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Fungal skin infection - scalp - Management
Basis for recommendation

Testing before treating

  • The recommendation to test before treating is based on expert opinion from the Health Protection Agency [HPA, 2009].

Oral antifungal

  • The recommendation to use oral treatment for scalp ringworm is from a British Association of Dermatologists guideline [Higgins et al, 2000] and is supported by evidence from a Cochrane systematic review [González et al, 2007].
  • Oral antifungals penetrate the hair shafts (whereas topical antifungals do not, and therefore cannot eradicate hair shaft infection) [Andrews and Burns, 2008].
  • Specialist advice is suggested before prescribing an oral antifungal for children younger than 16 years of age because terbinafine is not licensed for this age group and there is a lack of suitable preparations for children.

Topical antifungal

  • The recommendation not to use topical antifungals alone to treat scalp ringworm is based on expert opinion and clinical experience [Higgins et al, 2000]. Topical treatments do not eradicate hair shaft infection, and although there may be temporary improvement, this is followed by relapse in most people [HPA, 2007].
  • The recommendation to use topical antifungal preparations (with oral antifungal drugs) at the start of treatment to reduce the risk of transmission to others is based on evidence from case-control or cohort studies [Higgins et al, 2000]. The Health Protection Agency recommends that topical antifungals (selenium sulphide or ketoconazole shampoo, or terbinafine) are used at least twice weekly during the first 2 weeks of treatment [HPA, 2007].

Topical corticosteroids

  • CKS has not recommended topical corticosteroids for inflammatory scalp ringworm and severe id reactions because there is controversy about their use. However, they may reduce discomfort and itching [Higgins et al, 2000].

Crust removal

  • Removal of surface crusts to relieve itching and secondary infection is recommended by experts [HPA, 2007].

Treatment of secondary infection

  • The recommendation to treat suspected secondary bacterial infection (usually Staphylococcus aureus) with flucloxacillin is based on expert opinion from the Health Protection Agency [HPA, 2007].

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