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Tinea capitis


Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Courtesy of Dr. E. E. Merika

Tinea capitis is a fungal infection of the scalp caused by dermatophyte species, most commonly Microsporum and Trichophyton , which are identified on microscopy and culture. Infections localized to the inside of the hair shaft, known as endothrix infections, are most commonly caused by Trichophyton species and principally occur in children, although they can occasionally be seen in adults. However, the condition is rare in adults and investigating for underlying causes of immunocompromise should be considered in these cases. Ectothrix infections, which affect both the inside and the outside of the hair shaft, are most commonly caused by Microsporum species and almost always affect children.

Tinea capitis typically presents as patchy alopecia with varying degrees of erythema and scale with associated lymphadenopathy. Ectothrix infections may appear as non-inflammatory patches of alopecia with fine scale. By contrast, a ‘black dot’ appearance, caused by breakage of hair shafts, indicates an infection with an endothrix species such as Trichophyton . The term kerion celsi refers to tinea capitis presenting as a boggy, tender swelling caused by the host’s inflammatory response. This can be misdiagnosed as a bacterial abscess. Secondary bacterial infection contamination can occur, which is rarely of pathological significance but can confuse the diagnosis if fungus is not suspected.

Scrapings and samples of loose fractured hairs should be processed for microscopy and culture. Swabs (taken using bacterial transport media) may provide an accurate, non-invasive alternative. Wood lamp examination may also aid diagnosis (ectothrix Microsporum exhibit green fluorescence), and trichoscopy is a useful, non-invasive diagnostic adjunct and may help distinguish the condition from alopecia areata.

Management Strategy

Treatment of tinea capitis is with oral antifungal agents as topical therapy alone is insufficient. Topical antifungal creams and shampoos may help when used in conjunction with systemic treatment in reducing infectivity by reducing fungal elements and the shedding of spores but should not be used alone or as prophylaxis as this does not reduce reinfection rates.

The aim is to eradicate the organism to prevent scarring and further transmission to others. Where possible, one should await confirmation of a fungal infection. However, this will delay treatment and can result in further spread; therefore, in patients presenting with kerion or obvious clinical signs (scaling, alopecia, or lymphadenopathy) it is reasonable to start treatment. The response of different dermatophyte species to different systemic agents is variable and treatment should be tailored accordingly. General consensus is that griseofulvin is more effective for the treatment of Microsporum infections and terbinafine against Trichophyton. While griseofulvin is an established therapeutic, evidence suggests that newer systemic antifungals (terbinafine and itraconazole) are equally safe and may be more cost effective. Their shorter treatment duration may also increase compliance. This is reflected in changes to medication licensing and prescribing practices in Europe and the United States.

Griseofulvin is a fungistatic drug, typically given at a dose of 15–20 mg/kg/day (in single or divided dose) for those <50 kg and 1 g/day for those >50 kg (in single or divided dose) for 6–8 weeks ( British Association of Dermatology ). Side effects include gastrointestinal disturbance, rash, and headache. Griseofulvin is contraindicated in pregnancy. In adults with tinea capitis due to Trichophyton species, terbinafine is given for 2–4 weeks (62.5 mg/day for those <20 kg; 125 mg/day for those 20–40 kg and 250 mg/day for those >40 kg) ( British Association of Dermatology ). Terbinafine is a fungicidal drug and is generally well tolerated; side effects are less commonly seen than with griseofulvin (gastrointestinal upset and rash).

Itraconazole has both fungistatic and fungicidal activity and can be given second-line if required. Itraconazole has activity against both Microsporum and Trichophyton species (50–100 mg/day for 4 weeks, or 5 mg/kg/day for 2–4 weeks).

The use of intermittent or pulsed treatment regimens using itraconazole or fluconazole has been explored, utilizing the long half-life of these agents in keratin. While this does not appear to confer any additional benefit in terms of cure, it may reduce the cost of treatment and compliance.

As a gold standard, mycologic cure should be confirmed with appropriate sampling following completion of treatment. Family members should be screened where possible to detect subtle subclinical infection/carriage to prevent relapse and reinfection of the index case.

Specific Investigations

  • Examination of hair and scalp scale by direct microscopy and culture

  • Wood lamp examination

  • Dermoscopy/trichoscopy

  • Screen contacts, particularly siblings, where possible

Efficacies and merits of the cotton swab technique for diagnosing tinea capitis in the pediatric population

Le M, Gabrielli S, Ghazawi FM, et al. J Am Acad Dermatol 2020; 83(3): 920–922.

A prospective study of 25 children with tinea capitis showed 100% concordance between swab and scraping results, and both endothrix and ectothrix species were isolated.

Trichoscopy of tinea capitis: a systematic review

Waskiel-Burnat A, Rakowska A, Sikora M, et al. Dermatol Ther (Heidelb) 2020; 10(1): 43–52.

A systematic review identified 37 eligible articles. The most commonly occurring dermatoscopic findings were of comma, corkscrew, barcode, bent, and block hairs, as well as perifollicular and diffuse scaling. The authors also conclude that trichoscopy may help distinguish between Microsporum and Trichophyton causes of tinea capitis.

Trichoscopy in paediatric patients with tinea capitis: a useful method to differentiate from alopecia areata

Ekiz O, Sen BB, Rifaioğlu EN, et al. J Eur Acad Dermatol Venereol 2014; 28(9): 1255–8.

A study of 25 children (15 with tinea capitis and 10 with alopecia areata) identified distinctive features on dermoscopy of the hair and scalp in children with fungal infections, including broken, dystrophic, corkscrew, barcode, and comma hairs, as well as black dots.

Screening for asymptomatic carriage of Trichophyton tonsurans in household contacts of patients with tinea capitis: results of 209 patients from south London

White JM, Higgins EM, Fuller LC. J Eur Acad Dermatol Venereol 2007; 21: 1061–4.

Over 50% of household contacts in this study had positive fungal cultures (7.1% were overt infection and 44.5% silent fungal carriage). Children under 16 were most likely to be affected ( p <0.01).

First-Line Therapies

  • Griseofulvin (generally more effective against Microsporum species)

  • A

  • Terbinafine (generally more effective against Trichophyton species)

  • A

British Association of Dermatologists’ guidelines for the management of tinea capitis 2014

Fuller LC, Barton RC, Mohd Mustapa MF, et al. Br J Dermatol 2014; 171(3): 454–63.

Griseofulvin remains the only licensed treatment for tinea capitis in children in the UK. Griseofulvin generally remains first-line treatment for Microsporum infections and terbinafine for Trichophyton species . Terbinafine requires a shorter course of treatment and compliance may therefore be higher. Itraconazole is a safe and effective second-line option. Other options, including fluconazole and voriconazole, can be used in refractory, exceptional cases.

‘ Children receiving appropriate therapy should be allowed to attend school or nursery ’.

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