Tinea capitis is a common superficial
fungal infection of the scalp in children, particularly in those of African descent. Trichophyton tonsuran, an anthropophilic dermatophyte, is responsible for the majority of cases in North America. The clinical presentations are variable and include: (i) a "seborrheic" form that is scaling, often without noticeable
hair loss; (ii) a pustular, crusted pattern, either localized or more diffuse; (iii) a "black dot" variety characterized by small black dots within areas of
alopecia; (iv) a kerion, which is an inflammatory mass; and (v) a scaly, annular patch. Most experts still consider
griseofulvin to be the
drug of choice, but recommend a higher dosage of 20-25 mg/kg/day for 8 weeks because of the increase in treatment failures. Despite a history of having an excellent tolerability profile, the long treatment course and higher doses required for
griseofulvin have led to consideration of new
antifungal agents for this
infection.
Terbinafine,
itraconazole, and
fluconazole compartmentalize in skin, hair, and nails, thereby allowing shorter treatment courses of < or =4 weeks. All have generally been shown to be effective in the treatment of
tinea capitis and appear relatively well tolerated, with gastrointestinal symptoms being the most common adverse effect. Monitoring for liver
enzyme elevations is generally unnecessary if
therapy is limited to </=4 weeks. As more data regarding efficacy, tolerability, and dose administration becomes available, one or more of these new
antifungal agents may become first-line
therapy for
tinea capitis. For now, we recommend their use in cases of treatment failure or recurrent noncompliance. Our personal preference in the younger child is
fluconazole. It has a favorable tolerability profile and is available in liquid form. In the older child who can take a
tablet,
terbinafine is recommended. More data is available on this
drug in the treatment of
tinea capitis than the other two, and it is the least expensive. Although the oral
antifungal agents are the most important aspect of
therapy, adjunctive
therapy may be beneficial. Sporicidal shampoos, such as
selenium sulfide, can aid in removing adherent scales and hasten the eradication of viable spores from the scalp in the hope of decreasing the spread of this
infection. The use of
corticosteroids for the treatment of kerions is controversial. Many of the studies have design flaws or show variable results. We recommend either a short burst of oral
corticosteroids or topical
corticosteroids in patients with the most severe disease.