Tinea capitis (overview) B35.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 14.12.2022

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capillary ringworm; Grindflecht; Kerion Celsi; tinea capitis (sensu stricto); trichophytia capillitii

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Tinea capitis is an infectious fungal disease of the terminal hair, eyebrows and eyelashes caused by pathogens of the genera Trichophyton and Mikrosporum.

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From a clinical point of view, a distinction is made between 2 forms whose development is pathogen-dependent:

  • Superficial or aphlegmatic form (Grey-patch tinea); mostly anthropophilic pathogens, see below Tinea capitis superficialis
    • moth-eaten tinea capitis
    • "Black-dot" form of tinea capitis. Slightly inflammatory form, hairs broken off at the skin level like stubble (tinea capitis superficialis)
    • Pityriasis - capillitii-like tinea capitis. Prominent diffuse scaling of the scalp without signs of inflammation
    • Pustulous tinea capitis with yellowish follicular pustules.
  • Deep, phlegmatic (chronic inflammatory infiltrative) form, see below Tinea capitis profunda; see also Kerion Celsi (always zoophilic pathogens);

For historical reasons, in addition to the infection criterion (superficial or deep tinea), tinea capitis is often divided into:

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Almost exclusively in children aged 2-14 years. Tinea capitis is a distinct rarity in adults.

Clinical features
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The clinical picture is varied (see classification). Depending on the pathogen and the immune situation of the diseased person, it includes a simple non-inflammatory, a seborrhoeic dermatitis-like disease (often caused by T.tonsurans). Furthermore, grey-scaly alopecic areas or, in the inflammatory forms, granulomatous plaques or nodules are found, often interspersed with follicular pustules.

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According to the guidelines, the following guidelines apply for pathogen detection:

  • Pathogen detection before therapy
  • Therapy always systemic+adjuvant topical
  • Objective: negative culture
  • Zoophilic pathogen: Testing pets
  • Anthrophilous pathogen: examine contact persons.

Microscopic examination of depilated hair and dandruff. Anthrophilic pathogens mainly grow endotrich (penetrating into the hair).

The exception is M. audouinii (see below microsphere).

Zoophilic pathogens grow ectotrich (around the hair) with large spore cuffs. Therefore, zoophilic pathogens are highly contagious.

Cultures must be observed for up to 5 weeks, because some pathogens ( T. verrucosum, T. violaceum, T. soudanense) grow very slowly.

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General therapy
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Basically, the necessity arises to always treat the tinea capitis combined systemically and locally. The pathogen specification is important as some antimycotics are less sensitive towards certain pathogens. In the European Society for Pediatric Dermatology guideline, the antifungal agents terbinafine, itraconazole, fluconazole (regardless of their approval status) were given recommendation grade A.

  • For Trichophyton species, terbinafine is the agent of choice due to its high efficacy and lack of pathogen gaps.
  • Itraconazole and griseofulvin have reduced efficacy.
  • Fluconazole is resistant to Trichophyton mentagrophytes var. granulosum and Trichophyton verrucosum.

Adults:terbinafine, griseofulvin (off label in Germany), itraconazole, fluconazole. Children:

  • Only griseofulvin is approved for systemic therapy, fluconazole for children > 1 year. Itraconazole or terbinafine can only be prescribed as an individual therapeutic trial ( off-label use), after appropriate information of the parents.
  • Itraconazole should only be prescribed for a maximum of 3 months due to potential toxic effects.

In a randomized comparative study of all commercially available antifungal agents, 50 children each with tinea capitis caused by a Trichophyton species were treated as follows: Griseofulvin (20mg/kgKG/day for 6 weeks), Terbinafine (>40kg bw - 250mg/day, 20-40kg bw - 125mg/day for 2 or 3 weeks), Itraconazole (5mg/kgKG/day 2 or 3 weeks), Fluconazole (6mg/kgKG/day 2 or 3 weeks). The cure rates after 12 weeks were: griseofulvin 92%, terbinafine 94%, itraconazole 82%, fluconazole 82%.

External therapy
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Local treatment with a topical antifungal agent of the fungicidal action type (cicloproxolamine, terbinafine) is recommended. This should be applied to the entire capillitium. Supplementary antimycotic shampoos should be used 2x a week.

In highly inflammatory forms, the use of fixed combinations of glucocorticoids and antifungals is recommended initially (maximum duration 1-2 weeks) (Mayser P 2014). Glucocorticoids lead to rapid decongestion of acute weeping lesions with resolution of pain and itching.

Internal therapy
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Overview of systemic therapeutics for the treatment of tinea capitis

Active substance


Duration of therapy

Griseofulvin (Griseo CT 125) in Germany off the market 10 mg/kg bw/day (internationally 20 mg/kg bw/day recommended) 1 time/day as ED after meals 8 weeks, if necessary also considerably longer (up to 1 year), adapted to the clinical picture
Itraconazole¹ (Sempera) 5 mg/kg bw/day (1 time/day together with food) 6-8 weeks (see above)
Terbinafine¹ (Lamisil) < 20 kg bw: 62.5 mg/day 6-8 weeks (see above)
20-40 kg bw: 125 mg/day
> 40 kg bw: 250 mg/day
Fluconazole² (Diflucan) 6 mg/kg bw/day or 1 time/week 8 mg/kg bw/day 6-8 weeks (see above)
¹ Preparations not approved for children; ² Approved for children > 1 year of age in the absence of alternatives Comment: Despite the approval of griseofulvin in children and the efficacy of itraconazole, both preparations are hardly ever used because of side effects (griseofulvin) and poor absorption (itraconazole). The drug of choice for Trichophyton species is Terbinafine. All Microsporum species are sensitive to fluconazole.

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In case of epidemic occurrence (reporting obligation according to IFSG §34), further measures such as isolation of infected persons and removal/decontamination of shared objects are necessary (Gray RM et al.2015).

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.


Last updated on: 14.12.2022