Treatment for Tinea Capitis
Organism-Directed First-Line Therapy is Essential
For Trichophyton species infections, use terbinafine as first-line therapy with weight-based dosing for 2-4 weeks; for Microsporum species infections, use griseofulvin for 6-8 weeks. 1, 2
Start Treatment Empirically Before Culture Results
- Begin systemic antifungal therapy immediately if any cardinal clinical signs are present: scale, lymphadenopathy, alopecia, or kerion 1
- Collect specimens via scalp scrapings, hair pluck, brush, or swab for microscopy and culture to confirm the organism 1, 2
- Do not delay treatment while awaiting culture results in symptomatic patients 1
Trichophyton Species: Terbinafine First-Line
Weight-based dosing for terbinafine: 1, 2
- Children <20 kg: 62.5 mg daily for 2-4 weeks
- Children 20-40 kg: 125 mg daily for 2-4 weeks
- Children >40 kg and adults: 250 mg daily for 2-4 weeks
Advantages of terbinafine: 1
- Shorter treatment duration improves compliance
- Fungicidal activity with superior efficacy against Trichophyton
- Gastrointestinal disturbances and rashes occur in <8% of children
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
Microsporum Species: Griseofulvin First-Line
Dosing for griseofulvin: 1, 2, 3
- Children <50 kg: 15-20 mg/kg/day for 6-8 weeks
- Children >50 kg and adults: 1 g/day for 6-8 weeks
Key evidence: Eight weeks of griseofulvin is significantly more effective than 4 weeks of terbinafine for confirmed Microsporum infection 1
Common pitfall to avoid: Do not underdose griseofulvin—higher doses are needed due to increasing treatment failures with lower doses 1
Second-Line Options for Treatment Failure
If initial therapy fails, consider: 1, 2
- Poor compliance
- Suboptimal drug absorption
- Organism insensitivity
- Reinfection
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: 5 mg/kg/day for 2-4 weeks (effective against both Trichophyton and Microsporum species)
- Fluconazole: Alternative for refractory cases with favorable tolerability profile and liquid formulation available
Mandatory Adjunctive Measures
- Use as adjunctive treatment only—never as monotherapy
- Topical antifungals cannot eradicate scalp infections alone
- Consider 2% ketoconazole or 1% selenium sulfide shampoo to reduce spore transmission
Screen and treat contacts: 1
- Screen all family members and close contacts, especially for T. tonsurans infections
- Cleanse hairbrushes and combs with bleach or 2% sodium hypochlorite solution
Special Clinical Scenarios
Kerion Management
Kerion is a fungal-driven inflammatory response, not a bacterial abscess: 1
- Initiate oral systemic antifungal therapy immediately
- Add topical or oral corticosteroids to alleviate severe inflammatory symptoms
- Evaluate for secondary bacterial infection only when clinically indicated
Dermatophytid (Id) Reaction
Pruritic papular eruptions after starting antifungals represent a cell-mediated response to dying dermatophytes: 1, 2
- Do not discontinue systemic antifungal therapy
- Provide symptomatic relief with topical corticosteroids (or oral steroids in severe cases)
- Continue the antifungal regimen
Favus (Chronic Variant)
Identify favus by yellow, cup-shaped crusted lesions ("scutula"): 1
- Most often caused by Trichophyton schoenleinii
- Can lead to scarring (cicatricial) alopecia if untreated
- Exhibits characteristic fluorescence under Wood's lamp examination
Treatment Endpoint: Mycological Cure, Not Clinical Improvement
The definitive endpoint is mycological cure (negative microscopy and culture), not just clinical improvement: 1, 2
- Repeat mycology sampling at the end of standard treatment period
- Continue monthly sampling until mycological clearance is documented
- Clinical relapse will occur if medication is not continued until the organism is eradicated 3
Monitoring and Safety
For terbinafine and itraconazole: 2
- Monitor liver function, especially in patients with pre-existing hepatic abnormalities or prolonged therapy
- Baseline liver function tests and complete blood count recommended before initiating therapy
Itraconazole drug interactions: 2
- Contraindicated in heart failure
- Significant interactions with warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin
School Attendance
Children receiving appropriate systemic and adjunctive topical therapy can attend school or nursery: 1
- Exclusion is impractical and unnecessary
- Proper treatment reduces transmission risk