See also separate related Dermatophytosis (Tinea Infections) article.
Tinea capitis, or scalp ringworm, is an exogenous infection caused by the dermatophytes Microsporum spp. and Trichophyton spp. These originate from a number of possible sources including other children or adults (anthropophilic), animals (zoophilic) or soil (geophilic).
- The pattern of infection varies around the world. Microsporum canis is the most common agent in Europe, particularly the countries bordering the Mediterranean. Trichophyton tonsurans, an anthropophilic dermatophyte, is mainly seen in the UK (50-90% of cases).This is possibly linked to an influx of African children. Trichophyton soudanense and Microsporum audouinii are becoming increasingly common in France.
- T. tonsurans is difficult to control. One study reported the need for intensive interventions before an outbreak in a UK childcare centre was brought under control.
- T. tonsurans is not a new infection in the UK. There were outbreaks of infections in schools in the 1970s. However, control was achieved by rigorous surveillance. Although there are some differences in the new pattern of infection, improving early detection rates is likely to provide some of the answers.
- M. canis is mainly seen in non-urban communities. It is principally acquired from puppies and kittens. It has a reported prevalence in Europe of 0.23% and 2.6%.
- Other animal hosts are occasionally identified - eg, Trichophyton verrucosum in cattle.
- Trichophyton schoenleinii in contrast is becoming less common. This is because of its striking clinical appearances and the tendency to scar. It causes a characteristic scalp infection - favus. It is recognised even in remote communities and patients with favus, or their parents, are more likely to present for treatment.
- Ideally, the annual diagnostic figures for tinea capitis should be collected from a number of sentinel diagnostic laboratories in order to monitor the progress of this epidemic and the effect of control measures.
Little is known about the risk factors for anthropophilic infection. Those cited include:
- Age (most common in pre-pubescent children).
- Overcrowding (households or schools).
- Hairdressing salons.
- Use of shared combs.
The current spread of T. tonsurans in the USA, Europe and South America is most often seen in black communities but this species has been found in West and East Africa as well. Although prevalent in black communities, infection occurs in children from other ethnic backgrounds. Ethnicity, social and cultural factors and hair styling all seem to play a part in the spread of infection; however, definitive proof is lacking.
- Clinical diagnosis alone is unreliable. There is a wide range of clinical presentations and it can, particularly in mild cases, be very difficult to detect. Infection in the hair and scalp skin is associated with symptoms and signs of inflammation and hair loss (mainly in prepubertal children). The main signs are scaling and hair loss but acute inflammation with erythema and pustule formation can occur.
- Laboratory methods should be used wherever possible to confirm the diagnosis.
- The dermatophytes that cause tinea capitis can affect nails and skin in other parts of the body (only very rarely the feet or groins).
- Children or adults who have neither signs nor symptoms of infection but from whose scalps causative fungi can be grown, are described as 'carriers'.The carrier stateCarriage of fungi, defined as positive cultures taken by brush sampling but absence of clinical signs of infection or positive direct microscopy of hair, can occur. However, in the case of T. tonsurans infection in some individuals, it is possible to overlook limited and symptom-free infections accompanied by hair shaft invasion without highly detailed examination of the scalp.
- Alopecia areata.
- Atopic dermatitis.
- Bacterial folliculitis.
- Drug-related rashes.
- Id reaction (autoeczematisation).
- Subacute cutaneous lupus erythematosus.
- Psoriasis (including plaque and pustular varieties).
- Seborrhoeic dermatitis.
- Syphilis (including secondary syphilis).
- Definitive diagnosis depends on an adequate amount of clinical material submitted for examination by direct microscopy and culture:
- Scalp scrapings - including hairs and hair fragments - should, wherever possible, be used as the primary method of detection. At least 5 mm2 of skin flakes and hair should be obtained wherever possible.
- This may be difficult (some children may not tolerate the plucking) and the second-line approach is to use sterile brushes (such as disposable toothbrushes).
- Any treatment cream should be wiped off before sampling.
- Do not refrigerate samples: keep at room temperature.
- Cultures should be repeated after therapy.
- Microscopy and culture:
- Routine direct microscopy takes 24 hours (depending on the laboratory). Microscopic examination of the infected hairs may provide immediate confirmation of the diagnosis of ringworm and establishes whether the fungus is small-spore or large-spore, etc.
- Culture may take several weeks. Culture provides precise identification of the species (for epidemiological purposes).
- Conventional sampling of a kerion (pus-filled boggy mass which looks like a bacterial abscess) can be difficult. Negative results are not uncommon in these cases.
- Include any treatment, animal contact and overseas travel in the details on the request form.
- Scrape material directly on to special black cards provided by the laboratory.
- Send samples for microscopy (results available within 24 hours) and culture (takes 2-3 weeks).
- Treatment of tinea capitis can be carried out in primary care and, for most cases, it is not necessary to refer children to a dermatologist. It is usual to delay treatment until the diagnosis is confirmed by laboratory procedures, including culture. However, in high-risk populations, in the presence of a kerion or typical features of scaling, lymphadenopathy and alopecia, it may be justified to start treatment immediately.
- There is no currently approved treatment for tinea capitis in childhood in the UK apart from griseofulvin. However, there are a number of options.
Options for treatment
Treatment options in the following clinical scenarios:
- Children - griseofulvin (1 month-12 years 15-20 mg/kg, maximum 1 g) once daily or in divided doses in patients with T. tonsurans infection. The duration of treatment is 6-8 weeks. A UK liquid paediatric formulation of griseofulvin was originally made available but the licence was revoked in 2013. However, crushed tablets or suspensions of crushed tablets can be used. It provides broad cover for all the different organisms that cause tinea capitis.
- Terbinafine (unlicensed use) is now well documented as a treatment for trichophyton infections, particularly those caused by T. tonsurans; the duration of treatment is four weeks. It is equivalent to griseofulvin given for eight weeks and it is increasingly recommended as the first treatment for T.tonsurans infections. Its use in Microsporum spp. infections is uncertain.
- Itraconazole and fluconazole are alternatives, particularly with Microsporum spp. infections.
- Topical treatment (usually selenium sulfide or ketoconazole shampoo but, occasionally, also topical antifungals like terbinafine cream) is recommended at least twice-weekly during the first two weeks of therapy, to minimise transmission to others.
- Children on treatment should NOT be kept off school unless their clinical condition warrants it (for example, a severe kerion).
|Antifungals for tinea capitis[2, 10]|
Daily dosage (weekly or intermittent dosage)
|Griseofulvin||15 -20 mg/kg/day for T. tonsurans).|
|Terbinafine||10-20 kg 62.5 mg, 20-40 kg 125 mg, >40 kg 250 mg - all daily.|
|Itraconazole||2-4 mg/kg/day. Some data suggest that 5 mg/kg in weekly pulses each month is effective - 2-3 pulses.|
|Fluconazole||2-5 mg/kg/day. Weekly treatment with 8 mg/kg may be as effective.|
|NB: there is no paediatric licence for this indication at present for any of the agents except griseofulvin.|
The doses recommended are based on non-comparative trial data.
- Do not generally need oral antifungals.
- They are given a topical preparation such as selenium sulfide shampoo at least twice-weekly.
- However, if there is heavy growth of dermatophytes from scalp brushes taken from children with clinically normal scalps, they should be treated with oral therapy as for infected cases.
Children in contact with tinea capitis
- Should be examined very carefully for signs of infection (may be just a few visible broken hairs).
- If infected hairs are seen and confirmed by mycological examination, the children should receive oral therapy.
Treatment of kerions
- The same treatment strategy for normal infections is used.
- However, it is more difficult to clear with 6-8 weeks of treatment. It is therefore recommended to continue therapy for 12-16 weeks.
- Steroids were once thought to be useful to reduce scarring but are no longer recommended for the treatment of kerion or indeed any other type of tinea capitis infection.
- Removal of surface crusts is often helpful (relieves itching and secondary infection). It can be painful and should be carried out after soaking with lukewarm water or saline with moistened dressings and then teasing off the crusts.
- Sometimes secondary bacterial infection (typically Staphylococcus aureus) requires antibiotics (for example, flucloxacillin) and an antifungal cream which also has anti-Gram-positive activity (miconazole, clotrimazole, econazole). This allows the scalp to heal and avoids the formation of new crusts.
- Severe hair loss.
- Scarring alopecia.
- Psychological impact (ridicule, bullying, isolation, emotional disturbance, family disruption).
Continuous shedding of fungal spores may last several months even with active treatment. Keeping patients with tinea capitis out of school is impractical.
The treatments are very effective. Treatment failure can occur because of:
- Relative insensitivity of the organism.
- Poor absorption of the medication.
- Poor compliance (the long courses of treatment).
In persistent positive cases (often T. tonsurans and Microsporum spp.) - that is, when fungi can still be isolated at the completion of treatment but clinical signs have improved - the recommendation is to continue the treatment for another month.
Asymptomatic carriers should be detected and treated. Increased surveillance in schools would be helpful. Spread should be prevented (avoid sharing of toys or other personal objects, such as combs and hairbrushes, with siblings and playmates of patients).
Further reading and references
Yoo JY, Mendese GW, Loo DS; Black dot tinea capitis in an immunosuppressed man. J Clin Aesthet Dermatol. 2013 May6(5):49-50.
Grover C, Arora P, Manchanda V; Comparative evaluation of griseofulvin, terbinafine and fluconazole in the Int J Dermatol. 2012 Apr51(4):455-8. doi: 10.1111/j.1365-4632.2011.05341.x.
Bennassar A, Grimalt R; Management of tinea capitis in childhood. Clin Cosmet Investig Dermatol. 2010 Jul 143:89-98.
Ginter-Hanselmayer G, Weger W, Ilkit M, et al; Epidemiology of tinea capitis in Europe: current state and changing patterns. Mycoses. 200750 Suppl 2:6-13.
Guidelines for the management of tinea capitis 2014; British Association of Dermatologists (Sept 2014)
Nasir S, Ralph N, O'Neill C, et al; Trends in tinea capitis in an Irish pediatric population and a comparison of scalp brushings versus scalp scrapings as methods of investigation. Pediatr Dermatol. 2014 Sep-Oct31(5):622-3. doi: 10.1111/pde.12093. Epub 2013 Feb 22.
Gray RM, Champagne C, Waghorn D, et al; Management of a Trichophyton tonsurans outbreak in a day-care center. Pediatr Dermatol. 2015 Jan-Feb32(1):91-6. doi: 10.1111/pde.12421. Epub 2014 Sep 25.
Bennassar A, Grimalt R; Management of tinea capitis in childhood. Clin Cosmet Investig Dermatol. 2010 Jul 143:89-98.
Tinea capitis in the United Kingdom: a report on its diagnosis, management and prevention; Health Protection Agency, 2007 (archived content)
Fungal skin infection - scalp; NICE CKS, September 2014 (UK access only)
Michaels BD, Del Rosso JQ; Tinea capitis in infants: recognition, evaluation, and management suggestions. J Clin Aesthet Dermatol. 2012 Feb5(2):49-59.
British National Formulary (BNF); NICE Evidence Services (UK access only)