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Chapter 86: Tinea Capitis

Catherine Reilly; Kaiane Habeshian; A. Yasmine Kirkorian

TINEA CAPITIS

Therapeutic Approach

Tinea capitis is a dermatophyte fungal infection that targets the hair follicle and shaft. It is commonly found in children but may also occur in adults. Tinea capitis presents with alopecia, scaly patches, pruritus, and lymphadenopathy. Severe cases may present with a kerion, a painful and inflamed abscess that can lead to scarring and permanent alopecia.a1

Zoophilic organism infections present with more inflammation than anthropophilic organisms.2 In ectothrix infections, fungi surround the outside of the hair shaft; in endothrix infections, species invade the hair follicle. This may cause hair breakage at the opening of the follicle, causing a “black-dot” appearance. Favus infections have a yellow appearance that may be nodular, crusted, or scutular.1-4

Clinical presentation and geographic location may guide empiric treatment, though ultimately cultures are needed to ascertain the exact species. Immigrant populations may carry species uncommon to the United States; for example, T. violaceum and T. soudanense have recently been identified among African patients.5 Recent literature suggests that terbinafine may be considered first-line treatment in the United States given the predominance of T. tonsurans, for which terbinafine may be most effective.4-11 In contrast, griseofulvin is more efficacious for zoophilic species. Fluconazole can be used for children under 2 years of age, griseofulvin for children age 2 years and older, and terbinafine for children ≥4 years of age or ≥20 kg.8-10 See Table 86-1.

Table 86-1Tinea Capitis Treatment Table
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Table 86-1 Tinea Capitis Treatment Table
MEDICATION NAME SPECIES DOSING DURATION ADVERSE EFFECTS SUGGESTED MONITORING NOTES LEVEL OF EVIDENCE
Systemic Therapy
Griseofulvin (microsize)b approved for children ≥ 2 y

M. canis

T. violaceum

T. verrucosum

 20-25 mg/kg/d (max 1g/d) ≥6 wk duration until clinically cleared

Abdominal discomfort, nausea, vomiting > pruritis, urticaria, scaling.12 Should be taken with fatty foods.8

Rare DRESSc

 Serum hepatic enzymes should be monitored if therapy extends past 8 wk.8

Griseofulvin is preferred for Microsporum.4,9-10

T. schoenleinii has shown resistant to griseofulvin and should be avoided for treatment.13

IA9

IB10

IV8
Griseofulvin (ultra-microsize)

M. canis

T. violaceum

T. verrucosum

 10-15 mg/kg/d ≥6 wk duration until clinically cleared Abdominal discomfort, nausea, vomiting > pruritis, urticaria, scaling.12 Should be taken with fatty foods.8 Serum hepatic enzymes should be monitored if therapy extends past 8 wk.8

Griseofulvin is preferred for Microsporum.4,9-10

T. schoenleinii has shown resistance to griseofulvin and should be avoided for treatment.13

IA9,11

IB10

IV8
Terbinafine tablets (250 mg)b approved for children ≥2 y for onychomycosis, should be considered for off-label use in this age group

T. tonsuranus

T. violaceum

T. schoenleinii

Either of the following dosing schedules may be used.

<25 kg: 125 mg/d

25-35 kg: 187.5 ...

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