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Dermatology (Skin Conditions)

Tinea Capitis

Superficial fungal infection of the scalp hair shafts and follicles, primarily affecting children.

Also known as: Ringworm of the Scalp, Scalp Fungus

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Referral and warning signs

When to refer

Refer to Dermatologist/Specialist if: Diagnosis uncertain. Failure to respond to Griseofulvin after 6-8 weeks. Severe kerion (consider steroids). Need for alternative systemic antifungals.

Red flags

  • Severe, boggy, inflamed kerion.
  • Rapidly progressing hair loss.
  • Signs of significant secondary bacterial infection.
  • Failure to respond to appropriate first-line therapy.

Signs and symptoms

  • Scaly patches on the scalp.
  • Hair loss (alopecia) within patches.
  • Broken hairs close to the scalp surface ('black dots').
  • Itching.
  • May have mild inflammation or significant inflammation with pustules, boggy swelling, and crusting (Kerion).
  • Occipital or cervical lymphadenopathy may be present.
  • Appearance varies depending on causative fungus (e.g., Trichophyton vs Microsporum).

Risk factors

  • Age (pre-pubertal children most common).
  • Close contact with infected individuals or animals (esp. Microsporum canis from cats/dogs).
  • Sharing contaminated items (combs, hats, bedding).
  • Crowded living conditions.
  • Poor hygiene.
  • Immunosuppression.

Diagnosis

Clinical assessment

Diagnosis often based on clinical appearance (scaly patches with alopecia/broken hairs +/- kerion).

Differential diagnosis

  • Seborrhoeic dermatitis (greasy scales, less hair loss).
  • Psoriasis (well-demarcated silvery plaques, often affects other areas).
  • Alopecia areata (smooth, completely bald patches).
  • Bacterial folliculitis / Scalp abscess.
  • Lichen planopilaris / Discoid lupus (scarring alopecia - rare in children).

Investigations

  • Fungal Examination (Confirmatory):
  • - KOH Microscopy: Pluck affected hairs (broken stumps) and scrape scales. Examine under microscope with Potassium Hydroxide (KOH) solution to visualize fungal hyphae/spores within or around hair shaft (ectothrix/endothrix).
  • - Fungal Culture: On Sabouraud's agar using hair/scales. Identifies specific species (takes weeks).
  • Wood's Lamp Examination: Some Microsporum species fluoresce green (less common cause now in many areas).

Diagnostic criteria

Clinical suspicion supported by positive KOH microscopy or fungal culture.

Management

Non-pharmacological management

  • Good hygiene.
  • Wash contaminated items (combs, bedding, hats) - may need antifungal shampoo use by contacts.
  • Avoid sharing personal items.

Pharmacological treatment

  • Systemic Antifungal Therapy is REQUIRED (topicals alone are ineffective as infection is within hair shaft). (LOC: HC2/3)
  • - First line: Griseofulvin (microsize) 10-20 mg/kg/day PO single dose (take with fatty meal for better absorption) for 6-8 weeks (or longer until cure confirmed).
  • - UCG recommends 10mg/kg/day for 6 weeks.
  • - Alternatives (often used if Griseofulvin fails/unavailable/specific fungi):
  • - Terbinafine PO (dose by weight) for 4-6 weeks (effective for Trichophyton, less for Microsporum).
  • - Itraconazole PO.
  • - Fluconazole PO.
  • Adjunctive Topical Therapy:
  • - Antifungal Shampoos (Ketoconazole 2%, Selenium Sulfide 2.5%) used 2-3 times weekly can reduce spore shedding and transmission (does NOT cure alone).
  • Kerion Management:
  • - Continue systemic antifungal.
  • - May require short course of oral corticosteroids (Prednisolone) to reduce severe inflammation and scarring risk (specialist advice).
  • - Antibiotics if secondary bacterial infection suspected.

Monitoring

Monitor clinical response (reduction in scaling/inflammation, hair regrowth). Consider repeat fungal exam if poor response. Monitor LFTs if using terbinafine/itraconazole long-term.

Complications

  • Permanent scarring alopecia (especially after severe kerion).
  • Secondary bacterial infection.
  • Psychosocial impact.

Prevention

  • Treating infected individuals and household contacts.
  • Treating infected pets.
  • Avoiding sharing personal items.
  • Good hygiene.

Patient education

  • Explanation of scalp ringworm as a fungal infection.
  • Need for ORAL antifungal medication for several weeks.
  • Importance of taking Griseofulvin with fatty food.
  • How to use antifungal shampoo.
  • Measures to prevent spread (hygiene, not sharing items).
  • Checking family members/contacts.
  • Reassurance that hair usually regrows (unless severe scarring).

Uganda-specific notes

Very common, particularly in school-aged children. Griseofulvin is the standard first-line treatment when available. Access to KOH microscopy/culture limited. Topical treatments often used inappropriately as sole therapy.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 22, Section 22.3.1 (Tinea Capitis section)

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