Tinea Capitis (1 of 7)

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Tinea Capitis (1 of 7)

ALTERNATIVE DIAGNOSISNo

Yes

A Non-pharmacological therapy• Patient education

B Pharmacological therapyOral AntifungalFirst-line Agents:• Griseofulvin• Terbinafi neSecond-line Agent:• ItraconazoleAlternative Agents:• Fluconazole• VoriconazoleAdjunctive � erapy - Topical AntifungalsAny one of the following:• Ciclopirox 1%• Ketoconazole 2%• Povidone-Iodine• Selenium sulfi de 1%, 2.5% shampoo

2DIAGNOSIS

Clinical presentation, microscopy &/or culture

confi rm tinea capitis?

1Patient (usually child) presents w/ 1 or several round patches of scale on

the scalp or alopecia suggestive of tinea capitis

Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.

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1 TINEA CAPITIS

• Infection of the scalp & hair follicles including surrounding skin caused by contagious dermatophytes• Most common in crowded areas as infection originates from contact w/ a pet or an infected person, & asymp-

tomatic carriage persists indefi nitely• Primarily aff ects children

- Also occurs in adults, women more commonly affl icted than men Clinical Presentation• Patients usually present w/ patches of hair loss on the scalp w/ accompanying scaling &/or black dots within

the hair follicle orifi ce• Patients present w/ any of several diff erent clinical patterns of tinea capitis infection• Cervical or occipital lymphadenopathy is typically presentPatterns of Clinical Infection• Host T-lymphocyte response determines clinical infection patternsSeborrheic Dermatitis Type• Diff use or patchy, fi ne, white, adherent scales on the scalp resembling dandruff • � ere are tiny perifollicular pustules &/or hair stubs (hair shafts breaking above the scalp surface) from the

scalpBlack Dot Pattern• Patient has areas of noninfl ammatory hair loss that are well demarcated; hairs are broken off at the follicular

orifi ce & debris left in the opening appears as a black dot• Color of “dot” will depend on hair color; bald spots may be a few to several centimeters in diameterGrey Patch Pattern• Patient has circular patches w/ hair loss & fi ne scaling which is dull grey in color• Greying is caused by the spores covering the aff ected hairInfl ammatory Forms/Kerion• Intense infl ammation manifests as single or multiple, boggy, tender areas of alopecia w/ pustules on &/or in

surrounding skin • Hypersensitivity to fungus may form a boggy, indurated, tumorlike mass that exudes pus & referred to as

kerion, which may lead to a scarring hair lossDiff use Pustular Type• Discrete pustules or scabbed areas without scaling or signifi cant hair loss• Pustules result from superimposed bacterial infectionFavus• An infl ammatory variant characterized by yellow cup-shaped crusted lesions called scutula• Commonly seen in the Middle East & North Africa, caused by T schoenleinii

2 DIAGNOSIS

• All specimens obtained (scalp scrapings, hair follicles) should undergo microscopy & culture, w/ causative organism identifi ed

Microscopy• Provides the most rapid means of diagnosis but may not always be positive in aff ected patients• Scalp scales &/or hair are mounted in 10-30% Potassium hydroxide (KOH) soln, gently heated & viewed under

light or fl uorescence microscope• Positive results reveal hairs and scales invaded by spores &/or hyphaeCausative Agents• Large-spored endothrix pattern chains of large spores within hair (Trichophyton tonsurans, T violaceum)• Large-spored ectothrix (T verrucosum, T mentagrophytes)• Small-spored ectothrix randomly arranged in masses inside & on the surface of the hair shaft (Microsporum

canis, M audouinii)Dermoscopy (Trichoscopy)• A noninvasive in vivo imaging technique that may aid in the diagnosis of tinea capitis, especially in patients

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B PHARMACOLOGICAL THERAPYPrinciples of � erapy• � erapy aims to eradicate the infection & its symptoms in a safe & quick manner, to reduce long-term eff ects

(eg scarring), & to prevent further transmission• May start treatment based on symptomatology while waiting for diagnostic confi rmation• Treatment of choice is based on main pathogenOral Antifungals - First-line AgentsGriseofulvin• Treatment of choice for tinea capitis, but length of therapy can aff ect patient compliance• Preferred for patients infected w/ Microsporum species (M canis, M audouinii)• Fungistatic & inhibits the mitosis of dermatophytes by interacting w/ microtubules & disrupting the mitotic

spindle• Eff ects: Has been used for many decades w/ proven safety & effi cacy in treating pediatric tinea capitis• Clinical response is assessed after 6-8 weeks; treatment should be discontinued after obtaining negative cultures

& negative KOHTerbinafi ne• Fungicidal as it inhibits the membrane-bound enzyme in the biosynthetic pathway of sterol synthesis of the

fungal cell membrane • Preferred for patients infected w/ Trichophyton species (T tonsurans, T violaceum, T soudanense)• Safety in children for tinea capitis has been established• Eff ects: Has been shown to be at least as eff ective as Griseofulvin• Duration of treatment is shorter than w/ Griseofulvin

- Treatment for 8-10 weeks may be needed if used to treat Microsporum tinea capitis


A NON-PHARMACOLOGICAL THERAPYPatient Education• Educate patient regarding contagiousness of the disease

- Identify & treat asymptomatic carriers in household members to avoid disease transmission - Avoid sharing hats, combs, towels, toys w/ an aff ected individual - Treat or remove an animal or pet infected w/ M canis - Disinfect belongings of infected patients such as hairbrushes, combs, beddings, etc

• Children may attend school while being treated• Follow-up visits are needed for assessment of treatment response

- Treatment course may be extended if patient is still symptomatic after completion of therapy

2 DIAGNOSIS (CONT’D)

Culture• Allows accurate identifi cation of organism but results may take up to 4 weeks• Use of Sabouraud agar w/ 1 or more plates w/ cycloheximide is recommended• Results may be positive even when microscopy is negative• Necessary in hair fungal infections to identify the source of infection & verify the infecting speciesWood’s Light Exam• Useful for certain ectothrix infections (eg M canis, M audouini, M rifalieri)• If present, will cause hair to fl uoresce bright green• T tonsurans which causes most tinea capitis does not fl uoresceAlternative Diagnosis• Seborrheic dermatitis• Alopecia areata • Psoriasis• Bacterial folliculitis

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B PHARMACOLOGICAL THERAPY (CONT’D)Oral Antifungals - Second-line AgentItraconazole• Fungistatic & fungicidal • Eff ects: Studies have shown it to be as eff ective as Griseofulvin & Terbinafi ne• May be used against both Trichophyton & Microsporum species• Duration of treatment is shorter than w/ Griseofulvin Oral Antifungals - Alternative AgentsFluconazole• Fungistatic triazole• Eff ects: Some small studies in children have shown that it may be an eff ective alternative to Griseofulvin• Duration of treatment is typically shorter than GriseofulvinVoriconazole• A 2nd generation triazole antifungal agent• More potent against dermatophytes but not commonly used due to its undesirable side eff ects (eg visual

disturbances, respiratory problems, headache, abdominal pain, etc)Adjunctive � erapyTopical Antifungals• Eg Ciclopirox 1%, Ketoconazole 2%, Selenium sulfi de 1%, 2.5% shampoo, Povidone-iodine• Topical agents are used as adjunctive therapy to control spore loads in patients & asymptomatic carriersOther � erapyCorticosteroids• A short course may be given for kerions & severely infl amed lesions together w/ antifungal agents• � is may reduce symptoms & lessen scarring• Further studies are needed in regards to the use of this drug for tinea capitis

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Dosage Guidelines

ANTIFUNGALS (ORAL)

DrugDosage

RemarksChildn Adults

Fluconazole 3-6 mg/kg/day PO x 4-6 wk

150 mg PO once wkly or8 mg/kg PO once wkly x 8-12 wk

Adverse Reactions• GI eff ects (abdominal pain, diarrhea,

fl atulence, N/V, taste disturbance, elevated liver enzyme levels); Hematological eff ect (epidermal necrolysis)

Special Instructions• Use w/ caution in patients w/ renal &

hepatic impairment

Griseofulvin 10 mg/kg/day PO as a single or in divided doses

500 mg PO 24 hrly or in divided doses

Adverse Reactions• CNS eff ect (headache); Dermatological

eff ect (rash, urticaria); GI eff ects (N/V, diarrhea, epigastric distress)

Special Instructions• Monitor hepatic, renal & hematopoietic

function if used long term• Clinical response is assessed after 6-8 weeks

Itraconazole 3-5 mg/kg/day PO x 4-6 wk

200 mg PO 24 hrly x 15 daysor100 mg PO 24 hrly x 4-8 wk

Adverse Reactions• GI eff ects (dyspepsia, abdominal pain,

nausea, constipation, diarrhea, increase in liver enzyme levels, hepatitis, cholestatic jaundice); CNS eff ects (headache, dizziness); Hypersensitivity reactions (pruritus, rash, urticaria, angioedema)

• Alopecia, edema & hypokalemia w/ prolonged treatment

Special Instructions• Avoid oral soln in childn since it may

cause diarrhea • Use w/ caution in patients at risk for heart

failure, hepatic impairment & renal insuffi ciency

• In patients w/ hypochlorhydria, absorption may be improved by administering the drug w/ an acidic drink (eg cola)

All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated.

Not all products are available or approved for above use in all countries.Products listed above may not be mentioned in the disease management chart but have been

placed here based on indications listed in regional manufacturers’ product information.Specifi c prescribing information may be found in the latest MIMS.

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All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated.



1Product combinations w/ corticosteroids are available. Please see the latest MIMS for specifi c formulations.

Dosage Guidelines

ANTIFUNGALS (ORAL) (CONT’D)

DrugDosage

RemarksChildn Adults

Terbinafi ne <20 kg: 62.5 mg PO 24 hrly20-40 kg: 125 mg PO 24 hrly>2 yr & >40 kg:250 mg PO 24 hrly x 4 wk

250 mg PO 24 hrly x 4 wk

Adverse Reactions• GI eff ects (N/V diarrhea, abdominal pain,

loss or disturbance of taste, liver dysfunction); CNS eff ect (headache); Hypersensitivity reactions (rash, urticaria)

Special Instructions• Do not use in patients w/ hepatic impairment• Perform liver function tests in all patients

before starting oral therapy• Use w/ caution in patients w/ psoriasis• Reduce dose in patients w/ renal impairment

TOPICAL ANTIFUNGALS

Drug Available Strength Dosage Remarks

Imidazoles

Clotrimazole1 1% lotion cream Apply directly on lesions 8-12 hrly x 2-4 wk

Adverse Reactions• Dermatological eff ects (local irritation,

atrophy, striae)Special Instructions• Use w/ caution in pregnant & nursing

women• Contraindicated in patients w/ skin TB,

measles, chickenpox, herpes simplex, & syphilitic skin infection

Econazole1 oint, cream Apply 12-24 hrly Adverse Reactions• Dermatological eff ects (burning sensation,

maceration, irritation), Ophthalmic eff ects (ocular hypertension, glaucoma), Endocrinological eff ects (DM, osteoporosis, growth delay in childn, suppression of hypothalamus-pituitary-adrenal axis)

Special Instructions• Use w/ caution in prolonged therapy, in

children, pregnant & nursing women• Avoid contact w/ eyes• Contraindicated in patients w/

hypersensitivity, bacterial & viral infections, acne vulgaris, rosacea© MIM

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1Product combination w/ Chlorhexidine is available. Please see the latest MIMS for specifi c formulations.

Dosage Guidelines

TOPICAL ANTIFUNGALS (CONT’D)

Drug Available Strength Dosage Remarks

Imidazoles (Cont’d)

Ketoconazole 2% shampoo Apply to hair & rinse off after 3-5 min twice wkly

Adverse Reactions• Dermatological eff ects (occasional local irrita-

tion, hypersensitivity, mild burning sensation, erythema, pruritus)

Miconazole 2% cream Apply 12 hrly x 2-5 wk

Adverse Reactions• Dermatological eff ects (burning sensation,

irritation, allergic contact dermatitis)Special Instructions• Discontinue use if sensitization & irritation

develops; avoid contact w/ eyes• Use w/ caution in pregnancy & childn <2 yr

Others

Povidone-iodine

7.5% cleanser, scalp lotion 10% soln

Apply to hair & rinse off after 5-10 min twice wkly

Adverse Reactions• Dermatological eff ects (occasional local irrita-

tion, hypersensitivity, mild burning sensation, erythema, pruritus

Selenium sulfi de

1% shampoo2.5% shampoo

Tolnaftate1 1% cream1% oint1% soln

Apply 12 hrly x 2-3 wk

Adverse Reactions• Dermatological eff ects (pruritus, irritation)Special Instructions• Use w/ caution in childn <2 yr• Avoid contact w/ eyes

All dosage recommendations are for non-pregnant & non-breastfeeding women,& non-elderly adults w/ normal renal & hepatic function unless otherwise stated.



Please see the end of this section for the reference list.

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© MIMS 2019

Tinea Capitis (1 of 7)

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