What is the recommended treatment regimen for tinea capitis in a child (3–12 years old)?

Recommended Treatment Regimen for Tinea Capitis in Children (3–12 Years Old)

For children aged 3–12 years with tinea capitis, initiate organism-directed oral antifungal therapy: terbinafine (weight-based dosing for 2–4 weeks) for Trichophyton species infections, or griseofulvin (15–20 mg/kg/day for 6–8 weeks) for Microsporum species infections, combined with adjunctive topical antifungal therapy. 1

Initial Diagnostic Approach

Before initiating therapy, obtain mycological specimens via scalp scrapings, hair pluck, brush sampling, or gauze swabs for both microscopy and culture to identify the causative organism. 1 However, if cardinal clinical signs are present (scale, lymphadenopathy, alopecia, or kerion), start empiric treatment immediately without waiting for culture results. 1

First-Line Treatment Selection Based on Organism

For Trichophyton Species (Most Common in North America)

Terbinafine is the preferred first-line agent due to its fungicidal activity and superior efficacy with shorter treatment duration. 1

Weight-based dosing: 1

• <20 kg: 62.5 mg/day for 2–4 weeks
• 20–40 kg: 125 mg/day for 2–4 weeks
• >40 kg: 250 mg/day for 2–4 weeks

The advantages include improved compliance from shorter treatment courses and gastrointestinal disturbances or rashes occurring in less than 8% of children. 1

For Microsporum Species

Griseofulvin is the preferred first-line agent and remains the only licensed treatment for tinea capitis in children in many countries. 2, 1

Dosing regimen: 1, 3

• Children <50 kg: 15–20 mg/kg/day for 6–8 weeks (divided doses acceptable)
• Children >50 kg: 1 g/day for 6–8 weeks

Critical caveat: 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

Second-Line Options for Treatment Failure

If initial therapy fails, consider poor compliance, suboptimal drug absorption, organism insensitivity, or reinfection. 1

Management algorithm: 1

• If clinical improvement but positive mycology persists: Continue current therapy for an additional 2–4 weeks
• If no clinical improvement: Switch to second-line therapy

Itraconazole

Effective against both Trichophyton and Microsporum species at 5 mg/kg/day for 2–4 weeks or 50–100 mg/day for 4 weeks. 2, 1 Note that itraconazole is not licensed in the U.K. for children aged ≤12 years with tinea capitis, though intermittent dosing regimens are effective and may be preferred. 2

Fluconazole

An alternative for refractory cases with favorable tolerability profile and availability in liquid form. 2, 1 Fluconazole is not licensed for tinea treatment in children aged <10 years in the U.K., though it is licensed for mucosal candidiasis in all children and for tinea in children >1 year in Germany. 2 Once-weekly dosing regimens have been used and appear well tolerated. 2

Mandatory Adjunctive Measures

Topical antifungal therapy should be used as adjunctive treatment only—never as monotherapy, as topical therapy alone cannot eradicate scalp infections. 1, 4 Sporicidal shampoos such as selenium sulfide can aid in removing adherent scales and hasten eradication of viable spores. 5

Family screening and treatment: For T. tonsurans infections (highly anthropophilic), screen all family members and close contacts, as more than 50% may be affected with occult disease. 2, 1 Failure to treat the whole family results in high recurrence rates. 2

Cleanse fomites: Hairbrushes and combs should be cleansed with disinfectant, bleach, or 2% sodium hypochlorite solution, as viable spores can be isolated from these items. 2, 1

Special Considerations for Inflammatory Variants

Kerion Management

Initiate oral systemic antifungal therapy immediately without awaiting culture results. 1 Add topical or oral corticosteroids to alleviate severe inflammatory symptoms. 1 Recognize that kerion is a fungal-driven inflammatory response, not a primary bacterial abscess, though secondary bacterial infection should be evaluated when clinically indicated. 1

Dermatophytid (Id) Reaction

Pruritic papular eruptions appearing after antifungal initiation represent a cell-mediated response to dying dermatophytes and do not require discontinuation of systemic therapy. 1 Provide symptomatic relief with topical corticosteroids while continuing the antifungal regimen. 1

Treatment Endpoint and Monitoring

The endpoint of treatment is mycological cure, not clinical improvement. 2, 1 Repeat mycology sampling is mandatory until mycological clearance is achieved. 2, 1 This is a critical pitfall to avoid—stopping treatment based solely on clinical improvement rather than mycological cure leads to recurrence. 6

School Attendance

Children receiving appropriate systemic and adjunctive topical therapy should be allowed to attend school or nursery, as exclusion is impractical and unnecessary. 2, 1

Common Pitfalls to Avoid

• Never use topical therapy alone as it cannot eradicate scalp infections 1
• Avoid underdosing griseofulvin—higher doses (15–20 mg/kg/day) are needed due to increasing treatment failures with lower doses 1
• Do not use terbinafine for Microsporum infections due to poor efficacy 1
• Do not stop treatment prematurely based on clinical improvement without confirming mycological cure 2, 1