BJD

GUI DEL IN ES British Journal of Dermatology

British Association of Dermatologists’ guidelines for the
management of tinea capitis 2014
L.C. Fuller,1 R.C. Barton,2 M.F. Mohd Mustapa,3 L.E. Proudfoot,4 S.P. Punjabi5 and E.M. Higgins6
1
Department of Dermatology, Chelsea & Westminster Hospital, Fulham Road, London SW10 9NH, U.K.
2
Department of Microbiology, Leeds General Infirmary, Leeds LS1 3EX, U.K.
3
British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K.
4
St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, U.K.
5
Department of Dermatology, Hammersmith Hospital, 150 Du Cane Road, London W12 0HS, U.K.
6
Department of Dermatology, King’s College Hospital, Denmark Hill, London SE5 9RS, U.K.

1.0 Purpose and scope
Correspondence
Claire Fuller. The overall objective of this guideline is to provide up-to-
E-mail: claire.fuller@nhs.net date, evidence-based recommendations for the management
of tinea capitis. This document aims to update and expand
Accepted for publication on the previous guidelines by (i) offering an appraisal of
8 June 2014 all relevant literature since January 1999, focusing on any
key developments; (ii) addressing important, practical clini-
Funding sources cal questions relating to the primary guideline objective, i.e.
None.
accurate diagnosis and identification of cases; suitable treat-
ment to minimize duration of disease, discomfort and scar-
Conflicts of interest
ring; and limiting spread among other members of the
L.C.F. has received sponsorship to attend conferences from Almirall, Janssen and
LEO Pharma (nonspecific); has acted as a consultant for Alliance Pharma (nonspe- community; (iii) providing guideline recommendations and,
cific); and has legal representation for L’Oreal U.K. (spouse; nonspecific). R.B. has where appropriate, some health economic implications
been an invited speaker for Pfizer. (tinea capitis is a common problem in resource-poor set-
tings and therefore treatments that are more easily and
L.C.F., R.C.B., L.E.P., S.P.P. and E.M.H. are members of the guideline develop- cheaply available and applicable to these settings have been
ment group, with technical support provided by M.F.M.M. factored in); and (iv) discussing potential developments and
future directions.
This is an updated guideline prepared for the British Association of Dermatologists
This guideline is presented as a detailed review with high-
(BAD) Clinical Standards Unit, which includes the Therapy & Guidelines (T&G)
lighted recommendations for practical use in the clinic (see
Subcommittee. Members of the Clinical Standards Unit who have been involved are
J.R. Hughes (Chairman T&G), A. Sahota, M. Griffiths, A.J. McDonagh, S. Pun-
Section Summary), in addition to the production of a patient
jabi, D.A. Buckley, I. Nasr, V.J. Swale, C.E. Duarte Williamson, P.M. McHenry, information leaflet [available on the British Association of Der-
N.J. Levell, T. Leslie, E. Mallon, S. Wagle (British National Formulary), matologists’ (BAD) website, http://www.bad.org.uk].
K. Towers (British National Formulary), R. Davis (British Dermatological Nursing
Group), C. Saunders (British Dermatological Nursing group), S.E. Haveron (BAD
Scientific Administrator), A.G. Brain (BAD Scientific Administrator), L.S. Exton
2.0 Stakeholder involvement and peer review
(BAD Information Scientist) and M.F. Mohd Mustapa (BAD Clinical Standards The guideline development group consisted of consultant, spe-
Manager). cialist registrar and associate specialist dermatologists, and a
mycologist. The draft document was circulated to the BAD
Produced in 2000 by the British Association of Dermatologists; reviewed and
membership, British Dermatological Nursing Group (BDNG)
updated 2014.
and Primary Care Dermatological Society (PCDS) for com-
DOI 10.1111/bjd.13196 ments, and was peer reviewed by the Clinical Standards Unit
of the BAD (made up of the Therapy & Guidelines Subcom-
NICE has accredited the process used by the British Association of mittee) prior to publication.
Dermatologists to produce guidelines. Accreditation is valid for 5 years
from May 2010. More information on accreditation, and full details of
our accreditation can be viewed at www.nice.org.uk/accreditation.
3.0 Methodology
This set of guidelines has been developed using the BAD’s
recommended methodology1 and with reference to the
Appraisal of Guidelines for Research and Evaluation (AGREE)

454 British Journal of Dermatology (2014) 171, pp454–463 © 2014 British Association of Dermatologists

soudanense) produces relatively nonin- flammatory patches of alopecia with fine scale. caused by dermatophyte fungi. where the presentation may be atypi- making the appropriate recommendations. Failure to adhere to these guidelines produces characteristic fine scaling with patchy circular should not necessarily be considered negligent.C. M.0 Limitations of the guideline thema.1 Definition Diffuse pustular In more inflammatory variants. randomized and nonran. case reports Although across Europe Microsporum canis remains the most and open studies involving tinea capitis published in the commonly involved organism. patchy Tinea capitis is an infection of scalp hair follicles and the sur. based on the best data available when the document was pre- pared. a diffuse. with no sign of a reduction in incidence.K. where necessary. in the U. The abstracts for the patterns. L. however. resulting in a ‘black The proposed revision for this set of recommendations is dot’ appearance. This may be associated with painful regional lymph- in the genera Microsporum and Trichophyton. resembling dandruff. T.0 Background 6. Limiting the review to English philic fungi (e. infection presents as generalized. usually species liculitis. zoophilic language references was a pragmatic decision. swollen hair stubs. but the authors or geophilic species (e. Each coauthor then per. © 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171. Common features are patchy hair loss with varying degrees of scaling and ery- 4. a shift towards English language from January 1999 to March 2014. Working in pairs. ectothrix Microsporum infection typically herein to be changed. the clinical signs may be subtle and diagno- This document has been prepared on behalf of the BAD and is sis can be challenging. T. Inflammation may be minimal with anthropo- against a claim of negligence. for example with the quality of evidence and immune compromised. infants are less frequently affected. gypseum) typically demon- recognize this may exclude some important information pub. domized controlled clinical trials. important interim Diffuse scale In some cases. scheduled for 2019. alopecia may coexist with scattered pustules or low-grade fol- rounding skin. disagreements in 6. canis.9 were subsequently collated and edited to produce the final The clinical appearance of tinea capitis is highly variable. lished in other languages.org). Fuller et al. Additional relevant references An accurate diagnosis remains a vital component of were also isolated from citations in shortlisted and reviewed management.6.5 were allocated separate subsections.3.g. case series. Clinicians unfamiliar with this condition often literature. especially inflammatory variants out by the coauthors.2 Inflammatory 6.agreetrust. search anthropophilic species continues to be observed. nor should alopecia. adenopathy.7 The incidence in discussions with the entire development group to resolve adults is generally low. common in inner-city cosmopolitan were searched for meta-analyses. Tinea capitis predominates in healthy preadolescent chil- formed a detailed appraisal of the selected literature with dren. phyte infections is attributed to immigration and travel sion were selected for further scrutiny. leading to delays in diagnosis and was then discussed and re-evaluated. M. It is recognized that under certain conditions it may be 6.3.4. Medline and Embase databases prepubertal children.g. pp454–463 .g. The PubMed. violaceum. M. M. the authors screened scalp isolates in the U. tonsurans is reported to account for 50–90% of dermatophyte tion (see Table S1).3 Trichophyton terms and strategies are detailed in the Supporting Informa. ferrugineum). Black dot Endothrix infection with Trichophyton species (e. strate more intense inflammatory response. shortlisted references were then reviewed and the full papers of relevant material were obtained. T. All subsections cal. but it is more commonly seen in the any issues.. depending on the causative organism. as well as (independent) targeted searches carried misdiagnose tinea capitis. The structure of the 2000 guidelines such as boggy kerions. and those relevant for first-round inclu. 6. Patches may be multiple.1 Noninflammatory necessary to deviate from the guidelines and that the results of future studies may require some of the recommendations Grey patch Small-spored. BAD guidelines for tinea capitis 2014. and different coauthors inappropriate management. dull grey in colour due to arthrospores coating the adherence to these recommendations constitute a defence affected hairs. audouinii. alopecia is minimal or absent and changes will be updated on the BAD website.K. communities. However.2 Epidemiology and aetiology developed for implementation in the National Health Service (NHS) using a process of considered judgement based on Tinea capitis continues to be predominantly a disorder of the evidence.8. guideline. classically stud- 5. type of hair invasion and degree of host inflammatory response. tonsurans.3 Clinical patterns and diagnosis the final selections were resolved by discussion among the entire development group. diffuse scaling of the scalp.0 Plans for guideline revision ded with broken-off. 455 instrument (www. A number of clinical patterns exist.3 This rise in anthropophilic dermato- the identified titles.2 Recommendations were 6.

inflammatory mass with associated alopecia. Regional lymphadenopathy may be asso- ized by yellow. using a blunt scalpel to remove hair and scalp 6. tonsurans or T. pp454–463 © 2014 British Association of Dermatologists .4. level of children with tinea capitis. Furthermore. Plaques may be solitary or multiple. Mis. L. Friedlander et al. Sampling of kerions may be problematic. schoenleinii infection.) It is considered that 6. this infection (exception: T. Kerion Also known as ‘kerion celsi’. level of evidence 3. also known as ‘dermato. cup-shaped lesions (‘scutula’) ciated with inflammatory variants of tinea capitis.18. scaling or lymphadenopathy is common. papular ‘id’ eruption. which develop around follicular openings. T. see Appendixes 1 and 2 for explanations of these measures.14 Post-treat- mediated host response to the dermatophyte after effective ment samples should be sent to ensure clearance.15 evidence 3. Lupus erythematosus. brush or swab as whereas corkscrew hairs have been reported in Afro-Caribbean appropriate to the lesion. particularly in urban areas. This packs. Black dot hair stubs most appropriate specimen. crusted. Inflammatory tinea capitis T. canis.1 Wood’s lamp under a Wood’s lamp may be plucked and constitute an appro- Ectothrix Microsporum species demonstrate bright green fluores. The differential diagnosis of tinea capitis is extensive.10 lichen planopilaris and trichotillomania should also be consid- Favus A chronic. Exclamation-mark hairs must be distinguished superseded in recent years by endothrix infections with either from the broken hairs of tinea capitis. Scalp psoriasis.4 Clinical diagnostic aids scale. A swab of the lesion may provide the adjunctive tool in diagnosing tinea capitis. Favus infections fluoresce under Wood’s lamp.1 Taking specimens severe. priate specimen. oral) corticosteroids may provide symptomatic relief.16 have shown that the cytobrush improves may aid clinical distinction from nonfluorescent Trichophyton both sensitivity and time to positive culture.12 These eruptions represent a cell. boggy.19 This suggests that multiple sampling methods. Bonifaz et al. may tively accurate.11.2 Clinical patterns swabs make an equally effective and often more convenient The presence of regional lymphadenopathy in combination sampling method. dermoscopy is being recommended as a useful culture is often negative. commonly seen with zoophilic.13. sec.5 Differential diagnosis tinea capitis presenting as a painful. this variant is most commonly encoun. A disadvantage of brush sampling is that it does not enable the laboratory to examine the specimen microscopically and permits only culture. T.) British Journal of Dermatology (2014) 171. ‘Comma-shaped’ hairs have Scalp lesions in suspected cases of tinea capitis should be been described in white children with ectothrix infection. therapy has been initiated and do not warrant cessation of sys- temic antimycotic therapy. inflammatory tinea capitis typically seen in ered. flammatory tinea capitis. folliculitis tered in the Middle East and North Africa.4. Kerion is more diffuse. but should not be confused confirm the diagnosis are advisable to isolate the causal organ- with a drug reaction. although these conditions are usually ondary bacterial infection should not be overlooked. Regional encompassing any condition causing patchy hair loss. and there may be characteristic signs elsewhere. T. decalvans or abscesses. violaceum. seborrhoeic dermatitis and host inflammatory response to the causative dermatophyte. appropriate investigation with fungal culture. Although the clinical diagnosis of tinea capitis is often rela- phytid’. laboratory investigations to accompany treatment initiation.20 (Strength of recommendation D. however. this has been onstrate erythema. verrucosum).3 Dermoscopy sampling the edge of scalp lesions may provide higher yields of Although the authors have no personal experience of this causal fungus.4. sampled by scalpel scraping. ism and direct the choice of systemic therapy.13. atopic dermatitis may be difficult to differentiate from nonin- diagnosis as bacterial abscess is not uncommon. is available as a sterile device and its soft bristles may cause less although the value of this investigation is limited given discomfort to children. schoenleinii can fluoresce dull green).14 such as a scalp scraping and a brush.C. particularly around the outer helix of the ear. large-spore ectothrix species Alopecia areata is generally nonscaly but may occasionally dem- (e. when considered. Topical (or occasionally. Specimens should be collected in paper or card cence of infected hairs under Wood’s lamp examination.0 Laboratory diagnosis of tinea capitis pecia. if very 7. this is the term given to 6. (Strength of recommendation D. composed of hyphae and keratin debris. Suspected tinea capitis lesions should be sampled either by plucking hairs. (Strength of recommendation D. Favus may result in cicatricial alo- 7. affected hairs identified by fluorescence 6. or by taking scalp brushings.17 have demonstrated that gauze 6. Fuller et al. Favus is character. Mentagrophytes. level of evidence the current predominance of nonfluorescing species of 3. are likely to lead to an increased yield of dermatophyte fungus from infected scalps. This variant represents a delayed scalp inflammation. although they are relatively rare. variants may be misdiagnosed as bacterial folliculitis. A pruritic. and technique. however.g.456 BAD guidelines for tinea capitis 2014. may be visualized more clearly. In cases of tinea capitis caused by M. hair pluck. studded with pustules and matted with thick crust.) Trichophyton. A comparison of sampling methods for the with alopecia and/or scale in a child suspected of having tinea detection of dermatophytes in asymptomatic carriage has been capitis is an important diagnostic clue and should encourage described.

cumulative evidence All specimens from cases of tinea capitis should be now demonstrates that newer antifungal agents have higher processed for microscopy and culture where possible. level of evidence 4. It is reasonable to begin treatment on the basis of one or Plates should be incubated for at least 2 weeks.) use of the drug. agents.21 (Strength of recommendation D. either by conducting microscopy at the patient side is no longer a licensed formulation in the U.24 (Strength of of the cell wall. alleviation of symptoms. Where more cardinal signs. and griseoful- or waiting for culture. it is reasonable to start ther.26 topical therapy alone is not recommended for the ide with or without calcofluor. prevention of Griseofulvin is a fungistatic drug that inhibits nucleic acid syn- scarring and reduction of transmission to others. There is over 50 years of experience in the recommendation A.28–30 this period for the presence of the slow-growing and Treatment protocols should therefore reflect local epidemiol- inconspicuous colonies of this species.24 The suspension fungus. The presence of hyphae and/or ar.2 Topical therapy Microscopy should be carried out on all scalp scrapings and Although a small percentage of patients may clear with topical plucked hairs. and examination by light or management of tinea capitis. Fuller et al. and are safe and more cost-effective. topical agents are used to reduce throconidia should be reported.1 When to start treatment suspension). and it remains the only licensed product for use in the treatment of tinea capitis in children in the U.1 Griseofulvin resulting in both a clinical and mycological cure as quickly and safely as possible.K. (Strength of recom. by mounting in 10–30% potassium hydrox..27 and povidone–iodine. vin tablets are no longer available in some European countries.) A prolonged mendation D.25. but recently the suspension has become increas- Ideally one should wait for confirmation of the presence of ingly expensive and not so widely available. While 4. Trichophyton violaceum.A.31. level of evidence 2% and selenium sulfide 1% shampoos have all shown efficacy 3. (Strength of recommendation C. L.. ment of resistance. So.13. exposure to cattle is documented and an infection caused (Strength of recommendation B.23 (Strength of recommendation D. All specimens should be cultured on 8. It is available in several forms (micronized.32 growing should be identified and reported. However.) we appreciate that the lack of licence in the U. griseofulvin remains the only licensed dence 3.) There is no routine indication course or a change of agent may be required in cases of treat- to test dermatophytes for susceptibility to antifungal agents. ultramicronized and 8.14 (Strength of recommendation B. Oral therapy thesis. soudanense Terbinafine apy immediately. transmission of spores. (Strength of recommendation D.24.) However. The aims of treatment are eradication of the organism.0 Management NHS organizations. level of evidence 1+. arrests cell division at metaphase and impairs synthesis is generally required to achieve these goals. level of evidence 2++.K. guideline should endorse clinical practice. in high-risk populations. in the presence of a kerion or when the diagnosis of a Table 1 Choice of drug according to organism isolated fungal infection is strongly suspected clinically based on the presence of very typical features of scaling.14 while awaiting confirmatory mycology.31 This causal agent fully identified where isolated. may limit the ease of prescribing according to our recommendations. level of evi. 8. of evidence 2++. ogists treating tinea capitis in the U. and the body of evidence supporting this The primary objective of this guideline is to inform dermatol.) Clear evidence by T. The sensitivity of micros.33 2–4 weeks to be available) and may further increase spread. pected fungus is identified on culture.) arrangement of arthroconidia is endothrix or ectothrix.K. level of evidence 1+.3. Trichophyton tonsurans Terbinafine lymphadenopathy or alopecia.22. level of evidence of antifungal therapies in parts of Europe and the U. Although in the U. ketoconazole copy is not high. pp454–463 .K. level fluorescence microscopy.3 Oral therapy Sabouraud agar with at least one agar plate containing cycloheximide to inhibit nondermatophyte mould growth. and the response rates.C.S. but this is often difficult. BAD guidelines for tinea capitis 2014. or if an unex- as many studies have shown little evidence for the develop. awaiting results increases delay (as culture results may take having been superseded by other agents. Susceptibility test. is reflected in recent changes to the licensing and availability ing is not indicated.) treatment for tinea capitis in children.2 Laboratory investigations 8. Any dermatophytes ogy and be based on the most likely culprit organism.) Where possible it should be determined whether the in this context.24 (Strength of recommendation B. ment failures (see Section Treatment failure).K. plates should be incubated for has now emerged to show that the optimal treatment regimen up to 3 weeks and examined very carefully at the end of varies according to the dermatophyte involved (Table 1). verrucosum is suspected.) © 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171. level of evidence 2+. (Strength of recommendation A. off-licence prescribing processes are well established in most 8. as these are strong predictive factors for Microsporum canis Griseofulvin or itraconazole tinea capitis. level of evidence Microsporum audouinii Griseofulvin or itraconazole 2+. 457 7.

. which interferes with 8. ciclosporin and the oral Itraconazole exhibits both fungicidal and fungistatic activity contraceptive pill. rum46. terbinafine appears well tolerated in children.31 (Strength of recom- but has much higher efficacy against Trichophyton species than mendation A. but accumulated evidence in children compared with adults. It may be necessary to use doses up to 25 mg kg 1 1875-mg packets to be sprinkled on food) has been licensed daily for more prolonged periods in resistant cases..K. in confirmed Microsporum infection. exten. the minimum inhibitory ated46–48 (Strength of recommendation B.39 and terbinafine has a clear cost British Journal of Dermatology (2014) 171.38 Itraconazole 100 mg per day 4 weeks £1192 (tablet) In contrast.34 The drug Advantages: fungicidal. safety. terbinafine is more effective Itraconazole is now the preferred agent in the majority of against M. fathering a child for 6 months after treatment.39 Although shorter treatment protocols ventional tablet.32 There is no evidence of However. canis infection.458 BAD guidelines for tinea capitis 2014.40 and offers A meta-analysis of seven studies28 showed that response rates significantly higher cure rates than standard griseofulvin are highly variable depending on the species involved: suspension.K. not licensed for treat- sive experience.2 Terbinafine membrane permeability. Contraindications: lupus erythematosus. 2014)a tributing to treatment failures.31 and higher doses for longer periods Side-effects include gastrointestinal disturbances and rashes (12–18 weeks) may be required in Trichophyton infections.42–44 in the clinical setting. Advantages: licensed for use in children in the U.. canis but confers no advantage over griseofulvin. like other azoles..3 Itraconazole liver disease. L. its primary mode of action is fungistatic.36 In part. bBased on halving a con- taken into account. for use in children > 4 years of age in the U.K.35 European countries33 and has activity against both Microspo- and prolonging treatment does not improve efficacy. its widespread use is reflected 20 mg kg 1 daily in single or divided doses for 6–8 weeks if in the publication of weight-related dosage schedules in recent < 50 kg. and very few (08%) are required to discontinue Side-effects occur in 20% of cases. there is no suggestion of any altered safety profile resistance to griseofulvin in vitro.47 and Trichophyton species. a new according to the type of formulation used and how easily it is granule formulation of terbinafine (available in 125-mg or absorbed. Drug Dose Duration Cost and cannot be incorporated into the hair shaft in children. so is contraindicated in pregnancy and men are cautioned against potential to improve compliance. increase compliance. through depletion of cell-membrane ergosterols. It shows activity against all dermatophytes.C.A.41 88  5% for Microsporum species compared with 677  9% for However. accounting for its Terbinafine 125 mg per day 4 weeks £212b relative inefficacy. Drug interactions: plasma concentration is decreased by rif- Disadvantages: increasingly expensive. so Griseofulvin 200–300 mg 8 weeks £4704 (tablet) does not effectively reach the scalp surface where the arthro- per day £11900 (syrup) conidia are located in Microsporum infections. Dosage recommendations vary Although not available in liquid form in the U.K. severe 8. The standard licensed treatment protocol for those aged advantage (Table 2). Drug interactions: include warfarin. shorter treatment regimens.A. meta-analysis of RCTs shows that 2–4 weeks of £10890 (liquid) terbinafine is at least as effective as 6–8 weeks of griseofulvin Fluconazole 180 mg 4 weeks £26568 in T. terbinafine is not excreted in the sweat or sebum of prepubertal children.S. Trichophyton species. suspension more palatable to children and ment of children in the U. editions of the British National Formulary for Children. porphyria. but. Pharmacokinetic studies of terbinafine show that children trolled trials (RCTs) suggests that 8 weeks of griseofulvin treat. con- Table 2 Comparative costs of antifungal treatment (U. in particular diarrhoea. A recent meta-analysis of randomized con.31 in < 8%.31 The drug is well toler- this is because for M.3. rashes and headache. depending on the tissue concentration of the drug. allows more accurate dosage adjustments.K.43 upset. Doses of 50–100 mg daily for Terbinafine is an allylamine that acts on the cell membrane 4 weeks45 or 5 mg kg 1 daily for 2–4 weeks have compara- and is fungicidal.23.29. tonsurans infections.37 Additionally. prolonged treatment ampicin and increased by cimetidine. even at higher dosage schedules (Table 3). However. level of evidence 1+.22 ble efficacy with griseofulvin or terbinafine. require significantly weight-normalized doses to approximate ment is significantly more effective than 4 weeks of terbinafine the equivalent drug levels needed for efficacy in adults. or 15– children in the U.42 suggests that the drug is less effective against Trichophyton species Overall.S. required with potential to affect compliance. it is not currently available or licensed in the U. pp454–463 © 2014 British Association of Dermatologists . cost. tion and improve bioavailability. when cost-efficiency and compliance are a Based on treatment of a 20-kg child. Fuller et al.3. level of evidence 2++) concentration for terbinafine (and to some extent itraconazole) and has been shown to be safe for use in the first year of can exceed the maximum concentration reported in hair.32 Terbinafine may now be considered (suspension) the optimal choice.24 it remains unlicensed for use in > 1 month is 1 g in children weighing > 50 kg.) Microsporum. granules provide a palatable alternative).K. Disadvantages: no suspension formulation (but in U. Taking the drug with fatty food may increase absorp.29. mostly gastrointestinal treatment.33 At higher doses.

lymphadenopathy. griseofulvin remains the only licensed treatment for tinea capitis in children.50 and may be pre. because it confers no cost advantage. Fuller et al.C. soudanense). Oral therapy is generally indicated to achieve both clinical and mycological cure (Strength of recommendation A) Choice of systemic therapy should be directed by causative dermatophyte and/or local epidemiology (Strength of recommendation A) First-line therapy Both griseofulvin and terbinafine have good evidence of efficacy and remain the most widely used first-line treatments. If itraconazole has been selected as first-line therapy. suboptimal absorption of drug. therefore repeat mycology sampling is recommended until mycological clearance is achieved [Strength of recommendation D (GPP)] life. although the suspension formulation is no longer licensed for use. other modalities to be considered in exceptional circumstances include fluconazole and voriconazole (see main text) Additional measures Children receiving appropriate therapy should be allowed to attend school or nursery [Strength of recommendation D (GPP)] Index cases due to T. relative insensitivity of the organism and reinfection. violaceum. licensed for the treatment of tinea capitis in children in the U. 8. audouinii). or 5 mg kg 1 per day for 2–4 weeks Alternative agents For cases refractory to the above regimens. and has been advocated as an alternative to terbinafine. for children aged use has been relatively limited because of side-effects and ≤ 12 years with tinea capitis. systemic treatment is generally justified [Strength of recommendation D (GPP)] The end point of treatment is mycological rather than clinical cure. shorter treatment protocols. and griseofulvin more effective against Microsporum species (M. which may increase compliance (Strength of recommendation A) Griseofulvin dose by body weight < 50 kg 15–20 mg kg 1 per day (single or divided dose) for 6–8 weeks > 50 kg 1 g per day (single or divided dose) for 6–8 weeks Doses up to 25 mg kg 1 per day may be required in some cases Terbinafine dose by body weight < 20 kg 625 mg per day for 2–4 weeks 20–40 kg 125 mg per day for 2–4 weeks > 40 kg 250 mg per day for 2–4 weeks Treatment failure Initially consider lack of compliance. brush or swab. available in liquid form. All specimens should be processed for microscopy and culture.) Comparative efficacy with griseofulvin in a histamines (specifically terfenadine. 459 Table 3 Summary of treatment choice Laboratory diagnosis Scalp lesions in suspected cases should be sampled via scalpel scraping.K. canis. effective and has activity against both Trichophyton and Microsporum species. If there has been no initial clinical improvement. at standard dosing regimens (Strength of recommendation C) Itraconazole. BAD guidelines for tinea capitis 2014. level of evidence 2+. tonsurans warrant screening of all family members and close contacts and treatment for those positive cases (Strength of recommendation B) In asymptomatic carriers (no clinical infection. culture positive) with a high spore load. Susceptibility testing is not indicated (Strength of recommendation D) Treatment In the presence of a kerion or where one or more of the cardinal clinical signs is present (scale. continue current therapy for a further 2–4 weeks.48. astemizole).4 Fluconazole Advantages: pulsed regimes. terbinafine is more efficacious against Trichophyton species (T. 50–100 mg per day for 4 weeks. the drug is not currently and rifampicin. Terbinafine requires a shorter course of treatment. some anti. hair pluck. As a general rule. M. anxiolytics (midazolam). level of evidence 3. where possible.K.3. In the U. T.24 but its Disadvantages: not licensed in the U. L. pp454–463 . ciclosporin and simvastatin (increased risk of myopathy).. has licence for use in children aged Fluconazole has been used in the treatment of tinea capitis52 > 12 years. (sertindole). phenytoin Although licensed in Europe. In cases of clinical improvement but ongoing positive mycology. ferred. alopecia) it is reasonable to commence treatment while awaiting confirmatory mycology (Strength of recommendation B) Topical therapy alone is not recommended for the treatment of tinea capitis. antipsychotics multicentre study of mixed pathogens53 and superior activity in © 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171. (Strength of recommendation C. digoxin. cisapride.K. tonsurans. tent dosing regimens are effective48. Drug interactions: enhanced toxicity of warfarin. aged 12 years and under. T. proceed to second-line therapy below Second-line therapy Itraconazole is safe.51 decreased efficacy with concomitant H2 blockers.49 (Strength of recommendation D. convert to terbinafine second line for Trichophyton infections or griseofulvin for Microsporum species.) Intermit.

level of evidence 4. T.) available. clinical signs have improved.55 Once-weekly dosing regimens have been used and appear well tolerated. Furthermore.4 Steroids > 1 year in Germany. it is imperative to ensure that the antifungal 9. (Strength of recommendation C.K.66 so tions and availability limit its current usage. canis).e. licensing restric. (ii) suboptimal absorption of drug.3. and (iv) reinfection. these should be cleansed with health priority in the U.460 BAD guidelines for tinea capitis 2014. verrucosum and M. and Europe in If fungi can still be isolated at the end of treatment.) matory varieties of tinea capitis (e. those individuals without overt clinical infection who are culture positive) is unclear. have been issued.g. ance. apy is usually justified. ketoconazole was withdrawn from use in U. level of evidence equipment. but simple bleach or a 2% aqueous solution of Fluconazole is not licensed for the treatment of tinea in sodium hypochlorite containing 165% salt are suitable alter- children aged < 10 years in the U. the options then are (i) to increase the dose or 9. Historically. level of evidence 2++.67 However.64 (Strength of recommendation D. but close fol- recommend screening of all family members and treating low-up is needed. The reasons for and it has shown comparability with griseofulvin. kerion and severe id reactions) may reduce itching and general discomfort. (Strength of recom. the drug is licensed for treatment of tinea in children aged 9.68 adults) may be affected. or (ii) to change to an alterna- Although the potential risk of transmission of infection to tive agent. cal and suggest that children receiving appropriate systemic and adjunctive topical therapy should be allowed to attend 9. tinea capitis is not considered a public For all anthropophilic species. tonsurans are highly tacts of individuals with T. tonsurans). L. Some individuals are not clear at follow-up. carriage (Strength of recommendation B. level of evidence 2++.3 Cleansing of fomites comprehensive and effective.54 but due its cost and limited has particular implications for barbers.65.55 most experts consider this impracti.3. including school nurses. (Strength of recommendation D. (Strength of recommendation B. oral steroids were thought to 8. however. canis has disinfectant.58 resolution this include (i) lack of compliance – especially in long treat- of symptoms appears slower and the side-effect profile is suffi. to ensure that treat- those found positive. are not recommended.6 Carriers school or nursery. but is controversial. Proprietary phenolic disinfectants are no longer 2++. so enforcement is British Journal of Dermatology (2014) 171.6 Ketoconazole 9.57 but cost. it is reasonable to continue ther- apy for a further 2–4 weeks. they do not reduce the time to clear- than griseofulvin or fluconazole.59–61 [Strength of recommendation D (GPP). griseofulvin remains the treatment of choice in that appropriate measures are taken to disinfect multiuser many parts of the world. pp454–463 © 2014 British Association of Dermatologists . compared with oral Voriconazole is more potent against dermatophyte isolates antifungal therapy alone..) 2+. level of evidence mendation C. itraconazole ? terbinafine (for T. tonsurans). Ideally.K. but current management practice depends 9. at present. the eradication of asymptomatic carriers requires the support and involvement of community healthcare workers.) This been shown with fluconazole.2 Family screening on the spore load.) for use in all children for mucosal candidiasis. and hair usually fully regrows after effective oral antifungal therapy alone. with repeat mycology. for example griseofulvin ? itraconazole unaffected classmates has led some authorities to recommend (for M.67 Asymptomatic carriage is highest in con- Index cases due to the anthropophilic T. ment courses. if there has been no clinical response. who need to ensure availability. ment has been effective.62 More than 50% of family members (including in M. but the 2013. tonsurans infection. although guidelines Viable spores have been isolated from hairbrushes and combs. level of evidence 3.) Scarring is rare in T.0 Additional measures therapy is appropriate for the causal organism identified on culture.C. eradication of T. it is licensed natives. but studies show that. violaceum.) Therefore we may be eradicated with topical treatment alone.K. to be 9.] The optimal management of asymptomatic carriers (i.63 Failure to In asymptomatic carriers with a high spore load. often with occult disease. level of evidence 4. oral ther- treat the whole family will result in high recurrence rates.5 Treatment failure Although the efficacy of ketoconazole in tinea capitis at doses of 33–66 mg kg 1 daily has been demonstrated in the past. Fuller et al. If so. However. or exclusion from school.5 Voriconazole reduce scarring. terbinafine ? itraconazole (for T.67 If the spore load is low.67 but can occur infectious. audouinii outbreaks as well. tonsurans infection.45. 8.10.1 Exclusion from school duration of the original drug. and therefore confer no long-term advantage. level of evidence 2+. (iii) relative ciently poor (especially the risk of hepatotoxicity) that oral insensitivity of the organism.56 (Strength of recommendation The use of corticosteroids (both oral and topical) for inflam- B.

Fraser M. 14 Lorch Dauk KC. A retrospective study been commenced on appropriate systemic and adjuvant of the management of pediatric kerion in Trichophyton tonsurans infec- topical therapy and followed up until mycological clear. Tosti A. The clinical presentation is highly the end of the standard treatment period and then monthly variable and dependent on the causative organism. Images in clinical medicine. etiology.] choose to audit all cases seen in the preceding 12 months. phytes will improve the diagnosis of tinea capitis. tonsurans from hairbrushes has also been described. Kohl K. Cohen BA. Analysis of the assays. Johnson EM. (Strength of Recom. tion is most commonly due to Microsporum and Trichophyton der- mendation D. Tinea capitis: predictive the brush technique. 11 Ilkit M. Tinea capitis in infants in their first year of life.0 Future directions Acknowledgments Studies continue to look at the emerging and changing epide.7 Follow-up 12. cost-effectiveness considerations are likely to evolve with time. 182:E839–42. 2 In the last 20 consecutive patients seen with tinea capitis. Gomar B. preferably using childhood tinea capitis. scale comparative studies of PCR. Laffitte E. 3 In the last 20 consecutive patients seen with tinea capitis.0 Summary The definitive end point for adequate treatment must be Details of evidence are given in the text. However. N Engl J Med 2012. 366:1142.K. 8 Buckley DA. 1 Bell HK. designed for dermatophyte infections. merase chain reaction (PCR) tests and PCR reverse-line blot 3 Borman AM. Mycoses 2005.) Treatment should therefore be tai. as well as the PCDS and BDNG. 128:e453–7. week. Cutaneous id reactions: a compre- ance was documented? hensive review of clinical manifestations. diagnostic tools do References seem to be emerging that might enable the laboratory diagno- sis to be made much more quickly.69–71 A method for the detection of last three decades. Writing a British Association of Dermatolo- ment decision making in the U. Table 3. Tinea T. even in the absence of clinical signs? value of symptoms and time to cure with griseofulvin treatment. 151:886–90. Durdu M. Tinea capitis is a common scalp infection. in the future. Tinea capitis in adults. J Am Acad Dermatol 2012. However. The predictive value of symptoms in diagnosing appropriate mycological samples taken. allow benchmarking between different units. matophyte species. 67:1040–8. have generally dermatophyte species isolated in the British Isles between 1980 performed well on clinical specimens including hair from and 2005 and review of worldwide dermatophyte trends over the patients with tinea capitis. 4 von Laer Tschudin L. level of evidence 4.72 Larger- capitis: no incision nor excision. The condi- until mycological clearance is documented. Browman GP et al.0 Recommended audit points of three cases. Lesson of the 1 In the last 20 consecutive patients seen with tinea capitis. Br J Dermatol 2009. and diagnosis guideline development. celsi. tion. seen pre- low-up with repeat mycology sampling is recommended at dominantly in childhood. 28:655–7. Morris-Jones R. Neonatal kerion Celsi: report 11. Karakasß M. Kho ME. level of evidence 4. contacts screened (both for tinea capitis and corporis) and 13 Hubbard TW. Baudraz-Rosselet F et al. microscopy and culture are 5 Proudfoot LE. fol. and management. which will enhance treat. Hair and scalp dermatoscopy. gists clinical guideline: an update on the process and guidance for authors. du Vivier AW. Pediatr Dermatol 2011. BMJ 2000. 48:76–9. Morris-Jones R. were specimens taken to confirm the diagnosis (as systemic 9 Ziemer A. 320:1389–90. 10. Br J Dermatol 2004. Real-time poly. reduce variation in the results due to a single patient. Rucker Wright D. 49:280–6. were children allowed to return to school once they had 10 Proudfoot LE. and to 15 Miteva M. 38:191–202. were family members and other close cations. pp454–463 . Pediatr Dermatol 2010. 45:131–41. Additionally. Higgins EM. majority of scalp isolates in the U. of tinea capitis is unlikely to be an exception. 461 hampered and widely variable. 42:E33–6. We are very grateful to Miss Sara Haveron (BAD Scientific miology of tinea capitis across Europe and the rest of the Administrator) and Miss Lesley Exton (BAD Information Scien- world. Campbell CK. 153:1150–3. Higgins EM. 9. The audit recommendation of 20 cases per department is to Clin Pediatr (Phila) 2010.24 [Strength of recommendation D departments unable to achieve this recommendation may (GPP). AGREE II: advancing fungal infections is likely to be a molecular one. Fuller et al. Fuller LC. Gil J et al. © 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171. Dermatophytid in tinea 4 In the last 20 consecutive patients seen with tinea capitis capitis: rarely reported common phenomenon with clinical impli- due to T. Blumer JL et al. Pediatrics 2011. with T. BAD guidelines for tinea capitis 2014. tonsurans. had patients been given effective therapy? 12 Cheng N. Rezusta A. rather than clinical response. 160:725–8. 7 Larralde M. Kerion required to determine whether DNA detection of dermato. L. 6 Gilaberte Y. Comrov E. 27:361–3.K. Crit Rev Microbiol 2012. Med Mycol 2007.C. Ormerod AD. Arch Pediatr Adolesc Med 1999. Trichophyton rubrum-induced therapy will be required)? inflammatory tinea capitis in a 63-year-old man. tonsurans now accounting for the lored to each individual patient according to response. and summarized in mycological cure. and may alter first-line medication recommendations tist). The future direction for laboratory diagnosis of superficial 2 Brouwers M. Boggio P et al. Therefore. epidemiology. Schroder G. Can Med Assoc J 2010. reporting and evaluation in health care. J Pediatr Surg 2007.

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463 59 Elewski BE. 18:211–14. pediatric hospital. Pediatr Infect Dis J 1999. Preuett B. Arthroderma vanbreuseghemii in rabbit skin specimens by PCR-RFLP. aStudies with a level of evi- dence ‘ ’ should not be used as a basis for making a recom- mendation. A large dermatophyte species in clinical material.g. ‘Hairbrush diagnosis’ in detection and eradication detecting Trichophyton tonsurans. Tinea capitis: recommendations for school attendance. Vet 61 Health Protection Agency. Shope TR. BAD guidelines for tinea capitis 2014. Rapid detection of 2005. outbreak of Trichophyton tonsurans among health care workers in a 16:704–10. London: Health Protection 70 Bergmans AM. Screening for asymptomatic car. from hairbrushes. NICE. Krahenbuhl L. Higgins EM. 17:322–6. in a Swiss school: assessment and management of patients and 60 Copeland KA. randomized controlled trial. on its Diagnosis. BMJ 1963. 66 Hussain I. Evaluation of a Agency. or 1+ Well-conducted meta-analyses. Bontems O et al. Asymptomatic dermatophyte scalp carriage: version of this article at the publisher’s website: laboratory diagnosis. directly or cohort studies. or RCTs with a low risk consisting principally of studies rated as 1+. formal consensus RCT. Ambul Pediatr 69 Arabatzis M. or RCTs with a very low risk of bias population. systematic reviews of RCTs. Abdel-Rahman SM. Microsporum audouinii tinea capitis 2000. Duggan AK. Dermatol Venereol 2007. 5:365–71. Dermatophyte identifi- 63 White JM. or confounding. systematic reviews rated 1++. 42:1–20. Am J Infect Control 2009. and directly applicable to the target of RCTs. overall consistency of results or RCTs with a high risk of biasa Evidence drawn from a NICE technology appraisal 2++ High-quality systematic reviews of case–control B A body of evidence including studies rated 2++. or and a moderate probability that the Extrapolated evidence from studies rated 2++ relationship is causal D Evidence level 3 or 4. Demirhindi H. case reports. Tinea Capitis in the United Kingdom: A Report Dermatol 2006. High-quality case–control applicable to the target population and demonstrating or cohort studies with a very low risk of overall consistency of results. 37:97–9. a causative agent of tinea capitis. tinea capitis: results of 209 patients from South London. epidemiology and management. National Institute for Health and Care Excellence. Muzaffar F. 2:363–5. Med Mycol 2006. systematic review or RCT 1++ High-quality meta-analyses. Additional Supporting Information may be found in the online 67 Ilkit M. Br J Dermatol 2013. Literature search strategy. griseofulvin alone. Bosshard PP. 21:1061–4. comparative Supporting Information trial of treatment of kerion celsi with griseofulvin plus oral pred- nisolone vs. RCT. A randomized. Real-time PCR TaqMan assay for 64 Mackenzie DW. or 2 Case–control or cohort studies with a high Extrapolated evidence from studies rated 2+. directly 2+ Well-conducted case–control or cohort studies applicable to the target population and demonstrating with a low risk of confounding. of non-fluorescent scalp ringworm. Clin Microbiol Infect 2010. 2007. guidelines for exclusion of ill children from child care. 49:324–8. Med Mycol 2011. or risk of confounding. pp454–463 . Med Mycol 1999. bias or chance and Formal consensus a significant D (GPP) A good practice point (GPP) is a recommendation for risk that the relationship is not causala best practice based on the experience of the guideline 3 Nonanalytical studies (e. Mycopathologia Table S1. Appendix 1 Appendix 2 Levels of evidence Strength of recommendation Level of Class Evidence evidence Type of evidence A At least one meta-analysis. randomized controlled trial. directly of bias applicable to the target population and demonstrating 1 Meta-analyses. Hiruma M. cation in skin and hair samples using a simple and reliable riage of Trichophyton tonsurans in household contacts of patients with nested polymerase chain reaction assay. Knowledge and beliefs about asymptomatic carriers. Olson-Burgess C. 71 Verrier J. 165:61–71. Hauser V. bias or chance overall consistency of results. systematic A systematic review of RCTs or a body of evidence reviews of RCTs. J Am Acad Dermatol 68 Donghi D. van der Ent M. Fuller et al. 44:579–81. Frangiadaki I et al. 2008. development group case series) 4 Expert opinion. Xylouri E. 72 Sugita T. J Eur Acad 168:295–301. bias or chance and a high Extrapolated evidence from studies rated 1++ or 1+ probability that the relationship is causal C A body of evidence including studies rated 2+. Rashid T et al.C. Klaassen A et al. Tinea capitis: a current perspective. Management and Prevention. Shiraki Y. L. 65 Honig PJ. Fuller LC. © 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171. single-tube real-time PCR for detection and identification of 11 62 Shroba J. 37:43–8.