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 including both plucked hair (to include the hair bulb) and skin scrapings
  • Antimicrobial treatment is dependent on the mycology species identified.
  • Most common in prepubescent children. But can affect any age.
  • 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 antifungals shampoos, used at least twice weekly, 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 if there is any skin or hair problem.
  • Post treatment sampling. Guidelines recommend to repeat skin scrapings after completion of treatment. This may be difficult in primary care if skin is healed but should be completed if any alopecia or scaling.

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2 Information and Resources 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

 

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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.
  • If there is any clinical suspicion of fungal infection, ketoconazole shampoo is recommended whilst awaiting mycology to prevent spread. School avoidance is then not required.

Click here to 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 if there is any clinical suspicion of fungal infection.

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9 Treatments

Quick info:
Trichophyton species
First line treatment is oral terbinafine

Child over 1 year; body weight 10-19 kg - 62.5mg (quarter of a tablet) once daily
Child body weight 20-39kg - 125mg (half a tablet) once daily
Child or adult body weight 40kg and above - 250mg once daily
N.B. Community pharmacy will be required to pre-cut tables or provide a tablet cutter
Duration of treatment: 4 weeks

Please note this is not currently licensed in children but is widely used and use supported by local dermatology consultants and the British Association of Dermatologists. Not available in suspension but tablets can be crushed and mixed with water immediately before use - maple syrup/banana milkshake flavouring are good at masking the taste.

Microsporum species
First line treatment is Griseofulvin (dose as per BAD guidelines)
Children from 1 month body weight < 50 kg: 15-20 mg per kg 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.
Suspension is not available in the community.

Second line for both species above is Itraconazole.
5mg per kg per day (Max. per dose 200mg) for 2-4 weeks
Liquid formulations are available

Not licensed for children but use supported by local dermatology consultants and the BAD guidelines.

Whilst awaiting mycology twice weekly ketoconazole shampoo is recommended to prevent spread. School avoidance is then not required.

Tips:

  • Advise family to clean hair brushes, combs etc in mild bleach solution. Also caps, towels, hoodies etc. should be washed to prevent recurrence.
  • LFTs are not routinely recommended in young healthy children.

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10 Post Treatment Review

Quick info:
Post treatment sampling.  Guidelines recommend to repeat skin scrapings after completion of treatment. This may be difficult in primary care if skin is healed but should be completed if any alopecia or scaling

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11 Referral to Community Clinic

Quick info:
Criteria for Advice and Guidance or 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