What is the recommended treatment for a 6-year-old male with a scalp skin infection?

Treatment of Scalp Skin Infection in a 6-Year-Old Male

For a 6-year-old male with a scalp skin infection, the diagnosis must first differentiate between fungal (tinea capitis) and bacterial etiologies, as treatment differs fundamentally: tinea capitis requires oral antifungal therapy with griseofulvin (15-20 mg/kg/day for 6-8 weeks) or terbinafine (62.5 mg/day for 2-4 weeks), while bacterial infections like impetigo require topical mupirocin 2% or oral antibiotics if extensive. 1

Diagnostic Approach

Clinical Examination for Tinea Capitis

• Look for cardinal signs: scaling, lymphadenopathy (especially posterior cervical), and alopecia—these strongly predict tinea capitis and justify starting treatment before culture confirmation 1, 2
• Identify specific patterns:
  • Non-inflammatory variants: grey patch, black dot pattern, or diffuse scale 2
  • Inflammatory variants: kerion (painful, boggy mass with alopecia), favus (yellow crusted cup-shaped lesions), or diffuse pustular variant 2
• Use Wood's lamp: Microsporum canis infections show green fluorescence, though Trichophyton species (now most common in North America) do not fluoresce 2, 3

Clinical Examination for Bacterial Infection

• Look for: honey-crusted lesions (impetigo), follicular pustules, or spreading erythema with warmth (cellulitis) 1, 4
• Assess severity: purulent drainage, systemic signs (fever, toxicity), or rapidly spreading infection require more aggressive therapy 1

Specimen Collection

• For suspected tinea capitis: Collect scalp scrapings, pluck affected hairs, or use brush/swab sampling before starting treatment when possible 1, 2
• For bacterial infection: Culture purulent lesions, especially if severe, not responding to initial therapy, or if MRSA is suspected 1

Treatment Algorithm

If Tinea Capitis is Diagnosed or Strongly Suspected

Oral systemic antifungal therapy is mandatory—topical therapy alone is ineffective 1

First-Line Oral Antifungal Selection:

• Griseofulvin 15-20 mg/kg/day (single or divided dose) for 6-8 weeks if Microsporum species suspected (based on local epidemiology or Wood's lamp fluorescence) 1

  • Take with fatty food to enhance absorption 1
  • Griseofulvin remains the only licensed treatment for tinea capitis in children in the UK 1
  • More effective than terbinafine for Microsporum infections 1

• Terbinafine dosing by weight if Trichophyton species suspected (most common in North America): 1, 3

  • <20 kg: 62.5 mg/day for 2-4 weeks
  • 20-40 kg: 125 mg/day for 2-4 weeks
  • Terbinafine is superior for Trichophyton but less effective for Microsporum 1
  • Shorter treatment duration improves compliance 1

Adjunctive Therapy:

• Add antifungal shampoo (ketoconazole 2%, selenium sulfide 1%, or povidone-iodine) to reduce spore transmission, though not curative alone 1, 2

Treatment Failure Management:

• If clinical improvement but positive mycology persists: Continue current therapy 2-4 more weeks 1
• If no initial clinical improvement: Switch to second-line therapy with itraconazole 5 mg/kg/day 1
• Consider: non-compliance, suboptimal drug absorption, organism resistance, or reinfection 1

Critical Follow-Up:

• Post-treatment mycological sampling is mandatory—clinical improvement alone is insufficient to confirm cure 2

If Bacterial Infection is Diagnosed or Suspected

For Minor/Localized Bacterial Infections:

• Topical mupirocin 2% ointment for impetigo or secondarily infected lesions (eczema, ulcers, lacerations) 1

For Purulent Infections (Abscesses, Furuncles):

• Incision and drainage is the primary treatment 1
• Add oral antibiotics if: multiple lesions, systemic signs, failed drainage alone, or immunocompromised 1
• Empiric oral antibiotic options for CA-MRSA coverage: 1
  • Clindamycin (preferred if local resistance <10%)
  • Trimethoprim-sulfamethoxazole (TMP-SMX)
  • Note: Tetracyclines are contraindicated in children <8 years old 1
  • For dual streptococcal/MRSA coverage: Clindamycin alone OR TMP-SMX plus amoxicillin 1

For Non-Purulent Cellulitis:

• Empiric therapy for β-hemolytic streptococci with a β-lactam antibiotic (e.g., cefazolin, amoxicillin-clavulanate) 1, 4
• Add MRSA coverage only if patient fails to respond to β-lactam therapy or has systemic toxicity 1

For Hospitalized/Severe Infections:

• Vancomycin is recommended for complicated skin infections in children requiring hospitalization 1
• Alternative: Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (40 mg/kg/day) if patient is stable and local clindamycin resistance is <10% 1
• Duration: 7-14 days based on clinical response 1

Common Pitfalls to Avoid

• Do not use topical therapy alone for tinea capitis—it will fail to eradicate the infection 1
• Do not stop antifungal treatment based on clinical improvement alone—mycological clearance must be documented 2
• Do not use tetracyclines in this 6-year-old patient—they are contraindicated under age 8 1
• Do not assume all scalp infections are fungal—bacterial scalp infections (impetigo, folliculitis, cellulitis) require different treatment 1, 4
• Do not use rifampin as monotherapy or adjunctive therapy for skin infections 1