Tinea Capitis - Leeds

1.  Background Information / Important Principles

Quick info:
Background Information:

  • Itchy, scaly area in scalp +/- hair loss. May progress to kerion (painful inflamed swelling that may cause scarring)
  • Send mycology samples i.e. plucked hair (to include the hair bulb) and skin scrapings.
  • Antimicrobial treatment is dependent on the mycology species identified.
  • Most common in prepubescent children.
  • 50-90% seen in the UK are caused Trichophyton tonsurans.
  • Microsporum species are most common across Europe.
  • Trichophyton Tonsurans is very likely to affect other family members, especially siblings so screening other family members is essential. Other species less likely.
  • Concurrent topical antifungals are thought to reduce the risk of transmission to others during the first 2 weeks of oral treatment
  • Please note pets can be the source of the infection and will need treatment.
  • Post treatment sampling to confirm clearance is now recommended.

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2.  Information Resource for Patients and Carers

Quick info:
Patient Information Leaflets:
British Association of Dermatologists - Tinea Capitis PIL

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3.  Development and Updates to this Pathway

Quick info:
Developed: January 2017

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4.  Training and Further Resources

Quick info:
Additional Resources:
Primary Care Dermatology Society - Tinea Capitis

See a video on how to take effective samples for Tinea Capitis

 

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5.  Patient Presents with Tinea Capitis

Quick info:
Clinically tinea capitis presents with pruritic, scaly patches in the scalp, usually associated hair loss. Left untreated, a large boggy erythematous nodule (Kerion) may develop with associated systemic upset, fever and lymphadenopathy.

History should include questions about other family members, pets and other animal contacts. Symptomatic family members should also have samples taken for mycology.

Photos (provided by Primary Care Dermatology Society - PCDS)
Figure 1 Tinea Capitis with scale, no scarring
Figure 2 Tinea Capitis
Figure 3 Tinea Capitis
Figure 4 Tinea Capitis - Tinea tonsurans isolated
Figure 5 Tinea Capitis - 'black dot ringworm'
Figure 6 Tinea Capitis with scale and early scarring
Figure 7 Tinea Capitis with a scaring alopecia
Figure 8 A kerion. This has been caused by an animal ringworm. (Copied with kind permission from Dermatoweb)

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6.  Sampling

Quick info:
The more material (i.e. lots of scaly skin and plucked hair) sent to the lab the higher chance of receiving a positive diagnosis.

Hair pluckings from the affected area (few hairs to include the hair bulb) are the gold standard. Also send skin scrapings using a cytobrush (ones used to take smears.) The whole brush and skin scrapings can be sent to the lab. Send in separate mycology envelopes using ICE system.

Tips:

  • Sometimes it may be better to give the parents instructions on how to take the samples at home.
  • Whilst awaiting mycology ketoconazole shampoo and topical terbinafine are recommended to prevent spread. School avoidance is then not required.

See a video on how to take effective samples for Tinea Capitis

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7. Diagnosis

Quick info:
Mycology will confirm which organism is present.
It is important to note which organism has been confirmed as this then determines the appropriate treatment.
Treatment will always be oral medication. Topical treatments are generally ineffective.

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8.  Screening

Quick info:
Trichophyton Tonsurans is very likely to affect other family members, especially siblings so screening other family members is essential. Other species less likely.

Even asymptomatic family member should be screened and sampling should be sent.

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9.  Treatment

Quick info:
Trichophyton species
First line treatment is oral terbinafine (4 weeks)
Child over 1 year; body weight 10-20 kg - 62.5mg (quarter of a tablet) once daily
Child body weight 20-40kg - 125mg (half a tablet) once daily
Child body weight over 40kg - 250mg once daily
N.b. Community pharmacy will be required to pre-cut tables or provide a tablet cutter)
Duration of treatment: 4 weeks
Evidence level A

Please note this is not currently licensed in children but is widely used and use supported by local dermatology consultants and the BAD. Not available in suspension but tablets can be crushed and mixed with water - maple syrup/banana milkshake flavouring are good at masking the taste.
Griseofulvin is less effective for this organism

Microsporum species
First line treatment is Griseofulvin
Body weight < 50 kg 15-20 mg kg1 per day (single or divided dose) for 6-8 weeks
Body weight > 50 kg 1 g per day (single or divided dose) for 6-8 weeks
Duration of treatment: 6-8 weeks. Review in 6 weeks - if redness of scaling still present, continue for a further 2 weeks.
Evidence level A
Suspension is not available in the community so tablets can be crushed.

Second line for both species above is Itraconazole.
5mg per kg per day for 2-4 weeks
Liquid formulations are available

Whilst awaiting mycology ketoconazole shampoo and topical terbinafine are recommended to prevent spread. School avoidance is then not required.

Tips:

  • Advise family to clean fomites (e.g. combs etc.) in mild bleach solution
  • LFTs are not routinely recommended in young healthy children.

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10. Post Treatment Review

Quick info:
Post treatment sampling to confirm clearance is now recommended (i.e. repeat sampling for mycology after the full treatment course.)

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11. Referral to Community Clinic

Quick info:
Criteria for referral to Community Dermatology clinic:

  • Uncertain diagnosis
  • Suspected kerion
  • Severe, extensive or recurrent infection
  • Failure to respond

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12. Referral to Secondary Care

Quick info:
Criteria for referral to Secondary Care clinic:

  • Immunosuppressed patients

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