Treatment of tinea capitis

Aims of Tinea capitis treatment include:

• eradication of the organism, resulting in both a clinical and mycological cure as quickly and safely as possible
• alleviation of symptoms
• prevention of scarring
• reduction of transmission to others.

Treatment should ideally be initiated following confirmation of the presence of fungus (either by conducting microscopy at the patient side or waiting for culture)

• in high-risk populations, awaiting results increases delay and may further increase spread, hence in the presence of following strong predictive factors for tinea capitis, treatment may be initiated immediately
  • presence of a kerion
  • presence of very typical features of scaling, lymphadenopathy or alopecia

Treatment options include:

• topical therapy
  • topical therapy alone is not recommended for the management of tinea capitis - topical agents used currently do not eliminate hair shaft infections, which usually result in relapse of the disease in most cases. But they can be used in the early stages of therapy as an adjunct to oral therapy
  • used to reduce transmission of spores
  • povidone–iodine, ketoconazole 2% and selenium sulfide 1% shampoos have all shown efficacy in this context
  • all family members should be treated with ketoconazole shampoo at least twice weekly for two weeks
    
    
• oral therapy
  • optimal treatment regimen varies according to the dermatophyte involved. Therefore, treatment protocols should reflect local epidemiology and be based on the most likely culprit organism
  • consult expert advice
    
    
  • Griseofulvin - for 6–8 weeks
    • is the only licensed treatment for tinea capitis in children, in the UK
    • has a high mycological cure and efficacy rates (between 80%–96%)
    • available in several forms - micronized, ultramicronized and suspension
    • standard licensed treatment protocol for those aged > 1 month is
      • 1 g in children weighing > 50 kg
      • 15– 20 mg/kg daily in single or divided doses if < 50 kg
      • in resistance cases, up to 25 mg/kg may be required for more prolonged periods
      • taking the drug with fatty food may increase absorption and improve bioavailability
      • dosage recommendations vary according to the type of formulation used and how easily it is absorbed
    • evidence suggests that the drug is less effective against Trichophyton species in the clinical setting
      • higher doses for longer periods (12–18 weeks) may be required in Trichophyton infections
        
        
  • terbinafine
    • active against all dermatophytes, but has much higher efficacy against Trichophyton species than Microsporum
      • meta-analysis of RCTs shows that 2–4 weeks of terbinafine is at least as effective as 6–8 weeks of griseofulvin in T. tonsurans infections
    • unlicensed for use in children in the U.K
    • terbinafine dose by body weight
      • < 20 kg 62.5 mg per day for 2–4 weeks
      • 20–40 kg 125 mg per day for 2–4 weeks
      • > 40 kg 250 mg per day for 2–4 week
        
        
  • itraconazole
    • is active against both Microsporum and Trichophyton species and is now the preferred agent in the majority of European countries
      • not licensed for children in the U.K. aged 12 years and under
    • doses of 50–100 mg daily for 4 weeks or 5 mg/kg daily for 2–4 weeks have comparable efficacy with griseofulvin or terbinafine
      
      
  • fluconazole
    • has been used as an alternative to terbinafine
    • use has been relatively limited because of side-effects and because it confers no cost advantage
    • not licensed for the treatment of tinea in children aged < 10 years in the U.K (1,2)

Treatment of a kerion

1. Treatment of kerions - systemic treatment eg with terbinafine may be needed for 12-16 weeks
2. Surgical excision should be avoided

Treatment failure

• may be due to
  • lack of compliance – especially in long treatment courses
  • suboptimal absorption of drug
  • relative insensitivity of the organism
  • reinfection
• if clinical signs have improved but fungi can still be isolated at the end of treatment - it is reasonable to continue therapy for a further 2–4 weeks
• if there has been no clinical response, it is imperative to ensure that the antifungal therapy is appropriate for the causal organism identified on culture. If so, the options then are
  • to increase the dose or duration of the original drug
  • to change to an alternative agent, for example griseofulvin®itraconazole (for M. canis); terbinafine ® itraconazole (for T. tonsurans); or itraconazole ®terbinafine (for T. tonsurans) (1) .

Carriers

• optimal management of asymptomatic carriers (i.e. those individuals without overt clinical infection who are culture positive) is unclear
• current management practice depends on the spore load
• asymptomatic carriage is highest in contacts of individuals with T. tonsurans infection,67 but can occur in M. audouinii outbreaks as well
• asymptomatic carriers with a high spore load – oral therapy can be prescribed
• if the spore load is low, carriage may be eradicated with topical treatment alone, but close follow-up is needed, with repeat mycology, to ensure that treatment has been effective (1)

Check the respective Summary of Product Characteristics (SPCs) before prescribing any of the medications mentioned in the text above.

Reference:

• (1) Fuller LC et al. British Association of Dermatologists' guidelines for the management of tinea capitis 2014. Br J Dermatol. 2014;171(3):454-63.
• (2) Bennassar A, Grimalt R. Management of tinea capitis in childhood. Clin Cosmet Investig Dermatol. 2010;3:89-98