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NEWS & PERSPECTIVE DRUGS & DISEASES CME & EDUCATION

Dermatology Nursing

Tinea Capitis: A Review

Khashayar Sarabi, MD; Amor Khachemoune, MD, CWS
RELATED DRUGS & DISEASES

Tinea Capitis

Pediatric Acropustulosis

Benign Skin Lesions

Abstract
Tinea capitis causes hair loss, scaling, erythema, and impetigo-like lesions.
It is the most common dermatophyte infection found in children under the
age of 12, especially in African Americans. A good knowledge and
understanding of the dosages, duration, and potential side effects of
different antifungals is important for managing tinea capitis.

Introduction
The dermatophytes (tinea) are a group of fungi that invade keratinized
tissue. Depending on the type of species, the epidermis and its structures
(such as nails and hair) are infected. Dermatophyte skin infections are the
most frequent clinically seen fungal infections in the world (Abdel-Rahman
et al., 2005).

Historical Perspective
The term "tinea" is an analogy to parasitic larvae, and over the years has
become the term applied to parasitic skin infections. A synonym for tinea is
"ringworm," which describes the ring-like lesions caused by that fungal
infection. The term "capitis" refers to the scalp, and hence the term "tinea

capitis," identifying a ringworm infection of the scalp. The epidemiology of

tinea capitis has changed with the advent of griseofulvin, and the sensitivity
of M. audouinii to this antifungal medication. However, unlikeM.
audouinii, T. tonsurans cannot be detected with the fluorescent Wood's
lamp, leaving many cases undetected (Elewski, 2000). Two separate
studies showed that since the mid-1970s, both New York City and Chicago
have had an increase in T. tonsurans infections from 1% to 3%, to 90% to
96% (Aly, 1999). By comparison, in western and eastern Europe, M.
audouinii and T. schoenleinii were the most common causes of infection,
respectively. Since that time, these rates have decreased due to the use of
griseofulvin and environmental changes, such as increased sanitation and
better personal hygiene. Currently, T. violaceum is the dominant species in
eastern Europe (Aly, 1999).
Causing hair loss, scaling, erythema, and impetigo-like lesions, tinea
capitis, the focus of this article, is the most common dermatophyte infection
found in children under the age of 12, especially in African Americans.
Tinea capitis also occurs in adults, although this is less common (AbdelRahman et al., 2005; Silverberg, Weinberg, & DeLeo, 2002). The incidence
of tinea capitis differs between gender and microorganisms. For
example, Microsporum canis infection occurs more frequently in boys,
while with the Trichophyton species, boys and girls are equally infected.
Women are infected more frequently than men, perhaps due to their caretaking role (Aly, 1999). Although many species can cause tinea capitis, the
most commonly occurring species are Microsporum canis, Epidermophyton
floccosum, Trichophyton mentagrophytes, Trichophyton tonsurans (mostly
in the United States), and Trichophyton rubrum(Trivino-Duran et al., 2005).
In this article, a review of the historical and clinical scope of tinea capitis, as
well as new advents in the management of this common dermatophyte
infection, are presented.

Types of Tinea Capitis Infections

Tinea capitis infections are classified into three major groups:
anthropophilic, zoophilic, and geophilic. The anthropophilic infections are
parasitic on humans, usually forming larger hyphae and spores inside the
hair shaft, while the zoophilic tend to be parasitic on animals, usually

forming smaller hyphae and spores outside the hair shaft; the geophilic
infections are identified by location. In immunocompetent humans,
anthropophilic species cause mild lesions with minimal inflammation, but
geophilic and zoophilic species may result in extensive lesions secondary
to inflammation, leading to abscesses and pustules (Krajewska-Kulak et al.,
2003).
Tina capitis types are further divided by how dermatophytes invade the hair
shaft (for example, endothrix versus ectothrix). In endothrix, the hair shaft is
filled with hyphae and spores. Some causes of endothrix infection are T.
tonsurans and T. schoenleinii species. The associated endothrix species
also cause a "black dot" tinea capitis. In the ectothrix types, the hyphae and
spores cover the outside of the hair, which results in the destruction of the
cuticle. All of the Microsporum species and T. verrucosumare
involved. Microsporum infections (M. canis) cause a "gray patch" tinea
capitis. Ectothrix infections, unlike endothrix types, can be identified by
Wood's light. A very rare and severe form of tinea capitis infection is favus,
primarily caused by T. schoenleinii. Favus results in a honeycomb-type
destruction of the hair follicle, giving the hair a yellowish color (Kao, 2006).

Clinical Forms
Tinea capitis typically presents in two major forms: gray patch and black
dot.
Gray patch tinea capitis (GPTC). GPTC is generally found in the endemic
form within the United States, and the offending agent is typically M. canis.
It is usually spread from cats or dogs to humans; however, person-toperson transmission is also possible. Initial symptoms are an erythematous
area on the scalp with patchy alopecia and dry scaling. The affected area
then spreads in a centrifugal manner for up to a month, although it may
persist on the scalp for many years. These patches may coalesce, with
larger patches often visible on the scalp. Severe scaling of the scalp may
result, and due to cuticle breakage, the hair may become brittle, with
considerable broken hair visible on the patient (Habif, 2004).
Lesions may become secondarily infected with fungus or bacteria (such as
staphylococcus aureus), and will appear boggy and raised, with pus
exuding. This clinical presentation of tinea capitis is referred to as a kerion,
and is an immune granulomatous response to the offending agents. There
may be single or multiple plaques, and this type of inflammation may be

associated with painful episodes. Scarring will result if the kerion is not
treated appropriately. Typical treatment for this condition is the use of oral
antifungals for 6 to 8 weeks; corticosteroids may be prescribed for cases of
tenderness and scalp pain. Concurrently, posterior cervical
lymphadenopathy may present as an associated symptom (Fuller, Child,
Midgley, & Higgins, 2003) (see Figure 1).

(Enlarge Image)

Figure 1.
Patient with kerion.

The use of KOH examination or Wood's ultraviolet lamp are the main
methods for identifying GPTC in patients. M. audouinii and M.
canis infections appear as green-blue fluorescence under Wood's light. The
confirmatory diagnosis, if needed, may be obtained by culturing the hair on
Sabouraud's medium.
Black dot tinea capitis (BDTC). BDTC is the most common form of tinea
found in North America, and the causative agent is T. tonsurans. This form
primarily affects African-American children, typically spreading via child-tochild contact. Beginning with an erythematous scaling patch on the scalp,
BDTC progresses to single or multiple lesions. Hair is broken off at the
surface, and detritus within the follicle opening gives the appearance of a
black dot (Habif, 2004). In the most intense cases, which are accompanied
by inflammation, there may be a resemblance to pyoderma or discoid lupus
erythematosus. It may also be accompanied by lymphadenopathy (Fuller et
al., 2001). If secondary infection occurs (as in GPTC), there maybe a
sudden shift into the kerion form. Typical treatment is oral antifungals for 6
to 8 weeks, with the additional use of corticosteroids for tender and painful
scalp. If not treated, the scarring may cause permanent alopecia.
BDTC is also visualized by KOH examination of hair shaft spores, and its
confirmation is by culture on Sabouraud's medium. How ever, unlike GPTC,
fluorescence under Wood's light does not occur.
Favus. Primarily caused by T. schoenleinii, favus is a chronic inflammatory
reaction with an infection of the outer and inner hair shafts. Initially there is

erythema, followed by scutula (yellow crust) formation. Eventually, there is

considerable hair loss and scarring. If left untreated, favus will lead to
permanent alopecia (Matte, Lopes, Melo, & Beber, 1997).

Mycology
There are three genera of dermatophytes: Epidermophyton,
Microsporum, and Trichophyton. There are approximately 40 species that
are either anthropophilic, zoophilic, or geophilic. Some common examples
of each are anthropophilic (T. rubrum, T. tonsurans, M. audouinii, T.
violaceum); zoophilic (M. canis, T. verrucosum); and geophilic (M. fulvum).

Differential Diagnosis
Tinea capitis infections are often mistaken for other more common
dermatologic scalp diseases, especially in older adults (see Table 1 ). Tinea
capitis agents, such as M. audouinii and M. canis, can mimic impetigo and
pediculosis, or psoriasis and seborrhea, respectively. Since both causative
agents can be visualized under Wood's lamp, this method should be used
when the clinician is considering the above differential diagnosis. For
impetigo, the pain is generally more severe and individual hairs do not
appear to be broken. In psoriasis, the scales on the scalp are thicker, but
the hair is not broken off (Johnson & Nunley, 2000). Alopecia areata also
causes hair loss and may mimic T. tonsuransinfections, but does not cause
scaling of the scalp.

Management
Before 1958, when griseofulvin was first approved by the U.S. Food and
Drug Administration (FDA) for systemic treatment of tinea capitis, the only
available treatments were shaving the head, applying mercury/sulfur to the
scalp, or resorting to high-fat diets (Mhrenschlager, Seidl, Ring, & Abeck,
2005). However, griseofulvin quickly became the mainstay of treatment,
and the use of terbinafine and itraconazole in patients allergic to
griseofulvin were also successful (Gupta et al., 1999; Trivino-Duran et al.,
2005). In a meta-analysis study, Fleece, Gaughan, and Aronoff (2004)
showed terbinafine treatment for up to 4 weeks to be as effective in
treating Trichophyton spp. as 8 weeks of griseofulvin treatment. However, it
is important for the patient (and parents, if the patient is a minor) to be
aware that only griseofulvin is currently approved by the FDA for treating
tinea capitis, although many physicians choose to use other systemic

treatments such as terbinafine, fluconazole, and itraconazole, based on

many successful studies (Chan & Friedlander, 2004).
One important consideration in choosing a management plan is the type of
infection. For example, griseofulvin is only effective when
treating Microsporum, Epidermophyton, and Trichophyton (Chan &
Friedlander, 2004). When compared to other treatments
in Trichophyton infections, griseofulvin and terbinafine are equally effective,
but griseofulvin is advantageous when used against Microsporuminfections
(Fuller et al., 2001). Moreover, when treating Microsporum canis, the
dosage and treatment length of systemic treatments may need to be
increased (Mhrenschlager et al., 2005), with baseline and periodic LFTs
>1 month therapy and BUN/SCr for all systemic antifungal treatments, and
CBC for terbinafine.
Table 2 summarizes the different systemic drugs available, along with
dosages, durations, and side effects.

Nursing Measures
A good knowledge and understanding of the dosages, duration, and
potential side effects of different antifungals is important for the
management of tinea capitis.
Griseofulvin (Fulvicin) is prescribed at 15 to 25 mg/kg/day for a period of 8
weeks or more depending on the extent of infection and the speed of
recovery. This recovery is monitored by followup examinations and the
assistance of Wood's lamp for detecting M. audouinii and M. canis.
Griseofulvin can be taken with dairy products to increase absorption and
mask the taste of this medication for children. Patients should be cautioned
about side effects such as headache, nausea, transient rash, diarrhea, and
photosensitivity. Griseofulvin should not be used in patients with porphyria
or liver disorders. It may also precipitate systemic lupus erythematosus in
some patients.
Terbinafine (Lamisil) is prescribed based on the weight of the patient as
follows for the treatment of tinea capitis: 40 kg or more, 250 mg/day; 20 kg
to 40 kg, 125 mg/day; and 10 kg to 20 kg, 62.5 mg/day for a period up to 4
weeks, depending on the effectiveness of the treatment. A lower dose of 3
to 6 mg/kg/day for up to 4 weeks has been sufficient in patients with T.
tonsurans infections. Patients should be warned about alopecia, erythema

multiforme, Stevens-Johnson syndrome, and a partial or complete loss of

taste; the loss of taste is usually reversible upon discontinuation of
terbinafine. Immediate discontinuation is also warranted with signs of
neutropenia, agranulocytosis, and hepatic dysfunction.
Itraconazole (Sporanox) is given to children over 40 kg at a dose of 200
mg, 30 kg to 40 kg at 150 mg, 20 kg to 30 kg at 100 mg, and less than 20
kg, 50 mg per day for 4 to 6 weeks to treat tinea capitis. ForT.
tonsurans, itraconazole can be given at 3 to 5 mg/kg/day with meals for the
same duration of time. Patients with valvular heart disease, ischemic heart
disease, pulmonary disease, and renal failure should be excluded from this
prescription due to possible congestive heart failure. Patients should also
be cautioned about Stevens-Johnson syndrome, gastrointestinal
discomfort, and headaches.
Fluconazole (Diflucan) is prescribed at 5 mg/kg/day for a period up to 6
weeks for treatment of tinea capitis. Side effects are milder than other
treatment plans, and range from gastrointestinal discomfort to abnormal
liver function tests, nausea, and headaches.
For specific treatment of M. canis, a longer duration of therapy is indicated
for all antifungals.
Oral ketoconazole is also successful in treatment; however, due to its high
cost and possible hepatotoxicity, it has not been used as a first-line drug.

Treatment of Carriers
Shampoos, such as a 2% ketoconazole, 1% to 2.5% selenium sulfide, 1%
to 2% zinc pyrithione, and povidone-iodine, are also used as adjuncts,
along with an oral antifungal. These shampoos may decrease scaling and
itching substantially, but do not penetrate deeply enough to be the sole
treatment in patients. The shampoos are applied to the scalp at least three
times each week for 5 to 10 minutes. This also allows children to return to
school when both treatments are used together (Fleece et al., 2004).

Outcome and Prognosis

The outcome and prognoses of tinea capitis is difficult to assess due to its
variability and dependence on many factors. Short-term factors, such as
adherence to a drug regimen, clean environment, screening, and treatment
of asymptomatic household residents, are all important factors initially. This

will further depend on the rate of sensitivity of organisms to medications,

rate of re-infection, and the introduction of new organisms into the
environment. If results are not achieved and outcomes are not improved,
then the medication may be changed or the duration may be increased.
Another important fact to consider is that since the production of spores will
continue, close monitoring of children and their surrounding environment is
important (Higgins, Fuller, & Smith, 2000).

Patient Education
As tinea capitis may continue as a source of infection, even asymptomatic
patients, along with adults and other siblings in the household, should be
directed to use antifungals and shampoos, such as those containing 2.5%
selenium sulfide and povidone-iodine, to prevent the spread of the carrier
state. Further more, young children (up to the third grade) and the
playmates of patients should also be evaluated for tinea capitis infection,
since transmission through the sharing of play toys is a common route of
infection in this age group. Those with infection or asymptomatic carriers
should avoid close physical contact and sharing of any objects until full
treatment has been met with success. Prevention from attending school is
not necessary, and neither is wearing a hat or shaving the head of the child
during the course of the treatment. Complications that occur, such as
severe hair loss and scarring alopecia, may be detrimental to the patient.
Although the patient may be advised that some of the hair loss is
temporary, early proper treatment and education are absolutes.

References

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Dermatology Nursing. 2007;19(6):525-529. 2007 Jannetti Publications, Inc.

The print version of this article was originally certified for CE (continuing
education) credit. For accreditation details, please contact the publisher, Anthony
J. Jannetti, Inc., East Holly Avenue Box 56, Pitman, New Jersey 08071-0056

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