Tinea capitis management in children

Katariina Hannula-Jouppi

Level of evidence: C

Current dosing regimens of terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole may be safe for use in tinea capitis in children.

In a systematic review in 2018 «Gupta AK, Mays RR, Versteeg SG ym. Tinea capitis i...»1 a systematic literature search of PubMed, OVID, Cochrane Libraries and ClinicalTrials.gov. was conducted for children aged 18 years or younger. Twenty-one RCTs and 17 CTs were analyzed. Five oral antifungals (terbinafine, griseofulvin, itraconazole, ketoconazole and fluconazole) were examined in 3998 children. A few included studies also evaluated the efficacy and safety of combinations of oral and topical therapies across a total of 833 treated children. 25 children used only topical therapies.

Terbinafine was evaluated in twelve studies with a pooled total of 1592 children. Mycological cure after 4 weeks of treatment was 81.4 % (48/59) and clinical cure was 58.1 % (50/86). Dosage 4-6 mg/kg/day 6 weeks, M. Canis 8-12 weeks.

Twelve studies examined the effects of griseofulvin. The mycological cure after 6 weeks of treatment was 51.5 % (421/818) and after 8 weeks of treatment was 67.2 % (43/64). The clinical cure after 6 weeks of treatment was 46.6 % (373/801). Complete cure after 6 weeks of treatment was 32.8 % (263/801) and after 8 weeks the average increased to 71.8 % (46/64). Dosage microsized 20-55 mg/kg/day or ultramicrosized 10-15 mg/kg/day at least 6 weeks until clinically clear.

Itraconazole continuous therapy was found in two studies and the weighted average of the mycological cure at 12 weeks is 79.0 % (83/105). Dosage 5 mg/kg/day Trichophyton 2-4 weeks, Microsporum 4-6 weeks.

Ketoconazole was found in four studies, and the weighted average of the mycological cure measured at 12 weeks was 15.1 % (11/73). Dosage 4 mg/kg/day 12 weeks.

Terbinafine for 4 weeks was combined with either selenium sulphide shampoo or 1 % terbinafine cream for a mycological cure weighted average of 46.8 % (61/126). Griseofulvin plus ciclopirox or selenium sulphide shampoo had a mycological cure weighted average of 32.7 % (32/98). Itraconazole capsules plus selenium sulphide shampoo had a mycological cure weighted average of 79.1 % (53/67).

Terbinafine for Microsporum infections needs to be given for a longer period of time, 6 to 8 weeks, compared to 4 weeks for Trichophyton infections. It is recommended that baseline transaminase is monitored in children taking terbinafine

Topical treatment may be useful as an adjunct to systemic therapy to decrease the carriage rate of infected species; however, oral treatment is necessary to effectively eradicate tinea capitis. Treatments such as selenium sulphide, ketoconazole or ciclopirox shampoo can be applied 2 to 3 times per week for the duration of therapy or at least 2 weeks.

Among the different antifungal therapies (oral and combination thereof), continuous itraconazole and terbinafine had the highest mycological cure rates (79 % and 81 %, respectively), griseofulvin and terbinafine had the highest clinical cure rates (46 % and 58 %, respectively) and griseofulvin and terbinafine had the highest complete cure rate (72 % and 92 %, respectively). Griseofulvin more effectively treated Microsporum infections; terbinafine and itraconazole more effectively cured Trichophyton infections.

Out of 3998 treated children, total of 295 adverse effects (AEs) from terbinafine 51.2 % (151/295), griseofulvin 26.8 % (79/295), fluconazole 12.2 % (36/295), itraconazole 8.5 % (25/295) and ketoconazole 1.4 % (4/295) related to drug use were reported. Only 1.0 % of children had to discontinue medication based on adverse events. Adverse events were transient and limited to mild to moderate in severity. Bodyweight is used to determine drug dosing in most paediatric medicine to ensure a safe dose.

  • Study quality: High
  • Applicability: Good. Terbinafine and itraconazole are available and their current use is similar. Griseofulvin is available in Finland only by special permit. Ketoconatzole is not used in Finland for fungal infections.
  • Comment: The level of evidence is downgraded by either high or unclear risk of bias in original trials.


  1. Gupta AK, Mays RR, Versteeg SG ym. Tinea capitis in children: a systematic review of management. J Eur Acad Dermatol Venereol 2018;32:2264-2274 «PMID: 29797669»PubMed