Systemic antifungal therapy for tinea capitis in children

Katariina Hannula-Jouppi

Level of evidence: C

Systemic antifungal therapy for tinea capitis in children may promote the eradication of tinea capitis and side effects seem to be rare.

A Cochrane review «Chen X, Jiang X, Yang M ym. Systemic antifungal th...»1 of 29 studies with 7086 participants was conducted in children under the age of 18 with normal immunity with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both.

Terbinafine, itraconazole and fluconazole have similar effects on Trichophyton species. A meta-analysis of two studies indicated that there was no significant difference between itraconazole and terbinafin for achieving a complete cure in children infected with Trichophyton (RR 0.93, CI 0.72 to 1.19; N = 160; 2 RCTs; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole and terbinafine (82.0 % versus 94.0 %; RR 0.87, 95 %CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, a significant difference was not found between fluconazole and itraconazole (82.0 % versus 82.0 %; RR 1.00, 95 % CI 0.83 to 1.20; low quality evidence).

At standard doses for standard 6 week therapies terbinafin is at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species (49.5 % versus 37.8 %; RR 1.18, 95 % CI 0.74 to 1.88; N = 1006; low quality evidence). Terbinafine is more effective than griseofulvin in children with T. tonsurans infection (52.1 % versus 35.4 %; RR 1.47, 95 %CI 1.22 to 1.77; moderate quality evidence). For T. violaceum, terbinafin and griseofulvin have similar effects (RR 0.91, 95 % CI 0.68 to 1.24; N = 242; low quality evidence). Whereas ketoconazole may be less effective than griseofulvin.

For Microsporum infections, griseofulvin (6-12 weeks) is better than terbinafine (6-8 weeks) (50.9 % versus 34.7 %; RR 0.68, 95 % CI 0.53 to 0.86; moderate quality evidence).

There is very low to moderate quality evidence to support the use of griseofulvin to treat tinea capitis in children, caused by T. tonsurans, M. canis, T. mentagrophytes and T. violaceum. Overall griseofulvin is considered to be safe in children. The recommended dosage regimen for children is continuous therapy for six to eight weeks with tablets or suspension including microsized and ultra-microsized preparations, adjusted according to the child's weight.

Terbinafine may constitute a first-line drug that is well tolerated and has few side effects. Comparing two weeks versus four weeks duration of terbinafine treatment, a longer treatment duration was significantly better than a short duration for a complete cure, but the difference was not statistically significant (75.1 % versus 63.9 %; RR 0.84, 95 % 0.67 to 1.06. However, long-term (more than six weeks) terbinafine therapy cannot be recommended.

Only limited evidence based on small trials suggesting that oral itraconazole at weight-adjusted doses was effective and safe for tinea capitis caused by T. violaceum (two weeks of treatment) and M. canis (six weeks of treatment). More well-designed RCTs with large sample sizes are needed to confirm the safety, efficacy and optimal treatment regimens of itraconazole for paediatric tinea capitis patients.

Fluconatzole had been suggested as an alternative for terbinafin but the optimal regimen of fluconazole for treating paediatric tinea capitis remains unclear.

Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. The frequency of adverse events was similar for terbinafine and griseofulvin and severe adverse events were rare

  • Study quality: High
  • Applicability: Moderate. Griseofulvin is available in Finland only by special permit. Ketoconazole 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. There is no placebo-controlled trials in children.


  1. Chen X, Jiang X, Yang M ym. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev 2016;:CD004685 «PMID: 27169520»PubMed