorithm for treatment failure: 3

• If clinical improvement occurs but mycology remains positive: continue current therapy for additional 2-4 weeks
• If no clinical improvement: switch to second-line therapy

Second-line agents: 1, 3

• Itraconazole: 5 mg/kg/day for 2-4 weeks (effective against both Trichophyton and Microsporum species)
• Fluconazole: Demonstrated efficacy against T. violaceum, T. verrucosum, and M. canis, though not licensed for tinea in children <10 years in UK 1, 5

Critical Treatment Principles

The endpoint of treatment is mycological cure, not clinical improvement—repeat mycology sampling is mandatory until clearance is achieved. 1, 2, 3

Adjunctive Measures

• Topical antifungal therapy should be used as adjunctive treatment only, never as monotherapy 3
• Screen all family members and close contacts, especially for T. tonsurans infections (>50% of family members may be affected) 1, 2
• Cleanse hairbrushes and combs with bleach or 2% sodium hypochlorite solution 1

School Attendance

Children receiving appropriate systemic and adjunctive topical therapy can attend school or nursery—exclusion is impractical and unnecessary 1, 2

Common Pitfalls to Avoid

• Never use terbinafine for Microsporum infections—it will fail due to inability to reach arthroconidia in prepubertal children 2, 3
• Never rely on topical therapy alone—it cannot eradicate scalp infections 2, 3
• Avoid underdosing griseofulvin—higher doses (15-20 mg/kg/day) are needed due to increasing treatment failures with lower doses 3
• Do not stop treatment based on clinical improvement alone—continue until mycological clearance is documented 1, 2