From the Journals

Early diagnosis, treatment key to prevent permanent baldness in tinea capitis


Key clinical point: The psychosocial impact and overall lower quality of health associated with tinea capitis is significant.

Major finding: Wood’s light should not be the only method of organism identification.

Study details:
A systematic literature review of 4,190 studies.

Disclosures: The researchers had no relevant financial disclosures.

Source: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.



The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.


A child with tinea capitis and prominent lymphadenopathy

Tinea capitis, also known as ringworm, is the most common cutaneous fungal infection diagnosed in children and is most prevalent at age 3-7 years. Focused history, physical exam, trichoscopy, and microscopy are used to diagnose the condition, which originates in humans, animals, as well as soil; lifestyle, population, migration of people, and climatic conditions also are influencing factors.

Dr. Gupta and his colleagues evaluated efficacy rates that reported on mycologic cure (negative mycologic testing), clinical cure (complete absence of signs and symptoms), and complete cure (both mycologic and clinical cure). Trichophyton tonsurans was the most common organism reported in North America, and Wood’s light examination/light microscopic examination was the most common hair sample collection method identified.

In a population of 3,998 children who received treatment across all studies, five oral antifungals were used (terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole). In addition, several studies examined the safety and effectiveness of combined oral and topical treatment in 833 children, while 25 children received topical-only therapy.

Although topical treatment may be useful adjunctively, some studies noted that oral treatment is necessary for effective resolution of tinea capitis. While some experts recommend continuing topical treatment until clinical and mycologic cure are achieved, the authors cautioned that “the presence of a topical antifungal in a culture media would likely lead to a false negative result, so a clinical confirmation is necessary.”

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

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