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Tinea capitis: diagnostic criteria and treatment options.

Tinea capitis is a fungal infection involving the hair shaft of the scalp and hair follicles caused by dermatophyte fungi (Ali, Graham, & Forgie, 2007). While it may affect any age group, tinea capitis is particularly common among school-aged children (Alvarez & Silverberg, 2006). To treat tinea capitis, systemic anti-fungal rather than topical treatment is required. Topical anti-fungal treatments are not able to adequately penetrate the hair shaft to eliminate the infection (Ali et al., 2007; Chan & Friedlander, 2004). Because of the prevalence of tinea capitis, it is essential that nurses are aware of this condition and current available treatment regimens. This article will review the recent research-based publications on the diagnosis and treatment of tinea capitis, providing valuable evidence for nursing practice.

Currently, griseofulvin (Grifulvin[R]) and terbinafine (Lamasil Granules[R]) are the only two medications approved by the United States Food and Drug Administration (FDA) for the treatment of tinea capitis (FDA, 2007; Roberts & Friedlander, 2005). There are newer anti-fungal agents available that have been shown to be safe and effective with a shorter duration of treatment, but are not yet approved by the FDA for the treatment of tinea capitis. Medications such as fluconazole and itraconazole are currently being prescribed off-label for tinea capitis.

Off-label use refers to the use of legally available medications being prescribed for a function outside of the medication's approved label. For example, fluconazole (Diflucan[R]) is currently FDA-approved to treat vaginal yeast infections but is sometimes used in pediatrics to treat tinea capitis (off-label use). Prescribing off-label-approved medications is common and often necessary in pediatric practice (Moonestime-Williams, Dickerson, & Basco, 2007; Novak & Jackson-Allen, 2007). According to the FDA (1998), the off-label use of medication cannot significantly increase the risk or decrease the acceptability of the risks associated with use of the medication. Care must be used when prescribing and administering off-label medications in pediatrics because the pharmacokinetics of medications may be different in children than in adults (Novak & Jackson-Allen, 2007). Pediatric providers should consider consulting specialists for guidance on treatment with nonapproved medications until a "community standard of practice" with the non-approved drug is attained. Parents should also be informed when a medication is being used in an off-label manner (Moonestime-Williams et al., 2007).

Epidemiology

Fungi that cause tinea capitis infections are from geophilic, zoophilic, and anthropophilic organisms. Geophilic fungi inhabit the soil, zoophilic organisms (Microsporum canis) live on animals, and anthropophilic fungi (Trichophytan tonsurans) live on humans (Fuller, Child, Midgley, & Higgins, 2003). In the past, most pediatric tinea capitis infections in the United States were caused by zoophilic fungi after exposure to an infected animal (usually cats and dogs). Although the reasons for the change in infective fungi are not known, more recently, the most prevalent organisms causing tinea capitis infections in children are anthropophilic organisms, which spread directly from person to person (Fuller et al., 2003). Most cases tend to occur in children from the age of 4 to 7 years, although it does occur in adolescents, with both boys and girls appearing to be infected equally (Chen & Friedlander, 2001). In the United States, the spread of T. tonsurans has predominantly (but not exclusively) been seen in African-American children. It is unknown whether this is related to hair type or ethnicity. African Americans may have a higher risk of developing tinea capitis, but it is important to realize that all children are susceptible to tinea capitis infections regardless of their ethnic backgrounds (Hay, 2001).

Clinical Manifestations

Tinea capitis infections have been called "the great masqueraders" (Roberts & Friedlander, 2005, p.191). Tinea capitis infections present in an assortment of ways that may cause them to be confused with other skin disorders of the scalp (see Figure 1). It may present as either a non-inflammatory or as an inflammatory condition. Symptoms may be subtle with non-inflammatory presentation, such as dandruff-like scaling of the scalp, slight pruritis, and minimal hair loss (Ali et al., 2007). Hair growth will return as the fungal infection clears. With the inflammatory form of the disease (kerions), the infected area may be boggy, oozing, and have pustular masses. Kerions may sometimes be incorrectly diagnosed as bacterial abscesses leading to inappropriate and ineffective treatment (Roberts & Friedlander, 2005). Permanent scarring may result from kerions (Ali et al., 2007). Figure 2 shows a child with an inflammatory kerion.

[FIGURE 1 OMITTED]

The clinical triad of scalp scaling, alopecia, and lymphadenopathy (occipital and/or posterior cervical) is typically associated with tinea capitis (Roberts & Friedlander, 2005). A differential diagnosis of tinea capitis should include other common scalp disorders that may present with scalp scaling and head and neck adenopathy, such as atopic dermatitis, psoriasis, and seborrheic dermatitis (Roberts & Freidlander, 2005). It is important to keep in mind that not all individuals with tinea capitis will display symptoms. In the general population of the United States, the asymptomatic carrier state is estimated to be 5%. However, in urban school-age populations, the percentage increases to nearly 15% (Chen & Friedlander, 2001).

Diagnosis

"The clinical diagnosis of the infection is notoriously unreliable..." (Hay, 2001, p. 122). Microscopic examination and/or fungal culture should be used to confirm the clinical diagnosis of tinea capitis because of the extended nature of most treatment regimens (Ali et al., 2007). Microscopic examination consists of scraping the scales of the lesions onto a slide and viewing the sample, which is prepared with a 20% potassium hydroxide (KOH) solution, under the microscope to look for the presence of hyphae (Chen & Friedlander, 2001). This test may be difficult to interpret or may be falsely negative with early or inflammatory lesions. Therefore, the final diagnosis of tinea capitis should be made by culture. Culture documentation of the infection is a crucial component to treatment of tinea capitis (Roberts & Friedlander, 2005). If the clinical index of suspicion is high, therapy should be initiated after the culture is obtained because it may take at least two weeks for culture results to return. However, oral anti-fungals should be deferred if there is low index of clinical suspicion until positive culture results have been obtained (Roberts & Friedlander, 2005).

[FIGURE 2 OMITTED]

Traditional scalp culture methods include a scalp scraping with a scalpel and removal of hairs; however, culturing the scales and hair of tinea capitis lesions with a cotton swab or cytobrush is a reliable, inexpensive, and less-traumatic means of gathering a sample for the fungal culture (Bonifaz et al., 2007; Friedlander, Pickering, Cunningham, Gibbs, & Eichenfeld, 1999). Culturing the suspected fungal lesion with a cotton applicator involves rubbing and rotating a moistened swab over the affected area and placing the swab in the appropriate culture medium. Hubbard and de Triquet (1992) determined that using a toothbrush in a manner similar to that of the cotton swab is also a reliable manner of gathering a scalp sample for fungal culture in the diagnosis of tinea capitis. While this technique has been shown to be easy to perform and painless, one disadvantage of this method is that it requires an office to be stocked with toothbrushes, which are more expensive than cotton swabs (Friedlander et al., 1999).

Historically, when the majority of tinea capitis infections in the United States were caused by the Microsporum species, a Wood's lamp examination was helpful in assisting providers in diagnosing tinea capitis; the Microsporum species would fluoresce when examined using a Wood's lamp due to the formation of a sheath by fungal spores on the outside of the hair shaft (ectothrix). However, with tinea capitis infections that are caused by the Trichophytan species, the fungal spores form on the inside of the hair shaft (endothrix), and there is no fluorescence (Fuller et al., 2003). Therefore, the Wood's light examination is not a reliable method for diagnosing tinea capitis caused by the Trichophytan species because this species does not fluoresce.

Available Treatments for the Management of Tinea Capitis

There are several pharmacologic treatments for the management of tinea capitis, as shown in Table 1 and discussed in detail below.

Griseofulvin (Grifulvin[R]). Griseofulvin (Grifulvin) is currently the standard treatment for tinea capitis infections in the pediatric population. However, griseofulvin has a restricted spectrum of action and is only effective against a small number of dermatophyte species (Trichophytan, Microsporum, and Epidermophyton). A meta-analysis of studies researching the efficacy of grisefulvin noted that after 6 to 8 weeks of treatment, griseofulvin was nearly 68% effective when treating the Trichophytan species and 88% effective when treating the Microsporum species (Gupta, Cooper, & Bowen, 2008).

Researchers have been concerned with the observed "troublesome decrease in the sensitivity of tinea capitis infections to this agent" (Chen & Friedlander, 2001, p. 332). This concern over the decrease in sensitivity of tinea infections to griseofulvin is supported by changes in the initial response and cure rates, and increases in recommendations for dosages and duration of treatment with griseofulvin (Chen & Friedlander, 2001; Roberts & Friedlander, 2005). Mycologic cure rates with griseofulvin have been shown to range from 71% to 92% (Fuller, Smith, & Cerio, 2001; Gupta, Adam, & Dlova, 2001) depending on the infective organism, the dose of medication, and the duration of therapy.

There is an apparent relationship between the dose of medication and recurrence rate of infection. Absorption of griseofulvin is increased by "microsizing" or reducing the particle size of the medication. The medication is even more rapidly absorbed with the "ultramicrosized" form of griseofulvin that allows for a dosage reduction of 33% to 50%. The microsized formulation of the medication should be administered at a dose of 20 to 25 mg/kg per day, while the ultra-microsized preparation should be dosed at 10 to 15 mg/kg/day. The normal duration of treatment is 6 to 8 weeks (up to 16 weeks) depending on clinical and mycological cure. It has poor water solubility and should be taken with food or milk to enhance absorption (Roberts & Friedlander, 2005). Currently, only the microsized preparation is available in liquid form (Roberts & Friedlander, 2005).

The most common side effects associated with griseofulvin are headaches and gastrointestinal complaints. Increased sensitivity to the sun may occur. Patients should be advised to use sunscreen with at least SPF 15 and avoid tanning booths. Griseofulvin may affect the efficacy of oral contraceptives pills. Adolescent girls taking griseofulvin should be instructed to use a different or an additional form of contraception while taking griseofulvin. BUN, creatinine, and liver function tests should be monitored after 8 weeks of therapy with griseofulvin (Wynne, Woo, & Olyaei, 2007).

Terbinafine (Lamasil Granules[R]). Terbinafine (Lamisil Granules) is currently FDA-approved to treat tinea capitis in children 4 years of age and older. A meta-analysis of randomized clinical trials comparing terbinafine to griseofulvin for the treatment of tinea capitis was conducted, and results favored terbinafine after 12 weeks of treatment (Fleece, Gaughan, & Aronoff, 2002). More recent randomized controlled trials comparing griseofulvin to terbinafine oral granules supported the results of the earlier meta-analysis in patients infected with tinea from the Trichophytan species. Rates of mycological and clinical cure were significantly higher for terbinafine than for griseofulvin for patients with Trichophytan tonsurans. For patients with Microsporum canis, mycological and clinical cure rates were significantly higher for patients treated with griseofulvin than those treated with terbinafine oral granules (Elewski et al., 2008).

The approved terbinafine granules dose for the treatment of tinea capitis is 125 mg/day (25 kg weight), 187.5 mg/day (25 to 35 kg weight), and 250 mg (greater than 35 kg weight). The maximum dose is 250 mg/day. Children should be treated once daily for 6 weeks. The oral granules should be taken with non-acidic foods, such as pudding or mashed potatoes. The oral granules should not be taken with applesauce or other fruit-based foods (Deglin & Vallerand, 2009).

The most common side effects reported when using terbinafine are headache, nasopharyngitis, rash, and gastrointestinal symptoms. Because there is a risk of hepatotoxicity when using terbinafine oral granules, this medication should not be used in patients with a pre-existing liver condition. Pre-treatment serum liver transminases (ALT and AST) and a potassium level should be obtained. If treatment is to continue beyond 6 weeks, liver transaminases and a potassium level should be re-obtained along with a complete blood count (CBC) with differential to monitor the absolute neutrophil count. The medication should be continued if abnormal values occur (Deglin & Vallerand, 2009).

Fluconazole (Diflucan[R]). Fluconazole (Diflucan) is FDA-approved to treat candidiasis and systemic fungal infections (Deglin & Vallerand, 2009) but not tinea capitis. It is available in both liquid and tablet formulations, and greater than 90% of the medication is absorbed regardless of presence of food in the stomach. The recommended dose for treatment of fungal infections in children is 6 mg/kg/day for 3 weeks depending on the clinical response, and this dose has been proposed for the treatment of tinea capitis (Roberts & Friedlander, 2005). At 6 mg/kg/day for 2 to 3 weeks of treatment, studies have shown mycological cure rates of between 84% to 89% (Gupta et al., 2001; Solomon, Collins, & Sharma, 1997).

Gastrointestinal symptoms and headaches are the most common side effects. The medication is cleared primarily by renal excretion. BUN and creatinine levels should be obtained prior to treatment with fluconazole. Liver tests (ALT, AST, Alkaline phosphatase, bilirubin) should also be obtained prior to treatment (Deglin 8, Vallerand, 2009).

Itraconazole (Sporanox[R]). ltraconazole (Sporanox) is currently not FDA-approved to treat tinea capitis, but it is approved to treat onychomycosis and fungal infections of the esophagus and mouth (Deglin & Vallerand, 2009). There are different formulations of itraconazole--capsules and liquids. The capsules should be taken with food, and can be opened and mixed with food. The liquid form of the medication should be taken on an empty stomach and may cause some gastrointestinal disturbances, such as diarrhea. The liquid form of the medication is given at a lower dose due to its greater bioavailability.

For the Trichophytan species, mycological cure has been shown to be 86% with continuous dosing for 2 to 3 weeks (Gupta et al., 2001), and mycological cure rates range from 67% to 81% after receiving 3 to 5 medication pulses (Gupta, Hofstader, & Summerbell, 1998; Gupta, Solomon, & Adam, 1998). Pulse medication regimens usually consist of administering the medication daily for 1 week, with no medication being administered during the following 2 to 3 weeks. After the 2 to 3-week respite period, the medication is re-started for 1 week.

The recommended dose for itraconazole in treating tinea capitis depends on the chosen medication administration regimen. For a continuous medication regimen with capsules, the recommended dose is 5 mg/kg/day for 4 weeks (Roberts & Friedlander, 2005). If using pulse therapy, the dosing should be 5 mg/kg/day for 1 week each month for 2 to 4 months. The recommended dose for oral solution is 3 m/kg/day for 4 weeks (Roberts & Friedlander, 2005).

The most common side effects are gastrointestinal symptoms, headaches, and rash. As with fluconazole, elevated transaminase levels may occur. Pre-therapy laboratory studies of hepatic function tests and a potassium level should be obtained (Deglin & Vallerand, 2009). Consultation with a specialist prior to prescribing itraconazole for tinea capitis is recommended.

Adjunct Therapies

Transmission of tinea capitis between individuals may be reduced when anti-fungal shampoos are used in conjunction with oral therapy. Selenium sulfide shampoos have been shown to have success in eliminating the shedding of viable tinea capitis spores (Wynne et al., 2007). In a prospective, randomized, non-blinded clinical trial of 54 pediatric patients with culture-proven tinea capitis, Givens, Murray, and Baker (1995) found that when used twice weekly, both the 1% and 2.5% preparations of selenium sulfide shampoos were superior to a non-medicated control shampoo in terms of the time required to eliminate the shedding of viable spores. When the 1% and 2.5% preparations of selenium sulfide were compared to each other, there was no difference between the two in the time required to produce a negative culture. This finding led the researchers to conclude that the 1% selenium sulfide shampoo, which is commercially available, is an equally effective but less expensive alternative sporicidal adjunct to the oral treatment of tinea capitis.

Similarly, Greer (2000) found that 2% ketoconazole shampoo reduced the number of viable spores in a sample of 16 children with culture-proven tinea capitis infections caused by Trichophytan tonsurans. The children were treated daily for 8 weeks without any oral medication. Greer noted that marked clinical improvement occurred in all children within the first 2 weeks of therapy; after 8 weeks of therapy, 93% of the children were clinically healed. Complete culture cure was obtained in 33% of cases using of 2% ketoconazole shampoo as a treatment for tinea capitis, and these children remained culture negative for at least 1 year after treatment.

No studies were located researching alternative therapies for tinea capitis. However, one article discussed alternative treatments for fungal skin infections, such as tinea corporis and tinea cruris, using a 1:1:1 mixture of honey, olive oil, and beeswax. Al-Waili (2004) found that 71% of individuals with tinea cruris and 61% of those with tinea corporis obtained a mycological cure after 4 weeks of treatment.

Other Considerations

Families with children with infections should be cautioned against sharing personal items, such as combs, brushes, and hats. Fungal spores may attach themselves to these items and be transmitted from person to person if these items are shared. Children with tinea capitis may return to school once treatment with an anti-fungal shampoo or an anti-fungal agent has been started.

Conclusion

This evidence-based review sought to provide nurses with current information on the diagnosis and treatment of tinea capitis. While griseofulvin and terbinafine remain the only FDA-approved medications for the treatment of tinea capitis in children, the evidence presented indicates that other anti-fungal agents, such as itraconozole and fluconazole, are effective in the treatment of tinea capitis infections. ltraconozole and fluconazole are not, however, currently approved for use in treating tinea capitis by the FDA, and therefore, should not be used as first-line therapy but considered for use with consultation with a dermatologist for infections resistant to standard approved therapy.

It is important for nurses and other pediatric health care providers to remember that caution should be used when prescribing or administering off-label medications to children because the pharmacokinetics of medications may be different in children than in adults (Novak & Jackson-Allen, 2007). A specialist should be consulted for guidance on treatment with non-approved medications, and parents should be informed when a medication is being used in an off-label manner (Moonestime-Williams et al., 2007).

Acknowledgment: The author would like to thank Pat Jackson-Allen for her assistance in the preparation of this article.

References

Al-Waili, N. (2004). An alternative treatment for pityriasis versicolor, tinea cruris, tinea corporis and tinea faciei with topical application of honey, olive oil and beeswax mixture: An open pilot study. Complementary Therapies in Medicine. 12, 45-47.

Ali, S., Graham, T., & Forgie, S. (2007). The assessment and management of tinea capitis in children. Pediatric Emergency Care, 23, 662-665.

Alvarez, M., & Silverberg, N. (2006). Tinea capitis. Curls, 78, 189-196.

Bonifaz, A., Isa-lsa, R., Araiza, J., Cruz, C., Hernandez, M., & Ponce, R. (2007). Cytobrush-culture method to diagnose tinea capitis. Mycopathologia, 163, 309-313.

Chan, Y. & Friedlander, S. (2004). New treatments for tinea capitis. Current Opinion in Infectious Diseases, 17, 97-103.

Chen, B., & Friedlander, S. (2001). Tinea capitis update: A continuing conflict with an old adversary. Current Opinion in Pediatrics, 13, 331-335.

Deglin, J.H., & Vallerand, A.H. (2009). Davis' drug guide for nurses (11th ed.). Philadelphia: F.A. Davis Company.

Elewski, B., Caceres, H., DeLeon, L., El Shimy, S., Hunter, J., Korotkiy, N., et al. (2008). Terbinafine hydrochloride oral granules versus oral griseofulvin suspension in children with tinea capitis: Results of two randomized, investigator-blinded, multicenter, international, controlled trials. Journal of the American Academy of Dermatology, 59, 41-54.

Fleece, D., Gaughan, J., & Aronoff, S. (2002). Griseofulvin versus terbinafine in the treatment of tinea capitis: A meta-analysis of randomized clinical trials. Pediatrics, 114, 1312-1315.

Food and Drug Administration (FDA). (1998). "Off-label" and investigational use of marketed drugs, biologics, and medical devices. Retrieved January 5, 2009, from http://www.fda.gov/ oc/ohrt/irbs/offlabel.html

Food and Drug Administration (FDA). (2007). Lamisil approved to treat scalp ringworm in children. Retrieved January 5, 2009, from http://www.fda.gov/consumer/updates/lamisil100907.html

Friedlander, S., Pickering, B., Cunningham, B., Gibbs, N., & Eichenfeld, L. (1999). Use of cotton swab method in diagnosing tinea capitis. Pediatrics, 104, 276-279.

Fuller, L., Child, F., Midgley, G., & Higgins, E. (2003). Diagnosis and management of scalp ringworm. British Medical Journal, 326, 539-541.

Fuller, L., Smith, C., & Cerio, R. (2001). A randomized comparison of 4 weeks of terbinafine versus 8 weeks of griseofulvin for the treatment of tinea capitis. British Journal of Dermatology, 144, 321-327.

Givens, T., Murray, M., & Baker, R. (1995). Comparison of 1% and 2.5% selenium sulfide in the treatment of tinea capitis. Archives of Pediatrics and Adolescent Medicine, 149, 808-811.

Greer, D. (2000). Successful treatment of tinea capitis with 2% ketoconazole shampoo. International Journal of Dermatology, 39, 302-304.

Gupta, A., Adam, R, & Dlova, N. (2001). Therapeutic options for the treatment of tinea capitis caused by Trichophytan species: Griseofulvin versus the new oral anti-fungal agents, terbinafine, itraconazole, and fluconazaole. Pediatric Dermatology, 18, 433-438.

Gupta, A., Cooper, E., & Bowen, J. (2008). Meta-analysis: Griseofulvin efficacy in the treatment of tinea capitis. Journal of Drugs in Dermatology, 7, 369-372.

Gupta, A., Hofstader, S., & Summerbell, R. (1998). Treatment of tinea capitis with itraconazole capsule pulse therapy. Journal of the American Academy of Dermatology, 39, 216-219.

Gupta, A., Solomon, R., & Adam, P. (1998). Itraconazole oral solution for the treatment of tinea capitis. British Journal of Dermatology, 139, 104-106.

Hay, R. (2001). Endemic scalp ringworm: An object lesson in control of a common fungal infection. Current Opinion in Infectious Diseases, 14, 121-122.

Hubbard, T., & de Triquet, J. (1992). Brush-culture method for diagnosing tinea capitis. Pediatrics, 90, 416- 418.

Moonestime-Williams, N., Dickerson, L., & Basco, W., Jr. (2007). Off-label prescribing of medications for children. Journal of the South Carolina Medical Association, 103, 130-133.

Novak, E., & Jackson-Allen, P. (2007). Prescribing medications in pediatrics: Concerns regarding FDA approval and pharmacokinetics. Pediatric Nursing, 33, 64-70.

Roberts, B., & Friedlander, S. (2005). Tinea capitis: A treatment update. Pediatric Annals, 34, 191-200.

Solomon, B., Collins, R., & Sharma, R. (1997). Fluconazole for the treatment of tinea capitis in children. Journal of the American Academy of Dermatology, 37, 274-275.

Wynne, A., Woo, T., & Olyaei, A. (Eds.). (2007). Drugs affecting the integumentary system. In Pharmacotherapeutics for nurse practitionerprescribers (2nd ed.). Philadelphia: RA. Davis Company.

Mikki Meadows-Oliver, PhD, RN, is an Assistant Professor, Yale University School of Nursing, New Haven, CT.
Table 1. Medications Used to Treat Tinea Capitis

Medication             Dosage          Duration of Treatment

Griseofulvin     20 to 25 mg/kg/day    16 to 8 weeks (up to
(Grifulvin[R])                         16 weeks) II

Fluconazole *    6 mg/kg/day           3 weeks
(Diflucan[R])

Itraconazole *   5 mg/kg/day           4 weeks
(Sporanox[R])

Terbinafine      125 mg/day            6 weeks
(Lamisil         (25 kg weight)
Granules[R])
                 187.5 mg/day
                 (25 to 35 kg weight)

                 250 mg/day (greater
                 than 35 kg weight)

Medication       Labs                     Other Considerations

Griseofulvin     Consider baseline        Should be taken with
(Grifulvin[R])   CBC, LFTs, renal         food or milk to enhance
                 function tests           medication absorption.

Fluconazole *    Needs baseline CBC,      May be taken with food
(Diflucan[R])    LFTs, renal function     if GI symptoms occur.
                 tests

Itraconazole *   Needs baseline CBC,      Capsules should be
(Sporanox[R])    LFTs, renal function     taken with food; cap-
                 tests                    sules may be opened
                                          and sprinkled on food;
                                          liquid preparation
                                          should be taken on
                                          an empty stomach.

Terbinafine      Needs baseline CBC,      May be taken with non-
(Lamisil         LFTs, renal function     acidic, non-fruit based
Granules[R])     tests, potassium level   foods, such as pudding
                                          or mashed potatoes, if
                                          GI symptoms occur.

* Medications not currently FDA-approved for the treatment
of tinea capitis.
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Title Annotation:Primary Care Approaches
Author:Meadows-Oliver, Mikki
Publication:Pediatric Nursing
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2009
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