Tinea capitis: epidemiology, diagnosis and management strategies.

Tinea capitis is a common superficial fungal infection of the scalp in children, particularly in those of African descent. Trichophyton tonsuran, an anthropophilic dermatophyte, is responsible for the majority of cases in North America. The clinical presentations are variable and include: (i) a "seborrheic" form that is scaling, often without noticeable hair loss; (ii) a pustular, crusted pattern, either localized or more diffuse; (iii) a "black dot" variety characterized by small black dots within areas of alopecia; (iv) a kerion, which is an inflammatory mass; and (v) a scaly, annular patch. Most experts still consider griseofulvin to be the drug of choice, but recommend a higher dosage of 20-25 mg/kg/day for 8 weeks because of the increase in treatment failures. Despite a history of having an excellent tolerability profile, the long treatment course and higher doses required for griseofulvin have led to consideration of new antifungal agents for this infection. Terbinafine, itraconazole, and fluconazole compartmentalize in skin, hair, and nails, thereby allowing shorter treatment courses of < or =4 weeks. All have generally been shown to be effective in the treatment of tinea capitis and appear relatively well tolerated, with gastrointestinal symptoms being the most common adverse effect. Monitoring for liver enzyme elevations is generally unnecessary if therapy is limited to </=4 weeks. As more data regarding efficacy, tolerability, and dose administration becomes available, one or more of these new antifungal agents may become first-line therapy for tinea capitis. For now, we recommend their use in cases of treatment failure or recurrent noncompliance. Our personal preference in the younger child is fluconazole. It has a favorable tolerability profile and is available in liquid form. In the older child who can take a tablet, terbinafine is recommended. More data is available on this drug in the treatment of tinea capitis than the other two, and it is the least expensive. Although the oral antifungal agents are the most important aspect of therapy, adjunctive therapy may be beneficial. Sporicidal shampoos, such as selenium sulfide, can aid in removing adherent scales and hasten the eradication of viable spores from the scalp in the hope of decreasing the spread of this infection. The use of corticosteroids for the treatment of kerions is controversial. Many of the studies have design flaws or show variable results. We recommend either a short burst of oral corticosteroids or topical corticosteroids in patients with the most severe disease.