# Tinea Capitis

Confirm suspected scalp dermatophyte infection with hair and scale microscopy or culture when feasible, begin systemic therapy because topical agents do not reach the follicular infection, identify inflammatory kerion promptly to limit permanent alopecia, and interrupt household transmission with contact assessment and sporicidal shampoo.

**Clinical question:** How should clinicians confirm, treat, and contain tinea capitis while recognizing kerion and alternative scalp disorders?

Updated: 2026-09-15T23:51:12.554817+00:00

## What matters in practice
- Treat tinea capitis with an oral antifungal; topical antifungals alone are ineffective because infection involves the hair follicle root and hair shaft. [12][16][17]
- Obtain scale and affected-hair specimens for KOH microscopy and fungal culture when feasible; culture provides definitive organism identification. [1][4][20]
- In the United States, Trichophyton tonsurans is the predominant cause and usually does not fluoresce under Wood lamp examination. [3][13][14][18]
- Use microsize griseofulvin 15-20 mg/kg orally once daily, maximum 1 g/day, or ultramicrosize griseofulvin 5-10 mg/kg once daily, maximum 750 mg/day; administer with a fatty meal. [17]
- Treat painful boggy inflammatory scalp disease as kerion with systemic antifungal therapy; short-course systemic corticosteroid therapy may be used as adjunctive anti-inflammatory treatment in selected cases. [8][16]
- Examine household contacts, avoid shared hair implements, and use selenium sulfide or antifungal shampoo to reduce shedding and transmission; affected children receiving treatment may attend school. [16][17]

## Identify cases requiring immediate systemic treatment

Scalp involvement changes management because topical treatment alone will not eradicate follicular infection.

Start oral antifungal therapy when the clinical pattern is compatible with tinea capitis, particularly in a prepubertal child with scalp scale, broken hairs, patchy alopecia, pustules, or inflammatory swelling. Tinea capitis occurs primarily in prepubertal children but can occur at any age, including adulthood. [13][14] The dermatophyte penetrates the follicular outer root sheath and may invade the hair shaft; therefore, topical antifungal monotherapy is ineffective. [12][16][17]

Escalate urgency for a painful, boggy, pustular scalp plaque or nodule consistent with kerion. This inflammatory form can result in permanent alopecia, unlike typical noninflammatory tinea capitis. [16] Obtain mycologic specimens before or at treatment initiation when possible, but do not defer systemic therapy for culture results in a clinically convincing kerion. Oral griseofulvin, terbinafine, itraconazole, or fluconazole may be required for kerion, with anti-inflammatory treatment considered as an adjunct rather than a replacement for antifungal therapy. [7][8][16]
- Ask about affected household members, shared combs, brushes, hats, ribbons, or hair ornaments; these exposures direct transmission-control measures. [17]
- Ask about animal exposure and travel when culture identification may alter organism-directed treatment decisions; Microsporum and Trichophyton species cause tinea capitis. [16][19]
- Do not shave the head, prescribe a haircut, or require cap use as treatment measures. [17]

*Clinical branch points at presentation*

| Presentation | Most useful immediate action | What changes next |
| --- | --- | --- |
| Scaly alopecic scalp lesion with broken hairs | Collect scalp scale and affected hairs for KOH microscopy and fungal culture; initiate systemic therapy when clinical suspicion is high. [1][4][12] | Culture identifies the causative dermatophyte and supports adjustment if the clinical response is inadequate. [4][20] |
| Painful boggy plaque, pustules, or marked inflammatory swelling | Treat as kerion with an oral antifungal; consider a short systemic corticosteroid course as adjunctive anti-inflammatory therapy. [8][16] | Prompt treatment aims to reduce inflammation-associated risk of permanent alopecia. [16] |
| Scalp scaling but no alopecia or hair-shaft findings | Perform KOH examination and culture rather than relying on clinical appearance alone. [1][4] | A negative mycologic evaluation should redirect assessment toward nondermatophyte scalp disease. |

## Use KOH microscopy and culture correctly

Specimen quality determines whether testing meaningfully changes treatment selection and follow-up.

Sample active scalp scale and plucked affected hairs for direct microscopy and fungal culture. KOH examination can provide immediate confirmation, whereas culture is required for definite identification in selected infections and permits species-level assessment. [1][4][5] KOH dissolves keratin and permits visualization of fungal septate hyphae; reported KOH sensitivity and specificity are 61% and 95%, respectively, with performance dependent on specimen quality and examiner technique. [3]

Use Wood lamp examination as a supplemental, not exclusionary, test. Some ectothrix Microsporum infections fluoresce blue-green, but T tonsurans—the leading U.S. cause—does not fluoresce. [3][13][14][18] A negative Wood lamp examination therefore does not rule out tinea capitis in U.S. practice.
- A positive KOH supports immediate systemic antifungal treatment. [1][3][12]
- A negative KOH in a high-probability presentation should not end the evaluation; send fungal culture from scale and plucked hairs. [3][4]
- Dermoscopy may show comma hairs and dystrophic broken hairs in kerion, but mycologic examination establishes the organism. [20]

### Alternative diagnoses requiring different tests

When a groin eruption accompanies the scalp complaint, distinguish tinea from candidiasis and erythrasma by site-specific examination and microscopy. Erythrasma produces coral-red Wood lamp fluorescence and has negative KOH preparation and fungal culture, whereas tinea cruris is evaluated with KOH or culture. [2] This Wood lamp finding pertains to erythrasma, not to routine exclusion of tinea capitis.

*Interpretation of commonly used mycologic tests*

| Test | Positive result | Important limitation | Clinical use |
| --- | --- | --- | --- |
| KOH microscopy | Fungal septate hyphae visible after keratin dissolution. [3] | Reported sensitivity is 61%; a negative result does not exclude infection. [3] | Rapid confirmation from scale or hair specimens. [1][3] |
| Fungal culture | Dermatophyte growth permits causative-organism identification. [4][20] | Does not provide immediate treatment guidance in a clinically convincing kerion. | Confirm infection and identify organism, especially after negative microscopy or treatment failure. [4][5] |
| Wood lamp | Blue-green fluorescence supports selected Microsporum ectothrix infections. [3] | T tonsurans does not fluoresce and is the predominant U.S. pathogen. [3][13][14] | Adjunctive examination; never use a negative result to exclude tinea capitis. [3] |

## Select and dose oral antifungal therapy

Systemic therapy is required; treatment choice should incorporate organism data, formulation, and clinical response.

Griseofulvin remains a core first-line systemic option. Use microsize griseofulvin 15-20 mg/kg orally once daily, maximum 1 g/day, or ultramicrosize griseofulvin 5-10 mg/kg orally once daily, maximum 750 mg/day. Give griseofulvin after a meal containing fat to optimize administration. [17] A typical course is 4-6 weeks and should continue for 2 weeks beyond clinical resolution. [17] Another clinical reference describes systemic therapy courses of 4-8 weeks, supporting reassessment based on clinical and mycologic response rather than a fixed calendar endpoint alone. [16]

Terbinafine is an oral alternative, and continuous dosing has demonstrated high mycologic cure rates; griseofulvin and terbinafine are both supported therapies for tinea capitis. [10][16] Organism identification is clinically useful because treatment duration may vary by dermatophyte: one review describes 2-4 weeks for Trichophyton infections and 8-12 weeks for Microsporum infections. [22] Do not infer species from a negative Wood lamp examination, because the common U.S. organism T tonsurans does not fluoresce. [3][18]

Reserve itraconazole or fluconazole as oral alternatives when a standard agent is unsuitable or response is inadequate, with species confirmation and reassessment of the diagnosis. [7][16] Available excerpts do not provide regimen-specific doses, renal adjustments, hepatic monitoring schedules, or contraindication algorithms for terbinafine, fluconazole, or itraconazole; use current product labeling and local prescribing guidance before selecting these agents.
- Do not use a topical antifungal alone for scalp dermatophyte infection. [12][16][17]
- If improvement is inadequate, verify adherence, repeat scale and hair sampling, and reconsider organism identification or an alternative diagnosis. [4][15]
- Griseofulvin has historically been the only FDA-approved oral agent for tinea capitis. [18]

*Systemic treatment options supported in the cited literature*

| Agent | Dose and duration supported here | Selection considerations |
| --- | --- | --- |
| Microsize griseofulvin | 15-20 mg/kg orally once daily; maximum 1 g/day; usually 4-6 weeks and continue 2 weeks beyond clinical resolution. [17] | Administer with a fatty meal; established systemic therapy for tinea capitis. [17][18] |
| Ultramicrosize griseofulvin | 5-10 mg/kg orally once daily; maximum 750 mg/day. [17] | Use the formulation-specific dose; do not substitute microsize and ultramicrosize doses. [17] |
| Terbinafine | Continuous oral dosing is reported to achieve high mycologic cure rates; no regimen-specific dose is provided here. [10] | Oral alternative; culture may guide duration because Trichophyton and Microsporum courses may differ. [10][22] |
| Itraconazole or fluconazole | Oral alternatives; no regimen-specific dose is provided here. [7][16] | Consider when griseofulvin or terbinafine is unsuitable or after inadequate response with reassessment. [7][16] |

## Manage kerion without mistaking inflammation for treatment failure

Kerion requires antifungal eradication plus control of severe inflammation.

A kerion is the inflammatory presentation of tinea capitis and may present as a painful nodular or boggy scalp lesion with pustules. [16][20] Because inflammatory tinea capitis may result in scarring alopecia, begin systemic antifungal therapy promptly and document baseline alopecia and the distribution of inflammatory disease for response assessment. [16]

Consider short-course systemic corticosteroids as adjunctive anti-inflammatory therapy for kerion or severe id reactions; corticosteroids do not replace oral antifungal treatment. [8][16] Reassess after treatment initiation for reduced pain, swelling, pustulation, and progression of alopecia. Persistent or progressive disease should trigger repeat fungal sampling and verification of the causative organism. [4][15]
- Use oral antifungal therapy for kerion; topical treatment alone is inadequate. [7][12][16]
- Consider corticosteroid adjunctive therapy only in the inflammatory setting described for kerion or severe id reactions. [8][16]
- Pustules, ulceration, and severe inflammatory change warrant close follow-up because permanent alopecia is a recognized complication. [16][20]

*Kerion treatment priorities*

| Priority | Action | Reason |
| --- | --- | --- |
| Eradicate dermatophyte infection | Start an oral antifungal agent. [7][16] | The infection is follicular and cannot be adequately treated with topical therapy alone. [12][16] |
| Limit inflammation | Consider a brief systemic corticosteroid adjunct for kerion or severe id reaction. [8][16] | Inflammatory tinea capitis may lead to permanent alopecia. [16] |
| Confirm unresolved disease | Repeat skin and hair sampling when response is inadequate. [15] | Culture and microscopy can identify persistent dermatophyte infection and causative organism. [4][20] |

## Reduce household spread and manage school attendance

Transmission control accompanies systemic treatment and targets ongoing shedding and shared fomites.

Examine siblings and other household contacts for evidence of tinea capitis. [17] One clinical reference recommends treating asymptomatic individuals and using antifungal or selenium shampoo for 2-4 weeks to interrupt ongoing transmission. [16] Recommend that household members avoid sharing combs, brushes, ribbons, hats, and other hair-care items. [17]

Use selenium sulfide shampoo or an antifungal shampoo as adjunctive shedding reduction, not as curative monotherapy. [16][17] Children receiving treatment can attend school and usual activities; school exclusion is not required simply because tinea capitis is diagnosed. [17] Instruct affected children not to share combs, hair brushes, hats, or hair ornaments with classmates until treatment has begun. [17]

At follow-up, assess clinical resolution and adherence to the full systemic course. For griseofulvin, treatment is usually continued for 2 weeks beyond clinical resolution. [17] If disease remains active, repeat scalp and hair sampling and reassess the organism, treatment duration, and competing diagnosis rather than extending treatment without reevaluation. [4][15]
- Adjunct shampoo reduces shedding but does not replace oral therapy. [16][17]
- Do not require shaving, hair cutting, or cap wearing during treatment. [17]
- Allow school attendance once treatment is underway; reinforce fomite avoidance. [17]

*Transmission-control actions for index patients and contacts*

| Target | Action | Timing |
| --- | --- | --- |
| Index patient | Begin systemic antifungal therapy and add selenium sulfide or antifungal shampoo to reduce shedding. [16][17] | At diagnosis; shampoo is adjunctive, not definitive treatment. [16] |
| Household contacts | Examine for tinea capitis; asymptomatic individuals may be treated with antifungal or selenium shampoo. [16][17] | Use shampoo for 2-4 weeks when used for transmission control. [16] |
| School and sports setting | Permit usual attendance during treatment; prohibit sharing hair implements and accessories. [17] | After treatment has started. [17] |

## References
1. Trichophytosis - an overview | ScienceDirect Topics — www.sciencedirect.com — https://www.sciencedirect.com/topics/medicine-and-dentistry/trichophytosis
2. Dermatophyte - an overview | ScienceDirect Topics — www.sciencedirect.com — https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/dermatophyte
3. Potassium Hydroxide - an overview — www.sciencedirect.com — https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/potassium-hydroxide
4. single-centre, retrospective cohort study of paediatric tinea capitis in ... — academic.oup.com — https://academic.oup.com/skinhd/advance-article/doi/10.1093/skinhd/vzag101/8732061
5. Current concepts in systemic and topical therapy for superficial mycoses - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S0738081X09002582
6. Abstract | Medical Mycology | Oxford Academic — academic.oup.com — https://academic.oup.com/mmy/article/56/suppl_2/S1/5033473
7. The kerion: an angry tinea capitis - John - 2018 - Wiley Online Library — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1111/ijd.13423
8. British Association of Dermatologists' guidelines for the ... — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1111/bjd.13196
9. Oral Griseofulvin Remains the Treatment of Choice for Tinea Capitis ... — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1046/j.1525-1470.2000.01784.x
10. An update on tinea capitis in children - Gupta - Wiley Online Library — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/10.1111/pde.15708
11. Infectious Diseases Associated With Organized Sports and Outbreak ... — publications.aap.org — https://publications.aap.org/pediatrics/article/140/4/e20172477/38139/Infectious-Diseases-Associated-With-Organized
12. Superficial Fungal Infections | Pediatrics In Review - AAP Publications — publications.aap.org — https://publications.aap.org/pediatricsinreview/article/33/4/e22/36563/Superficial-Fungal-Infections
13. Tinea Capitis (Ringworm of the Scalp) - AAP Publications — publications.aap.org — https://publications.aap.org/aapbooks/monograph/797/chapter/16871852/Tinea-Capitis-Ringworm-of-the-Scalp
14. Tinea Capitis (Ringworm of the Scalp) | Red Book - AAP Publications — publications.aap.org — https://publications.aap.org/redbook/book/755/chapter/14082659/Tinea-Capitis-Ringworm-of-the-Scalp
15. Scenario: Management of fungal skin infection - scalp - CKS - NICE — cks.nice.org.uk — https://cks.nice.org.uk/topics/fungal-skin-infection-scalp/management/management
16. Tinea Capitis - StatPearls - NCBI Bookshelf — ncbi.nlm.nih.gov — https://ncbi.nlm.nih.gov/books/NBK536909
17. Red Book - AAP — composer.publications.aap.org — https://composer.publications.aap.org/media/0r3eomm0/redbook2003.pdf
18. In vitro pharmacodynamic characteristics of griseofulvin against dermatophyte isolates of Trichophyton tonsurans from tinea capitis patients - PubMed — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/pubmed/19212895
19. Epidermophyton - an overview | ScienceDirect Topics — www.sciencedirect.com — https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/epidermophyton
20. First report of kerion (tinea capitis) caused by combined Trichophyton mentagrophytes and Microsporum canis — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S2211753920300312
21. Prevalence and risk factors of tinea capitis in primary school children ... — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S2052297525001064
22. Tinea Capitis: Trends in Spain - ScienceDirect.com — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S1578219012001400
23. Malassezia Furfur - an overview — www.sciencedirect.com — https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/malassezia-furfur
24. Consensus‐based Guideline on tinea capitis - Wiley Online Library — onlinelibrary.wiley.com — https://onlinelibrary.wiley.com/doi/full/10.1111/ddg.70395x

## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.