ESPD PRACTICE GUIDELINES Pediatric Dermatology Vol. 27 No. 3 226–228, 2010
Section Editors: Arnold P. Oranje, M.D., and Antonio Torrelo, M.D.
Guidelines for the Management of Tinea Capitis in Children Talia Kakourou, M.D.,* and Umit Uksal, M.D. *First Pediatric Department, Athens University, Aghia Sophia Children’s Hospital, Athens, Greece, Dermatology Department, Deutsches Krankenhaus Taksim, Istanbul, Turkey
Abstract: Practice guidelines for the treatment of tinea capitis (TC) from the European Society for Pediatric Dermatology are presented. Tinea capitis always requires systemic treatment because topical antifungal agents do not penetrate the hair follicle. Topical treatment is only used as adjuvant therapy to systemic antifungals. The newer oral antifungal agents including terbinafine, itraconazole, and fluconazole appear to have efficacy rates and potential adverse effects similar to those of griseofulvin in children with TC caused by Trichophyton species, while requiring a much shorter duration of treatment. They may be, however, more expensive (Grading of recommendation A; strength of evidence 1a). Griseofulvin is still the treatment of choice for cases caused by Microsporum species. Its efficacy is superior to that of terbinafine (Grading of recommendation A; strength of evidence 1b), and although its efficacy and treatment duration is matched by fluconazole (Grading of recommendation A; strength of evidence 1b) and itraconazole (Grading of recommendation A; strength of evidence 1b), griseofulvin is cheaper. It must be noted, however, that griseofulvin is nowadays not available in certain European countries (e.g., Belgium, Greece, Portugal, and Turkey).
These guidelines were prepared on behalf of the European Society for Pediatric Dermatology (ESPD). They were edited by the ESPD committee on Tinea Capitis management, namely E. Bonifazi, A. Mota, A. Oranje, H. Sillevis-Smitt, and A. Taieb, and then approved by the board members of ESPD.
DEFINITION—EPIDEMIOLOGY Tinea capitis (TC) is a dermatophyte infection of the scalp hair follicles and intervening skin, mainly caused by anthropophilic and zoophilic species of the genera Trichophyton and Microsporum (1,2). Although an overall
Extended paper available at: http://www.espd.info. Address correspondence to Arnold P. Oranje, M.D., Erasmus MC, KinderHaven, Havenziekenhuis, Rotterdam, The Netherlands, or e-mail: [email protected]
2010 Wiley Periodicals, Inc.
Kakourou and Uksal: Management of Tinea Capitis
increase in the number of anthropophilic scalp infections is reported in Europe, Microsporum canis remains the predominant organism with the highest incidence in the Mediterranean and their bordering countries (3). TREATMENT Oral Tinea capitis always requires systemic treatment because topical antifungal agents do not penetrate the hair follicle. Topical treatment is only used as adjuvant therapy to systemic antifungals. Factors that may inﬂuence the choice between equally eﬀective therapies include tolerability, safety, compliance, availability of liquid formulation and cost. Since the late 1950s, griseofulvin has been the gold standard for systemic therapy of TC. It is active against dermatophytes and has a long-term safety proﬁle. The main disadvantage of griseofulvin is the long duration of treatment required (6–12 weeks or longer) which may lead to reduced compliance (4). The newer oral antifungal agents including terbinaﬁne, itraconazole, and ﬂuconazole appear to have eﬃcacy rates and potential adverse eﬀects similar to those of griseofulvin in children with TC caused by Trichophyton species, while requiring a much shorter duration of treatment. They may be, however, more expensive (5) (Grading of recommendation A; strength of evidence 1a). Consequently, the treatment decision between griseofulvin and newer antifungal agents for children with TABLE 1. Dosing Regimens for the Treatment of Tinea Capitis Antifungal agent Dosage Griseofulvin Microsize Ultramicrosize
20–25 mg ⁄ kg ⁄ day 10–15 mg ⁄ kg ⁄ day
10–20 kg: 62.5 mg ⁄ day 20–40 kg: 125 mg ⁄ day >40 kg: 250 mg ⁄ day Or 4–5 mg ⁄ kg ⁄ day Capsules: 5 mg ⁄ kg ⁄ day Oral solution: 3 mg ⁄ kg ⁄ day
Daily dosing: 5–6 mg ⁄ kg ⁄ day Weekly dosing: 8 mg ⁄ kg once weekly
Duration of treatment 6–12 weeks or longer until fungal cultures are negative Trichophyton spp.: 2–4 weeks Microsporum spp.: 8–12 weeks Daily dosing: 2–6 weeks Pulse regimen (1 week with 2 weeks oﬀ between the ﬁrst 2 pulses and 3 weeks between the 2nd and 3rd): 2–3 pulses (range: 1–5) 3–6 weeks 8–12 weeks
Trichophyton spp tinea capitis can be based on an individual patient on the balance between duration of treatment ⁄ compliance and economic considerations. On the contrary griseofulvin is still the treatment of choice for cases caused by Microsporum species. Its eﬃcacy is superior to that of terbinaﬁne (6) (Grading of recommendation A; strength of evidence 1b), and although its eﬃcacy and treatment duration is matched by that of ﬂuconazole (7) (Grading of recommendation A; strength of evidence 1b) and itraconazole (8) (Grading of recommendation A; strength of evidence 1b), griseofulvin is cheaper. It must be noted, however, that griseofulvin is nowadays not available in certain European countries (e.g., Belgium, Greece, Portugal, and Turkey). It must be noted that country-speciﬁc prescribing information, and formula availability of any antifungal should be considered prior to prescription (Table 1). Topical Adjunctive topical therapies such as Selenium sulﬁde (9) (Grade of recommendation B; strength of evidence II a) or ketoconazole (10) (Grade of recommendation B; strength of evidence III) shampoos as well as fungicidal creams or lotions (11) have been shown to decrease the carriage of viable spores responsible for the disease contagion and reinfection and may shorten the cure rate with oral antifungal. The topical fungicidal cream ⁄ lotion should be applied to the lesions once daily for a week (11) (Grade of recommendation C; strength of evidence IV). The shampoo should be applied to the scalp and hair for 5 minutes twice weekly for 2–4 weeks (12,13) or three times weekly until the patient is clinically and mycologically cured (4) (Grade of recommendation C; strength of evidence IV). The latter in conjunction with 1 week of topical fungicidal cream or lotion application is recommended by the authors. Follow-up Clinical and mycologic examinations of the children should be conducted at regular intervals (2–4 weeks). The treatment may be stopped after the culture becomes negative or when hair regrowth is clinically evident; consequently, the duration of treatment can be individualized according to the response. REFERENCES 1. Gupta AK, Summerbell RC. Tinea capitis. Med Mycol 2000;38:255–287. 2. Elewski B. Tinea capitis: a current perspective. J Am Acad Dermatol 2000;42:1–20.
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3. Hay RJ, Robles W, Midgley G et al. European Confederation of Medical Mycology Working Party on Tinea Capitis. Tinea capitis in Europe: new perspective on an old problem. J Eur Acad Dermatol Venereol 2001;15:229–233. 4. Elewski BE. Treatment of tinea capitis: beyond griseofulvin. J Am Acad Dermatol 1999; 40(6 Pt 2): S 27–30. 5. Gonzalez U, Seaton T, Bergus G et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Sys Rev 2007;17:CD004685. 6. Elewski BE, Ca´ceres HW, DeLeon L et al. Terbinaﬁne hydrochloride oral granules versus griseofulvin suspension in children with tinea capitis: results of two randomized, investigator-blinded, multicenter,international, controlled trials. J Am Acad Dermatol 2008;59:41–54. 7. Foster KW, Friedlander SF, Panzer H. A randomized controlled trial assesing the eﬃcacy of ﬂuconazole in treatment of pediatric tinea capitis. J Am Acad Dermatol 2005;53:798–809. 8. Lo´pez-Go´mez S, Del Palacio A, Van Cutsem J et al. Itraconazole versus griseofulvin in the treatment of tinea
9. 10. 11. 12.
capitis: a double-blind randomized study in children. Int J Dermatol 1994;33:743–747. Allen HB, Honig PJ, Leyden JJ et al. Selenium sulﬁde: adjunctive therapy for tinea capitis. Pediatrics 1982;69:81– 83. Greer DL. Successful treatment of tinea capitis with 2% ketoconazole shampoo. Int J Dermatol 2000;39:302– 304. Seebacher C, Abeck D, Brasch J et al. Tinea capitis: ringworm of the scalp. Mycoses 2007;50:218–226. Gupta AK, Ahmad I, Summerbell RC. Comparative eﬃcacies of commonly used disinfectants and antifungal pharmaceutical spray preparations against dermatophytic fungi. Med Mycol 2001;39:321–328. Fuller LC, Smith CH, Cerio R et al. A randomised comparison of four weeks of terbinaﬁne versus eight weeks of griseofulvin for the treatment of tinea capitis – advantages of a shorter treatment schedule. Br J Dermatol 2001;144:321–327.
APPENDIX Grading the Evidence Levels of Evidence Ia: Evidence obtained from meta-analysis of randomized controlled trials. Ib: Evidence obtained from at least one randomized controlled trial. IIa: Evidence obtained from at least one well-designed controlled study without randomization. IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study. III: Evidence obtained from well-designed non-experimental descriptive studies such as comparative studies, correlation studies, and case control studies. IV: Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities. Grading of Recommendations A (Evidence levels Ia, Ib)
B (Evidence levels IIa, IIb, III)
C (Evidence level IV)
Requires at least one randomized controlled trial as part of the body of literature of overall good quality and consistency addressing the speciﬁc recommendation. Requires availability of well-conducted clinical studies but no randomized clinical trials on the topic of recommendation. Requires evidence from expert committee reports or opinions and ⁄ or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.