Treatment of Scalp Fungal Infections
For scalp fungal infections (tinea capitis), oral antifungal therapy is mandatory—topical treatments and antifungal shampoos alone are insufficient for cure, though shampoos serve an important adjunctive role in reducing transmission and spore burden. 1
Primary Treatment Algorithm
Oral Antifungal Therapy (Required for Cure)
The choice of oral agent depends on the causative organism:
- For Trichophyton species infections: Terbinafine 2-4 weeks is first-line therapy 1
- For Microsporum species infections: Griseofulvin 6-8 weeks is first-line therapy, as terbinafine fails against Microsporum 1
- Critical caveat: Griseofulvin must be taken with fatty food to ensure adequate absorption 1
Confirm the diagnosis with fungal culture before starting treatment whenever possible, as this prevents treatment failure and permanent scarring from using the wrong agent 1. While culture results take 2-4 weeks, you can start treatment immediately if clinical features strongly suggest fungal infection 1.
Adjunctive Antifungal Shampoo Therapy
While shampoos cannot cure scalp infections, they play an important role:
Ketoconazole 2% shampoo applied twice weekly reduces fungal spore burden and transmission to household contacts 2, 3. In one multicenter trial of 575 patients, ketoconazole 2% shampoo used twice weekly for 2-4 weeks produced excellent response in 88% of seborrheic dermatitis cases, with prophylactic once-weekly use reducing relapse from 47% to 19% over 6 months 2.
Application technique for adjunctive shampoo therapy:
- Massage into wet scalp and allow to remain for 2-3 minutes 4
- Rinse thoroughly and repeat application 4
- Use twice weekly during active treatment phase 2
- Continue once weekly as prophylaxis to prevent transmission 2, 3
Monitoring Treatment Success
Treatment success is determined by negative fungal cultures, not just clinical improvement 1. This is a critical pitfall—clinical improvement without mycological cure leads to relapse 1.
- Repeat fungal cultures monthly until negative 1
- Do not discontinue therapy based on symptom resolution alone 1
Preventing Transmission and Reinfection
Screen and treat all family members and close contacts simultaneously to prevent reinfection 1. The recurrence rate drops from 60% to 4% when prophylactic antifungal washes are used along with treatment 3.
Additional measures include:
- Remove jewelry before shampoo application as products may cause damage 4
- Wash hands thoroughly after each application 4
- Disinfect shared items like combs, brushes, and hats 1
Special Considerations for Kerion
Kerion (severe inflammatory scalp infection with pustules and crusting) requires immediate treatment to prevent permanent scarring and hair loss 1. Do not delay therapy while awaiting culture results in these cases 1.
Common Pitfalls to Avoid
- Never rely on appearance alone to determine cure—fungal elements persist despite clinical improvement 1
- Never use terbinafine without knowing the organism, as it fails against Microsporum species 1
- Never use antifungal shampoo as monotherapy for scalp infections—oral therapy is mandatory 1
- Never discontinue treatment prematurely when symptoms resolve rather than completing the full course 5