What is the recommended treatment for a mild case of Tinea (ringworm of the scalp) capitis?

Treatment of Mild Tinea Capitis

For mild tinea capitis, start oral antifungal therapy immediately based on clinical presentation—use terbinafine 62.5-250 mg daily for 2-4 weeks if Trichophyton species is suspected (most common in North America), or griseofulvin 15-20 mg/kg/day for 6-8 weeks if Microsporum species is suspected or confirmed. 1

Diagnostic Approach Before or During Treatment

• Collect scalp specimens via scraping, hair pluck, brush, or swab for microscopy and culture to confirm the diagnosis and identify the causative organism 1, 2
• Start treatment empirically if cardinal clinical signs are present: scale, lymphadenopathy, alopecia, or kerion 1
• In high-risk populations, the presence of even one cardinal symptom has an 88% positive predictive value for tinea capitis 3
• Potassium hydroxide (KOH) preparation provides rapid preliminary diagnosis while awaiting culture results 1

First-Line Treatment Selection

For Trichophyton Species (Most Common in North America)

Terbinafine is the preferred first-line agent due to its fungicidal activity, superior efficacy, and shorter treatment duration of 2-4 weeks 1

Weight-based dosing for terbinafine: 1, 2

• Under 20 kg: 62.5 mg daily for 2-4 weeks

• 20-40 kg: 125 mg daily for 2-4 weeks

• Over 40 kg: 250 mg daily for 2-4 weeks

• Terbinafine has excellent tolerability with gastrointestinal disturbances and rashes occurring in less than 8% of children 1

• The shorter treatment duration (2-4 weeks vs 6-8 weeks) significantly improves compliance 1

• Terbinafine achieves 94% cure rates for Trichophyton species infections 4

For Microsporum Species

Griseofulvin is the preferred first-line agent for Microsporum infections, as terbinafine fails against this organism 1, 2

Dosing for griseofulvin: 1, 5, 6

• Children under 50 kg: 15-20 mg/kg/day for 6-8 weeks

• Children over 50 kg and adults: 1 g/day for 6-8 weeks

• FDA-approved dosing for children 30-50 lbs: 125-250 mg daily 6

• FDA-approved dosing for children over 50 lbs: 250-500 mg daily 6

• Griseofulvin achieves 88.5% response rates for Microsporum species compared to only 67.9% for Trichophyton species 2

• Eight weeks of griseofulvin is significantly more effective than 4 weeks of terbinafine for confirmed Microsporum infection 1

• Critical pitfall: Terbinafine cannot be incorporated into hair shafts in prepubertal children and doesn't reach the scalp surface where Microsporum arthroconidia are located 1

Mandatory Adjunctive Measures

• Topical antifungal therapy is required as adjunctive treatment only—never use topical therapy alone as monotherapy, as it cannot eradicate scalp infections 1, 5
• Screen and treat all family members and close contacts, especially for T. tonsurans infections where over 50% of household contacts may be affected 5
• Cleanse hairbrushes and combs with bleach or 2% sodium hypochlorite solution to prevent reinfection 1, 5
• Consider selenium sulfide shampoo to aid in removing adherent scales and eradicating viable spores 7, 3

Treatment Endpoint and Monitoring

The endpoint of treatment is mycological cure, not clinical improvement 1, 2, 5

• Repeat mycology sampling is mandatory until clearance is achieved 1, 2
• Clinical improvement alone is insufficient—continue treatment until negative cultures are obtained 1
• If clinical improvement occurs but mycology remains positive, continue current therapy for an additional 2-4 weeks 1, 5

Management of Treatment Failure

If initial therapy fails, assess the following factors: 1, 5

• Poor compliance with the medication regimen
• Suboptimal drug absorption (griseofulvin absorption improves with fatty meals)
• Organism insensitivity or wrong organism-drug match
• Reinfection from untreated contacts or contaminated fomites

If no clinical improvement occurs, switch to second-line therapy: 1, 5

• Itraconazole 5 mg/kg/day for 2-4 weeks (effective against both Trichophyton and Microsporum species)
• Fluconazole 6 mg/kg/day for 2-3 weeks (favorable tolerability profile, available in liquid form)
• Switch between terbinafine and griseofulvin based on organism identification

Critical Pitfalls to Avoid

• Never use terbinafine for Microsporum infections—it has poor efficacy and will lead to treatment failure 1, 2
• Never rely on topical therapy alone—oral antifungal therapy is mandatory for tinea capitis 1, 2, 6
• Avoid underdosing griseofulvin—higher doses of 20-25 mg/kg/day are needed due to increasing treatment failures with lower doses 1, 7, 3
• Do not stop treatment based on clinical improvement alone—mycological cure must be documented 1, 2
• Griseofulvin is contraindicated in lupus erythematosus, porphyria, and severe liver disease 5

School Attendance

Children receiving appropriate systemic and adjunctive topical therapy can attend school or nursery—exclusion is impractical and unnecessary 1, 5