Tinea capitis: Management

INTRODUCTION — 

Tinea capitis is a fungal infection of the scalp that most often occurs in children (picture 1A-F). Various dermatophyte fungi can cause tinea capitis. The most common causes are Trichophyton and Microsporum species. (See "Tinea capitis: Clinical features and diagnosis".)

In general, treatment of tinea capitis should be initiated promptly. Oral antifungal drugs, such as griseofulvin and terbinafine, are the mainstays of therapy (algorithm 1).

The management of tinea capitis will be reviewed here. The pathogenesis, clinical manifestations, and diagnosis of tinea capitis are reviewed separately.

●(See "Tinea capitis: Clinical features and diagnosis".)

Other dermatophyte infections are also reviewed separately.

●(See "Dermatophyte (tinea) infections".)

●(See "Onychomycosis: Epidemiology, clinical features, and diagnosis".)

●(See "Onychomycosis: Management".)

●(See "Infectious folliculitis", section on 'Dermatophytic folliculitis'.)

OVERVIEW — 

The treatment of tinea capitis involves oral antifungal therapy and adjunctive measures (algorithm 1).

●Timing – In general, treatment should begin promptly. Delaying treatment may increase the risk of disease progression, permanent hair loss, and disease transmission.

We typically start oral antifungal treatment once a diagnosis of tinea capitis is either confirmed with a potassium hydroxide (KOH) preparation or strongly suspected based on the clinical presentation. We do not usually wait for fungal culture or polymerase chain reaction (PCR) species identification results to select an initial oral antifungal drug. In our experience, delaying initial treatment for test results can contribute to the loss of patients to follow-up. (See "Tinea capitis: Clinical features and diagnosis", section on 'Confirmatory tests' and 'Selecting an oral antifungal agent' below.)

●Treatment options – The major options for oral antifungal therapy include terbinafine, griseofulvin, fluconazole, and itraconazole. Terbinafine and griseofulvin have the most robust efficacy data for tinea capitis and are our preferred initial treatments for most patients (algorithm 1). Fluconazole is our preferred treatment for tinea capitis in infants. (See 'Selecting an oral antifungal agent' below and 'Alternative therapies' below and 'Infants' below.)

Griseofulvin is the only commercially available treatment approved by the US Food and Drug Administration (FDA) for tinea capitis. Oral terbinafine granules, which also had FDA approval for tinea capitis, have been discontinued. (See 'Selecting an oral antifungal agent' below.)

Topical antifungal therapy is unlikely to be effective because of inadequate penetration of hair follicles and the potential to miss sites of subclinical infection. Treatment of tinea capitis with ionizing radiation is no longer advised due to the risk of long-term adverse effects [1].

●Adjunctive interventions – Adjunctive interventions for tinea capitis include the use of antifungal shampoo and other measures to reduce the likelihood of reinfection or disease transmission. (See 'Adjunctive measures' below and 'Cohabitant and household measures' below.)

●Follow-up – Patients treated for tinea capitis require clinical follow-up to determine when oral antifungal treatment can be discontinued. (See 'Assessing response' below.)

SELECTING AN ORAL ANTIFUNGAL AGENT

Preferred treatments — Oral griseofulvin and oral terbinafine are the most used therapies for tinea capitis in children (algorithm 1). The use of griseofulvin is based on the drug's efficacy in randomized trials and a long history of use for this indication [2]. Terbinafine has demonstrated efficacy in randomized trials and may sometimes allow for shorter treatment courses compared with griseofulvin. (See 'Oral terbinafine' below and 'Griseofulvin' below.)

In general, both griseofulvin and oral terbinafine are appropriate initial treatments for tinea capitis in children. Clinician familiarity with a particular drug, drug formulation preferences (only griseofulvin is available as a liquid), drug access, and the suspected causative organism can influence the selection between these treatments. (See 'Oral terbinafine' below and 'Griseofulvin' below.)

With the exception of infants (whom we most often treat with oral fluconazole), we generally reserve treatment with fluconazole or itraconazole for children in whom treatment with griseofulvin or terbinafine is not effective or feasible. (See 'Infants' below and 'Alternative therapies' below.)

Role of the causative organism — There may be advantages of treatment of Trichophyton tonsurans infections with oral terbinafine and treatment of Microsporum canis infections with griseofulvin. This often influences our choice of initial treatment when we suspect infection with one of these organisms. (See "Tinea capitis: Clinical features and diagnosis", section on 'Clinical manifestations' and "Tinea capitis: Clinical features and diagnosis", section on 'Etiology'.)

●T. tonsurans infections – Our preference for oral terbinafine for T. tonsurans infections is based on data demonstrating that oral terbinafine is at least as effective as griseofulvin for Trichophyton infections with shorter durations of treatment. T. tonsurans is the most common cause of tinea capitis in the United States [3-5]. (See "Tinea capitis: Clinical features and diagnosis", section on 'Etiology'.)

In a meta-analysis of randomized trials, four weeks of oral terbinafine was as effective for achieving complete (clinical and mycologic) cure for Trichophyton infections as eight weeks of griseofulvin (risk ratio 1.06, 95% CI 0.98-1.15) [2].

There were also data that suggested greater efficacy of the discontinued formulation of terbinafine granules compared with griseofulvin for T. tonsurans infections when given for a similar duration. Pooled data from two randomized trials (n = 1549) that compared a six-week course of terbinafine granules (at 125 mg per day for children <25 kg, 187.5 mg per day for children 25 to 35 kg, and 250 mg per day for children >35 kg) with a six-week course of griseofulvin microsize (weight-based dosing approximating 10 to 20 mg/kg per day) in children found similar efficacy for tinea capitis overall but greater efficacy of terbinafine for the subgroup of children with T. tonsurans infections (complete cure rate 52.1 versus 35.4 percent, risk ratio 1.47, 95% CI 1.22-1.77) [6]. There was no difference in effect for Trichophyton violaceum infections.

Although the dose range for griseofulvin in the randomized trials was lower than often used for tinea capitis in clinical practice, response rates for patients treated with doses greater than 20 mg/kg per day (49 patients) were similar when compared with the overall rate of response in the griseofulvin group [6]. (See 'Griseofulvin' below.)

●M. canis infections – Griseofulvin appears to be more effective for M. canis infections than terbinafine and is our preferred therapy for known or suspected M. canis infections. A systematic review and meta-analysis of randomized trials found a lower cure rate for Microsporum infections (primarily M. canis) in children for a six-week course of terbinafine than for a 6- to 12-week course of griseofulvin (34.7 versus 50.9 percent, risk ratio 0.68, 95% CI 0.53-0.86) [2].

Griseofulvin

●Administration – Griseofulvin is available in a microsize formulation as tablets or a suspension. In addition, an ultramicrosize formulation is available as tablets.

Griseofulvin is absorbed more effectively when given with fatty food (eg, peanut butter, ice cream). Therapeutic failures are often due to lack of absorption. (See 'Determining cause' below.)

Griseofulvin remains available in the United States but is no longer marketed in some locations [7].

Typical treatment regimens for children are:

•Microsize formulation – The pediatric dose for tinea capitis ranges from 10 to 25 mg/kg per day. We typically treat children with 20 mg/kg per day [8,9]. The maximum daily dose is 1000 mg per day.

•Ultramicrosize formulation – The pediatric dose for tinea capitis ranges from 10 to 15 mg/kg per day [8]. The maximum daily dose is 750 mg per day.

Adult regimens are provided separately. (See 'Adults' below.)

We reassess patients after six to eight weeks of griseofulvin treatment. Treatment can be discontinued once signs of infection have resolved. If active infection persists, we extend the course of griseofulvin, increase the dose of griseofulvin (for patients initially treated with lower doses), or switch to a different oral antifungal treatment. (See 'Assessing response' below and 'Treatment failure' below.)

●Adverse effects and monitoring – Griseofulvin is typically well tolerated. Gastrointestinal distress, headache, and cutaneous eruptions are potential side effects. Examples of uncommon serious side effects include hepatotoxicity, granulocytopenia, leukopenia, lupus erythematous or lupus-like syndrome, and severe cutaneous reactions.

Laboratory evaluation prior to griseofulvin treatment is not necessary. However, if therapy is continued beyond eight weeks or repeated courses of griseofulvin are given, liver function tests and a complete blood count should be obtained to evaluate for hepatic or hematologic toxicity.

Oral terbinafine

●Administration – Dosing for children is based on weight. Standard pediatric dose regimens for terbinafine tablets are:

•10 to 20 kg – 62.5 mg daily for four to six weeks

•20 to 40 kg – 125 mg daily for four to six weeks

•Above 40 kg – 250 mg daily for four to six weeks

Higher-dose regimens for terbinafine tablets or terbinafine granules have also been reported [6,10,11].

Terbinafine tablets can be taken without regard to meals. Tablets can be crushed and mixed with foods, such as pudding or chocolate syrup, for children who are unable to swallow pills but should not be mixed with applesauce due to decreased efficacy [12].

Terbinafine granules are no longer commercially available, and terbinafine is not available in a liquid formulation.

Adult regimens are provided separately. (See 'Adults' below.)

We assess the response to oral terbinafine treatment after four to six weeks. (See 'Assessing response' below and 'Role of the causative organism' above.)

●Adverse effects and monitoring – Oral terbinafine is usually well tolerated. Headache, gastrointestinal distress, taste disturbances, cutaneous eruptions, and liver enzyme abnormalities are potential side effects. Examples of uncommon severe side effects include drug hypersensitivity syndrome, drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), serum sickness-like reaction, fulminant hepatic failure, drug-induced lupus, pancytopenia, and pancreatitis.

Although baseline liver function testing is advised in the package insert for oral terbinafine, we do not typically obtain baseline liver function tests prior to or during terbinafine therapy for tinea capitis in healthy children given the rarity of pre-existing liver disease and terbinafine-related liver function test abnormalities in children [13-15]. We obtain baseline liver function tests in adults.

Although obtaining liver function tests in patients treated with oral terbinafine for more than six weeks is often advised, we generally do not exceed six weeks of treatment for tinea capitis, and the utility of checking liver function tests during treatment has been questioned [13].

Special populations

Kerion — Oral antifungal therapy is the mainstay of treatment for kerion (picture 2). Treatment regimens for kerion are similar to treatment regimens for other forms of tinea capitis. (See 'Selecting an oral antifungal agent' above.)

Oral glucocorticoids (eg, 0.5 to 1 mg/kg of prednisone for one week) are occasionally used in conjunction with antifungal therapy for patients with severe inflammation. However, it is unclear whether the addition of a systemic glucocorticoid improves outcomes [16,17].

Infants — Tinea capitis is uncommon in children under the age of one (picture 1D). Infants have been successfully treated with fluconazole, griseofulvin, and terbinafine [9,18-20]. We typically treat infants with fluconazole, given the extensive experience with oral fluconazole therapy in infants for other indications. (See 'Fluconazole' below.)

In a survey in which 56 pediatric dermatologist respondents were asked which oral medication they start prior to laboratory confirmation of tinea capitis, griseofulvin and fluconazole were the most common treatment choices for children ages zero to two years [9]. For children under two months of age, approximately one-half of clinicians (20 out of 39) preferred to wait for laboratory confirmation of the diagnosis prior to starting treatment compared with only 9 of 49 clinicians for children ages two months to two years. No respondents reported starting terbinafine in children below two months of age prior to diagnostic confirmation.

Effective treatment with topical agents has been reported in infants [18,20]. However, data are insufficient to recommend routine use of topical therapy [20].

Adults — The same medications are used to treat tinea capitis in both children and adults. The optimal treatment regimens for adults are unclear.

Typical doses for adults are terbinafine 250 mg per day, itraconazole 5 mg/kg per day (maximum 200 mg per day), fluconazole 6 mg/kg per day (maximum dose 200 mg per day), griseofulvin microsize 20 to 25 mg/kg per day (maximum 1000 mg per day), and griseofulvin ultramicrosize 10 to 15 mg/kg per day (maximum 750 mg per day) [21]. Treatment durations are similar to those used for children. (See 'Oral terbinafine' above and 'Griseofulvin' above and 'Fluconazole' below and 'Itraconazole' below.)

Alternative therapies — Fluconazole and itraconazole are effective, less frequently used treatments for tinea capitis. Compared with griseofulvin and terbinafine, efficacy data for fluconazole and itraconazole are more limited.

Oral ketoconazole should not be used for the treatment of tinea capitis. The drug is associated with risk for severe liver injury and adrenal insufficiency.

Fluconazole

●Administration – Children can be treated with 6 mg/kg per day of fluconazole for three to six weeks [22]. The maximum daily dose is 200 mg.

Limited data suggest that once-weekly dosing of fluconazole also may be effective [23,24]. Children can be treated with a pulse dose of 6 mg/kg once weekly for 6 to 12 weeks. Some patients find the convenience of once-weekly dosing preferable despite the longer duration of treatment.

Adult regimens are provided separately. (See 'Adults' above.)

●Efficacy – Oral fluconazole can be effective for tinea capitis [23,25]. Randomized trials performed in populations where Trichophyton infections predominated have demonstrated similar efficacy between regimens of fluconazole and griseofulvin [25-27]. In addition, a randomized trial that compared the efficacy of two to three weeks of treatment with fluconazole, itraconazole, or terbinafine and six weeks of treatment with griseofulvin for tinea capitis caused by Trichophyton species did not find significant differences in efficacy among these therapies [26].

Itraconazole

●Administration – The optimum regimen for itraconazole for tinea capitis is unclear. When used for tinea capitis in children, itraconazole is commonly prescribed at a dose of 3 to 5 mg/kg daily for four to six weeks, with a usual maximum of 200 mg per day.

Pulse therapy also may be effective. Pulsed itraconazole is given at a dose of 5 mg/kg per day for one week each month for two to three months in children [8,28]. The suggested childhood dose for pulse therapy with the oral solution of itraconazole is 3 mg/kg per day [8].

Adult regimens are provided separately. (See 'Adults' above.)

●Efficacy – Relatively few randomized trials have evaluated itraconazole for tinea capitis [26,29,30]. These trials have reported similar efficacy of two-week courses of itraconazole and terbinafine in children with tinea capitis caused by Trichophyton species [30] as well as similar efficacy between six-week courses of itraconazole and griseofulvin in a trial population in which most patients had M. canis infections [29].

In addition, a randomized trial that compared the efficacy of two-week courses of itraconazole, fluconazole, or terbinafine (with an additional week of treatment as needed) and six-week courses of griseofulvin in children with tinea capitis caused by Trichophyton species did not find statistically significant differences in efficacy between the treatment groups [26].

●Adverse effects – Potential side effects of itraconazole include gastrointestinal distress, skin eruptions, headache, sleepiness, dizziness, and liver function test abnormalities. Liver function tests are indicated prior to treatment in patients with pre-existing hepatic dysfunction. These tests also should be obtained in patients treated for longer than one month.

ADJUNCTIVE MEASURES — 

The management of tinea capitis includes measures to reduce the spread of the infection and the likelihood of recurrence (algorithm 1).

Antifungal shampoo — We advise patients with tinea capitis to use a shampoo with antifungal properties (eg, selenium sulfide 1% or 2.5%, ciclopirox 1%, or ketoconazole 1% or 2% shampoo) at least twice weekly (if feasible based on hair texture and washing preferences) to decrease shedding of fungal spores [31,32].

Continuation of twice-weekly antifungal shampoo for a few months after resolution of infection is proposed to help decrease the rate of reinfection from the local environment.

Cohabitant and household measures

Cohabitants — Household members of an individual diagnosed with tinea capitis should be physically examined for signs of tinea capitis and treated simultaneously if tinea capitis is detected.

Asymptomatic carriers of dermatophytes may serve as reservoirs for recurrent infection. Because of this possibility, we generally advise household members to use an antifungal shampoo for two to four weeks [33].

Household members begin using the shampoo when the infected individual begins treatment for tinea capitis. However, data are insufficient to confirm benefit of this intervention.

Personal care and household items — Children with tinea capitis should avoid sharing hair care tools and headwear (eg, helmets or hats) with other individuals. Pillowcases should not be shared. In addition, participation in sports with head-to-head contact should be avoided [34].

Combs and hair-trimming equipment used by the infected individual should be cleaned and disinfected (eg, with household bleach) [35]. Bedding and towels used by the infected individual should be washed. Fabrics such as baby seats or pet bedding that are frequently in direct contact with the affected individual or pet should be washed, if possible.

Pets — Cats or dogs (especially kittens and puppies) or other animals (eg, cows, guinea pigs, and other animals) may be reservoirs for infection. The animals can have clinical signs of dermatophyte infection with scaling and hair loss but can also be asymptomatic carriers.

If there is an outbreak of tinea in a household, the pet (especially if new) should be evaluated by a veterinarian. The animal should also be evaluated if the patient or other household members experience recurrent dermatophyte infections [36].

SCHOOL ATTENDANCE — 

We do not advise removal of children from school for tinea capitis.

PROGNOSIS — 

The prognosis of tinea capitis is excellent, with complete clearance occurring in most patients after a course of treatment. Complete hair regrowth occurs in most children with hair loss. Patients with prolonged or severe infections (eg, kerion, favus) have the greatest risk for permanent alopecia.

Rarely, dermatophyte infections progress to deep tissue infections, pseudomycetomas, or disseminated infections, including potentially life-threatening infections [37]. Some risk factors may include chronic dermatophyte infection, solid organ transplantation, use of topical immunosuppressants, CARD9 mutations, diabetes, and trauma. Invasive dermatophyte infections involving the scalp have been reported [37].

There is at least one report of culture-proven fungemia in an immunocompetent patient after surgical excision of a kerion due to Trichophyton mentagrophytes [38].

ASSESSING RESPONSE — 

Clinical follow-up to assess for clinical clearance should be performed at the end of therapy to assess for clinical cure. Signs of ongoing infection include persistent erythema, scale, or drainage.

In patients who have experienced recurrent tinea capitis, we typically perform a fungal culture to confirm clearance after treatment. If live fungus is still detected by culture, the patient should be reassessed for clinical findings supportive of retreatment. (See "Tinea capitis: Clinical features and diagnosis", section on 'Fungal culture'.)

TREATMENT FAILURE

Determining cause — When the response to treatment is poor, the possibility of suboptimal treatment administration, incorrect diagnosis, and reinfection should be assessed (algorithm 1).

●Suboptimal treatment administration – Adherence to the treatment regimen should be assessed. This includes a review of the actual frequency of treatment and dose ingested, as well as the method of drug administration. For example, griseofulvin is much more effectively absorbed when given with fatty foods. (See 'Griseofulvin' above.)

If the patient has been unable to take the medication as prescribed, measures to improve adherence (eg, education or change in medication formulation) should be taken to increase the likelihood of adequate treatment.

●Incorrect diagnosis – Tinea capitis can resemble a variety of other disorders. Confirmatory testing should be performed if the diagnosis is in question. (See "Tinea capitis: Clinical features and diagnosis", section on 'Diagnosis' and "Tinea capitis: Clinical features and diagnosis", section on 'Differential diagnosis'.)

●Reinfection – The possibility of reinfection from contact with an infected individual or pet, contaminated fomites, or an asymptomatic carrier of the dermatophyte should be considered when tinea capitis recurs after treatment. (See 'Cohabitant and household measures' above.)

Adjusting treatment — When suboptimal treatment administration, diagnostic error, and reinfection do not appear to be factors in treatment failure, adjusting the treatment regimen may be beneficial. Options include switching to a different oral antifungal drug or extending the course of the current antifungal drug (algorithm 1).

In most cases, we switch the antifungal drug (eg, from griseofulvin to terbinafine or from terbinafine to griseofulvin or alternative oral antifungal therapies). However, for patients with known or suspected M. canis infections who were initially treated with griseofulvin and are improving on treatment, we often extend the course of griseofulvin up to a total of 12 weeks and increase the dose of griseofulvin (microsize to 25 mg/kg per day or ultramicrosize to 15 mg per day) in children receiving lower doses. Griseofulvin appears to be more effective than terbinafine for M. canis infections. (See 'Selecting an oral antifungal agent' above and 'Griseofulvin' above.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dermatophyte infections".)

SUMMARY AND RECOMMENDATIONS

●Overview – Tinea capitis is a fungal infection of the scalp that most often occurs in children (picture 1A-F). The treatment of tinea capitis involves treatment with an oral antifungal drug and adjunctive use of an antifungal shampoo. (See 'Overview' above and 'Adjunctive measures' above.)

●Timing of treatment – Oral antifungal therapy for tinea capitis should be started promptly. Delaying treatment may increase the risk for disease progression, permanent hair loss, and disease transmission.

We begin oral antifungal treatment once tinea capitis is either confirmed with a potassium hydroxide (KOH) preparation or highly suspected based on the clinical presentation. In general, we do not wait for fungal speciation results prior to starting therapy. (See 'Overview' above.)

●Selection of an oral antifungal drug for most children – For most children, we suggest oral griseofulvin or terbinafine therapy because these drugs have been the most extensively studied for tinea capitis (Grade 2C) (algorithm 1). Alternative options include oral fluconazole and itraconazole. (See 'Preferred treatments' above and 'Alternative therapies' above.)

Factors that influence the selection of either griseofulvin or oral terbinafine include the suspected causative organism, clinician familiarity with a particular drug, formulation preference (only griseofulvin is available as a suspension), and drug access.

There may be advantages of treatment of Trichophyton tonsurans infections with oral terbinafine and treatment of Microsporum canis infections with griseofulvin. This often influences our choice of initial treatment when we suspect infection with one of these organisms. (See 'Role of the causative organism' above.)

●Infants and adults – For infants with tinea capitis, we suggest oral fluconazole because of the extensive experience with oral fluconazole in infants for other indications. Adults with tinea capitis are typically treated with terbinafine, itraconazole, fluconazole, or griseofulvin. (See 'Selecting an oral antifungal agent' above and 'Special populations' above.)

●Adjunctive antifungal shampoo – We advise patients with tinea capitis on oral antifungal agents to also use a shampoo with antifungal properties (eg, selenium sulfide 1% or 2.5%, ciclopirox 1%, or ketoconazole 1% or 2% shampoo) at least twice weekly to decrease shedding of fungal spores. (See 'Antifungal shampoo' above.)

●Management of close contacts and habitat – Examples of adjunctive measures that may be beneficial include examination of household members for tinea capitis, treating household members with antifungal shampoo, cleaning certain household items, and instructing contacts to avoid sharing hair care tools and headwear with an infected individual. Children with tinea capitis do not need to be kept out of school. (See 'Cohabitant and household measures' above.)

●Follow-up and recognition of treatment failure – Although tinea capitis has an excellent prognosis, clinical follow-up is necessary to ensure adequate treatment. Signs of treatment failure include persistent erythema, scale, or drainage. Common causes of treatment failure include inconsistent or improper treatment administration, an incorrect diagnosis, and reinfection. (See 'Treatment failure' above.)