What is the recommended first‑line treatment for tinea capitis (tinea head)?

First-Line Treatment for Tinea Capitis

Oral griseofulvin remains the only FDA-approved systemic antifungal for tinea capitis in children and should be prescribed at 20-25 mg/kg/day for 4-6 weeks, though newer agents like terbinafine and itraconazole offer shorter treatment courses with comparable efficacy. 1, 2

Diagnostic Confirmation Required Before Treatment

• Obtain mycological confirmation with KOH microscopy and fungal culture before initiating systemic therapy, as clinical appearance alone cannot reliably distinguish tinea capitis from other scalp conditions 3
• Collect specimens by scalp scraping, hair pluck, or brush sampling from affected areas 3
• Mount specimens in 10-30% KOH for rapid preliminary diagnosis, then culture on Sabouraud agar for definitive species identification 3

Systemic Treatment Algorithm

First-Line Option: Griseofulvin (FDA-Approved)

• Dosage for children >2 years: 20-25 mg/kg/day (higher than the FDA label's 10 mg/kg/day) for 8 weeks due to increased treatment failures at lower doses 1, 2
• Pediatric weight-based dosing: 30-50 lbs = 125-250 mg daily; >50 lbs = 250-500 mg daily in divided doses 1
• Adults: 500 mg daily, adjustable to 750 mg-1 g daily for extensive infections 1
• Treatment duration: 4-6 weeks minimum 1

Alternative Options (Not FDA-Approved but Guideline-Supported)

Terbinafine (preferred alternative in older children who can swallow tablets):

• 250 mg daily for 2-4 weeks achieves 86% mycological cure rate 3
• Advantages: shorter treatment course, less expensive than other alternatives, most data available 2
• Effective against Trichophyton species (most common in North America and UK) 4

Itraconazole:

• 100 mg daily for 15 days achieves 87% mycological cure rate 3
• Effective against both Trichophyton and Microsporum species 3
• Critical drug interactions with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin 3

Fluconazole (preferred in younger children):

• Favorable tolerability profile and available in liquid formulation 2
• Treatment duration typically ≤4 weeks 2

Mandatory Adjunctive Topical Therapy

• Concomitant use of sporicidal shampoos (selenium sulfide) is required to remove adherent scales and eradicate viable spores from the scalp 1, 2
• This reduces transmission risk to others 2

Critical Monitoring Requirements

• The definitive endpoint is mycological cure, not clinical improvement alone 5, 3
• Repeat mycology sampling at end of standard treatment period, then monthly until mycological clearance documented 5, 3
• Liver function monitoring is generally unnecessary if therapy limited to ≤4 weeks with newer agents 2
• Monitor for liver enzyme elevations before initiating terbinafine or itraconazole, especially in patients with pre-existing hepatic abnormalities 3

Family and Contact Management

• Screen all family members for T. tonsurans cases, as >50% may be affected with occult disease 5
• Failure to treat the entire family results in high recurrence rates 5
• Cleanse hairbrushes and combs with bleach or 2% sodium hypochlorite solution 5

School Attendance

• Children receiving appropriate systemic and adjunctive topical therapy should be allowed to attend school or nursery 5
• Exclusion from school is considered impractical by most experts 5

Common Pitfalls to Avoid

• Dermatophytid reactions may occur after initiating antifungal therapy, representing a cell-mediated host response to dying dermatophytes—this is not treatment failure 3
• Do not stop treatment based on clinical improvement alone; continue until mycological clearance confirmed 5, 3
• Do not use topical antifungals as monotherapy—systemic treatment is mandatory 6, 7
• Recognize that griseofulvin requires longer treatment courses (4-8 weeks) compared to newer agents (2-4 weeks), which may affect compliance 2