Treatment of Tinea Capitis
Organism-Directed First-Line Therapy
For Trichophyton species infections, use terbinafine as first-line therapy; for Microsporum species infections, use griseofulvin. 1
Trichophyton Species (Most Common in North America)
- Terbinafine is the preferred agent due to its fungicidal activity and superior efficacy, with treatment duration of 2-4 weeks 1
- Weight-based dosing:
- Advantages include shorter treatment duration improving compliance, with gastrointestinal disturbances and rashes occurring in <8% of children 1
- Terbinafine achieves 94% effective treatment rates for Trichophyton infections 2
Microsporum Species
- Griseofulvin is the preferred agent with treatment duration of 6-8 weeks 1
- Dosing recommendations:
- Critical pitfall: Terbinafine fails against Microsporum species because it cannot be incorporated into hair shafts in prepubertal children and doesn't reach the scalp surface where arthroconidia are located 1
- Eight weeks of griseofulvin is significantly more effective than 4 weeks of terbinafine for confirmed Microsporum infection 1
When to Start Treatment Empirically
- Begin treatment before mycology results if any cardinal clinical signs are present: scale, lymphadenopathy, alopecia, or kerion 1
- Collect specimens via scalp scrapings, hair pluck, brush, or swab for microscopy and culture 1
- Oral therapy is required for both clinical and mycological cure—topical therapy alone cannot eradicate scalp infections 1
Second-Line Options for Treatment Failure
Assess Reasons for Failure First
- Consider poor compliance, suboptimal drug absorption, organism insensitivity, or reinfection 1
- If clinical improvement occurs but mycology remains positive, continue current therapy for an additional 2-4 weeks 1
- If no clinical improvement occurs, switch to second-line therapy 1
Second-Line Agents
- Itraconazole: 5 mg/kg/day for 2-4 weeks or 50-100 mg/day for 4 weeks, effective against both Trichophyton and Microsporum species 1
- Fluconazole: Alternative for refractory cases with favorable tolerability profile and availability in liquid form, particularly useful in younger children 1, 4
- Itraconazole achieves 86% effective treatment rates and fluconazole achieves 84% effective treatment rates 2
Critical Adjunctive Measures
- Topical antifungal therapy should be used as adjunctive treatment only, never as monotherapy 1
- Screen and treat all family members and close contacts, especially for T. tonsurans infections where >50% of household contacts may be affected 1
- Cleanse hairbrushes and combs with bleach or 2% sodium hypochlorite solution 1
- Use sporicidal shampoos (selenium sulfide or 2% ketoconazole) to aid in removing adherent scales and hasten eradication of viable spores 4, 5
Treatment Endpoint and Monitoring
- Mycological cure, not just clinical improvement, is the definitive treatment endpoint 1
- Repeat mycology sampling is mandatory until clearance is achieved 1
- Monitor for treatment side effects, though serious adverse events are rare (0.04% incidence) 6
- Children receiving appropriate systemic and adjunctive topical therapy can attend school or nursery—exclusion is impractical and unnecessary 1
Common Pitfalls to Avoid
- Never use terbinafine for Microsporum infections due to poor efficacy 1
- Never rely on topical therapy alone as it cannot eradicate scalp infections 1
- Avoid underdosing griseofulvin—higher doses (20-25 mg/kg/day) are needed due to increasing treatment failures with lower doses 1, 4
- Do not stop treatment based on clinical improvement alone—continue until mycological cure is documented 1