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Fungal skin infection - scalp - Management
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What advice should I give about scalp ringworm?

  • Objects that can transmit fungal spores (for example hats, combs, pillows, blankets, and scissors) should be discarded or disinfected (with bleach), where possible, to prevent re-infection or transmission of infection to others.
  • Advise the person that they should not share towels, and should wash them frequently.
  • It is not necessary to keep children off school. However, to ensure that the infection is not transmitted to others, they should carefully follow the recommendations on hygiene and treatment.
  • Parents should monitor the scalps of other children in the household, and if signs of scaling or hair loss occur they should seek medical advice.
  • If a pet is suspected of being the source of the fungal infection, advise veterinary assessment and treatment of the pet.
Basis for recommendation

These recommendations are based on a report from the Health Protection Agency [HPA, 2007], an expert-consensus guideline on the management of scalp ringworm from the British Association of Dermatologists [Higgins et al, 2000], and expert opinion [Gupta et al, 2004].

  • Although children with scalp ringworm can theoretically pass the infection to non-infected children, they are likely to have been at school for some time before detection of the infection. Exclusion from school merely reinforces the child's isolation and is probably too late to prevent spread [HPA, 2007]. However, they should start appropriate oral and adjuvant topical antifungal treatment before returning to school [Higgins et al, 2000].

How should I treat scalp ringworm?

  • If a kerion (pustular boggy mass) is suspected, refer immediately to dermatology. If infection is milder:
    • In adults, treat with an oral antifungal.
      • A positive microscopy or a positive culture of skin scrapings is recommended before starting treatment.
      • If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat the sample and start treatment.
    • If oral antifungal treatment is being considered in children, seeking specialist advice is usually advisable.
      • Consider prescribing only if confident of the diagnosis and experienced in treating scalp ringworm in children.
    • Use topical antifungal treatment twice weekly (ketoconazole shampoo, selenium sulphide shampoo, or topical terbinafine cream), in addition to oral antifungal treatment, during the first 2 weeks of treatment to reduce transmission.
    • Topical corticosteroids are not recommended.
    • Remove crusts if itch or secondary infection are problematic.
      • Crust removal can be painful, therefore soak them first with lukewarm water or saline applied topically in moistened dressings.
      • The softened crusts can then be gently teased away.
    • If secondary infection is present, treat with an oral antibiotic such as flucloxacillin and an antifungal cream active against Gram-positive organisms (such as miconazole, clotrimazole, econazole).
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].

Which oral antifungal should I prescribe?

  • If oral antifungal treatment is being considered in children, seeking specialist advice is usually advisable.
    • Consider prescribing only if confident of the diagnosis and experienced in treating scalp ringworm in children.
  • Prescribe either griseofulvin (licensed) or oral terbinafine (off licence) empirically until culture results are known.
    • If the person lives in an urban area, start treatment with terbinafine and review once the results of mycology are available.
    • If the person lives in a rural area, start treatment with griseofulvin and review once the results of mycology are available.
  • Once culture results are known:
    • If the infection is Trichophyton tonsurans, continue terbinafine if already taking it, or switch to treatment with terbinafine if currently taking griseofulvin.
    • If the infection is a Microsporum species, continue griseofulvin if already taking it, or switch to treatment with griseofulvin if currently taking terbinafine.
  • For more information on doses and duration of treatment, see Prescribing oral antifungals.
  • Itraconazole, fluconazole, and ketoconazole are not recommended.
Basis for recommendation

CKS found no evidence to guide the choice of antifungal drug. This recommendation is based on the fact that in the UK the most prevalent infection is now Trichophyton tonsurans, especially in cities [HPA, 2007]. However, feedback from experts reviewing this topic suggests that outside urban areas, or in rural areas, Microsporum canis is the most common organism, although infections are sporadic.

Terbinafine and griseofulvin

  • There is no evidence from placebo-controlled trials to indicate that terbinafine is an effective treatment for scalp ringworm, however there is limited indirect evidence from comparative studies with griseofulvin to support its use.
    • Terbinafine is well-documented as a treatment for Trichophyton infections, and is increasingly recommended as a first-line treatment for T. tonsurans infections [Gupta et al, 2004]. Its role in the treatment of Microsporum infections is uncertain [BNF for Children, 2008; BNF 57, 2009]. It appears to be less effective against Microsporum than Trichophyton although there is little in vitro evidence to support this [HPA, 2007]. Although terbinafine is not licensed for the treatment of scalp ringworm, adverse effects are usually mild and transient, and there are fewer drug interactions than with azole antifungals (itraconazole, fluconazole, and ketoconazole) [Gupta et al, 2004].
    • Griseofulvin: there are no placebo-controlled trials and only limited evidence from comparative trials to support the use of griseofulvin for scalp ringworm. However, it has been in use for many years and is generally regarded as an effective treatment. It is effective against most organisms that cause tinea capitis, although T. tonsurans infection has a variable response and may need a longer duration of treatment [HPA, 2007]. It is the only oral antifungal drug that is licensed for the treatment of scalp ringworm.
    • A recent meta-analysis showed no significant difference in tolerability or adverse effects between griseofulvin and terbinafine [Andrews and Burns, 2008].

Drugs not recommended

  • Itraconazole and fluconazole are not recommended for the treatment of scalp ringworm as there are limited trial data on effectiveness and safety [Andrews and Burns, 2008] and they are not licensed for this condition.
    • The Committee on Safety of Medicines has advised caution when prescribing itraconazole to people at high risk of heart failure (for example older people, those with cardiac disease, people receiving negative inotropic drugs such as calcium-channel blockers, and people receiving high doses or long treatment courses of itraconazole) [BNF 57, 2009].
    • Itraconazole is not recommended for use in children or in older people due to the lack of data on its safety and efficacy. Very rare cases of serious hepatotoxicity have been reported, including some cases of fatal acute liver failure [ABPI Medicines Compendium, 2009].
  • Oral ketoconazole should only be initiated by a physician who is experienced in the management of fungal infections because of the risk of serious hepatotoxicity. It should only be prescribed for the treatment of dermatophytosis that cannot be treated topically because of the site, extent of the lesion, or deep infection of the skin, in people resistant to or intolerant of both fluconazole and itraconazole [MHRA, 2008].

How should I prescribe oral antifungal treatment?

This is a guide only. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk) or the British National Formulary (BNF) (www.bnf.org).

Terbinafine (not licensed for scalp ringworm)

  • Treat for 4 weeks.
  • For adults, the recommended dosage is 250 mg once per day.

Griseofulvin

  • Treat for 8–10 weeks.
  • For adults, prescribe 500 mg once a day or 250 mg twice a day.
  • Women of childbearing age should be advised to avoid pregnancy during, and for 1 month after, treatment with griseofulvin. Men should ensure contraceptive precautions are taken during, and for the 6 months after, their own treatment due to potential adverse effects on the male reproductive system.
Basis for recommendation

Doses

  • The doses of oral antifungal drugs that are recommended are based on the British National Formulary [BNF 57, 2009] and the manufacturer's information for griseofulvin [Chemidex Pharma Ltd., 2005].
  • Doses for children have not been included because in most cases specialist advice will be needed. Also, terbinafine is not licensed for this purpose and there is no UK-approved liquid paediatric formulation of griseofulvin.

How should I manage contacts?

  • Take samples for microscopy and culture from household members and other people closely associated with the infected person (screening in schools is not necessary). For more information on how to do this, see Investigations.
  • Contacts, whether carriers or with clinical infection, should be treated.
    • If the person has symptomatic scalp ringworm treat with an oral antifungal medication. For more information, see Treatment.
    • If the person is asymptomatic, but is found to be a carrier, seek specialist advice from a dermatologist. Some people with a heavy growth or high spore count on brush culture may require oral antifungal treatment, but others may be treated with selenium sulphide, ketoconazole shampoo, or povidone iodine shampoo.
Basis for recommendation

This recommendation is based on a report from the Health Protection Agency [HPA, 2007], expert opinion from a guideline on the management of scalp ringworm from the British Association of Dermatologists [Higgins et al, 2000], and a review [Gupta et al, 2004].

Is follow-up needed?

  • Review the person 4–8 weeks after the end of their treatment course.
    • If the infection has not completely resolved or there is evidence of recurrence, repeat sampling and seek specialist advice.
    • If clinical cure is confirmed, no further investigations or treatment are necessary.
Basis for recommendation

No evidence or guidelines on follow up in a primary care setting were identified. Therefore this recommendation is based on expert opinion from reviewers of this topic.

When should I refer to dermatology?

  • Refer immediately to dermatology if a kerion (pustular boggy mass) is suspected.
  • Refer (urgently or routinely depending on the clinical circumstances) if:
    • The diagnosis is uncertain, or guidance on treatment is required.
    • There is no response to primary care management.
    • Infection is severe or extensive, or scarring is present.
    • Infection is recurrent.
    • The person is immunocompromised.
Basis for recommendation

CKS found no evidence or expert reviews on referral, and has therefore based this recommendation on common clinical practice.

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Oral antifungal

Age from 16 years onwards
Griseofulvin tablets: 500mg once a day for 8-10 weeks
Griseofulvin 500mg tablets
Take one tablet once a day.
Supply 28 tablets.
Age: from 16 years onwards
NHS cost: £24.52
Licensed use: yes
Patient information: Women of childbearing age should avoid pregnancy during, and for 1 month after, treatment with griseofulvin. Men should ensure contraceptive precautions are taken during, and for the 6 months after, their own treatment due to potential adverse effects on the male reproductive system.
Griseofulvin tablets: 250mg twice a day for 8-10 weeks
Griseofulvin 125mg tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 16 years onwards
NHS cost: £37.86
Licensed use: yes
Patient information: Women of childbearing age should avoid pregnancy during, and for 1 month after, treatment with griseofulvin. Men should ensure contraceptive precautions are taken during, and for the 6 months after, their own treatment due to potential adverse effects on the male reproductive system.
Terbinafine tablets: 250mg once a day for 4 weeks
Terbinafine 250mg tablets
Take one tablet once a day.
Supply 28 tablets.
Age: from 16 years onwards
NHS cost: £3.44
Licensed use: no - off-label indication
Patient information: These tablets need to be taken for 4 weeks.

Topical antifungal shampoo

Age from 12 years onwards
Ketoconazole 2% shampoo: use twice a week
Ketoconazole 2% shampoo
Shampoo the scalp twice a week for 4 weeks.
Supply 120 ml.
Age: from 12 years onwards
NHS cost: £3.70
Licensed use: no - off-label indication
Patient information: Wet hair thoroughly and massage a small amount of ketoconazole shampoo into the affected area. Leave for 3-5 minutes then rinse thoroughly. Do not use more often than directed. If you need to shampoo your hair more often, use your normal shampoo.
Selenium sulphide 2.5% shampoo: use twice a week
Selenium sulphide 2.5% shampoo
Shampoo the scalp twice a week for 4 weeks.
Supply 100 ml.
Age: from 12 years onwards
NHS cost: £1.96
OTC cost: £3.45
Licensed use: no - off-label indication
Patient information: Wet the hair then massage selenium sulphide into the affected area to form a lather. Leave for 3 minutes then rinse thoroughly and repeat. If you need to shampoo your hair more often than twice a week, use your normal shampoo. Avoid using 48 hours before or after applying hair colouring, straightening, or waving preparations.

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