Medical Care
Choice of treatment for tinea capitis is determined by the species of fungus concerned, the degree of inflammation, and in some cases, by the immunologic and nutritional status of the patient.
After microscopic or culture confirmation, medical therapy should be initiated. Systemic administration of griseofulvin provided the first effective oral therapy for tinea capitis, and resistance to the medication has remained minimal. [28, 29, 30] Dosing in the pediatric population is weight based. Recommended dosing is 20-25 mg/kg/day in single or two divided doses for microsized griseofulvin or 15-20 mg/kg/day in single dose or two divided doses for ultramicrosized griseofulvin. [31] The duration of treatment should be between 4 and 6 weeks.
Topical treatment alone usually is ineffective and is not recommended for the management of tinea capitis.
Newer antifungal medications, such as itraconazole, terbinafine, and fluconazole, have been reported as effective alternative therapeutic agents for tinea capitis. [28, 29] Of these agents, itraconazole and terbinafine are used most commonly. There may be some advantage to giving itraconazole with whole milk to increase absorption. [32] Data suggest that itraconazole and terbinafine have the highest mycological cure rates in children (79% and 81%, respectively), while griseofulvin and terbinafine have the highest complete cure rate (72% and 92%, respectively). Griseofulvin is more effective against Microsporum infections, while terbinafine and itraconazole are more effective in Trichophyton infections. [33] It should be noted that responses may vary geographically. [34]
Selenium sulfide shampoo may reduce the risk of spreading the infection early in the course of therapy by reducing the number of viable spores that are shed.
Prevention
Asymptomatic carriers should be detected and treated, since they are the continuous source of infection. Siblings and playmates of patients should avoid close physical contact and sharing of toys or other personal objects, such as combs and hairbrushes, since organisms can spread from one person to another and infectious agents can be transported to different classrooms within the same or in different schools. Shared facilities and objects also may promote spread of disease, both within the home and the classroom.
Those children receiving treatment should be allowed to return to school. [35]
Public health measures regarding the source of infection should be a concern for controlling tinea capitis.
The source of some zoophilic species often is difficult to trace. Outbreaks of M canis can be extensive. Patients' cats and dogs must be inspected under a Wood lamp and referred for treatment. At times, animal control agencies are contacted to round up stray dogs and cats. T mentagrophytes may follow known contact with rodents, but often, no source can be identified.
As many as 14% of asymptomatic children have been found to be carriers of causative dermatophyte for tinea capitis in a primary school in Philadelphia. [36] Without therapy, 4% developed symptoms of infection, 58% remained culture positive, and 38% became culture negative within an average 2.3-month follow-up period.
Long-Term Monitoring
Household contacts of tinea capitis patients should be screened for clinically silent fungal carriage on the scalp. [37] Asymptomatic carriers, including adults and siblings in the family of patients with tinea capitis and patient caretakers and playmates, require active treatment, since they may act as a continuing source of infection. [38]
Shampoo and oral antimycotic therapy have been advocated for eradication of the carrier state. Studies have shown that most children who received griseofulvin plus biweekly shampooing with 2.5% selenium sulfide were negative for fungi on scalp culture after 2 weeks. Shampoo containing povidone-iodine has been shown to be more effective in producing negative cultures than shampoos containing econazole and selenium sulfide and than Johnson's Baby Shampoo. Therapeutic shampoos are applied twice weekly for 15 minutes for 4 consecutive weeks. Both povidone-iodine and selenium shampoos require further clinical study for the control of fungal spore loads in infected children and asymptomatic carriers.
Classrooms with young children (ie, kindergarten through second grade) must be evaluated for tinea capitis infection, since these children are most susceptible and have a greater risk of disease transmission.
Playmates in close physical contact with patients can spread tinea capitis organisms by sharing toys or personal objects including combs and hairbrushes. These individuals need to be evaluated for the presence of infection.
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Gray-patch ringworm (microsporosis) is an ectothrix infection or prepubertal tinea capitis seen here in an African American male child. Gray patch refers to the scaling with lack of inflammation, as noted in this patient. Hairs in the involved areas assume a characteristic dull, grayish, discolored appearance. Infected hairs are broken and shorter. Papular lesions around hair shafts spread and form typical patches of ring forms, as shown. Culture from the lesional hair grew Microsporum canis.
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Typical lesions of kerion celsi on the vertex scalp of a young Chinese boy. Note numerous bright yellow purulent areas on skin surface, surrounded by adjacent edematous, erythematous, alopecic areas. Culture from the lesion grew Trichophyton mentagrophytes. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.
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Discrete patches of hair loss or alopecia caused by Trichophyton violaceum infection of the vertex scalp of a young Taiwanese boy. Courtesy of Skin Diseases in Chinese by Yau-Chin Lu, MD. Permission granted by Medicine Today Publishing Co, Taipei, Taiwan, 1981.
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Photomicrograph depicting an endoectothrix invasion of a hair shaft by Microsporum audouinii. Intrapilary hyphae and spores around the hair shaft are seen (hematoxylin and eosin stain with Periodic acid-Schiff counterstain, magnification X 250).
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Fungal hyphae and yeast cells of Trichophyton rubrum seen on the stratum corneum of tinea capitis. Periodic acid-Schiff stain, magnification 250X.
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Pronounced inflammatory tissue reaction with follicular pustule formation surrounding a hair follicle seen in a patient with clinical form of infection, termed kerion celsi. No fungal hyphae or spores were identified in the lesion in either tissue sections or culture. Fluorescein-labeled Trichophyton mentagrophytes antiserum cross-reacted with antigens of dermatophyte in the infected hairs within the pustule (hematoxylin and eosin stain, magnification X 75).
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Wood lamp examination of a gray-patch area on the scalp. In Microsporum canis infection, scalp hairs emit a diagnostic brilliant green fluorescence. Trichophyton tonsurans does not fluoresce with Wood lamp.
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Tinea capitis, presenting as alopecia with scale, in an African American child.
