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Child health Infections and infestations Skin and nail

Fungal skin infection - scalp

Last revised in February 2025

Fungal infection of the scalp (scalp ringworm or tinea capitis) is caused by dermatophytes and is most common among prepubescent children.

Fungal skin infection - scalp: Summary

  • Fungal infection of the scalp is also known as 'tinea capitis' or 'scalp ringworm', and it describes infection of scalp hair follicles and the surrounding skin caused by dermatophytes.
    • In UK cities, infection is usually caused by Trichophyton tonsurans. In Europe and rural parts of the UK, infection is usually caused by Microsporum canis.
    • It predominantly affects prepubertal Afro-Caribbean children.
  • The clinical features of fungal scalp infection vary depending on the degree of inflammatory response, and include:
    • Scaling and itch of the scalp, patches of hair loss.
    • Skin erythema, pustules, crusting, and lymphadenopathy.
    • Painful, pustular boggy masses, which may have a thick crust (kerion).
    • Associated fungal infection at other sites.
  • Assessment of suspected fungal scalp infection should include skin and hair sampling for fungal microscopy and culture, to confirm the diagnosis and identify the underlying cause.
  • Management of fungal scalp infection should include:
    • Advice on self-care strategies including surface crust removal; discarding or disinfecting objects that can transmit infection; inspecting other family members or household pets for signs of infection.
    • In adults, starting oral antifungal treatment before or after fungal microscopy and culture results are back, depending on clinical judgement.
    • In children, starting oral antifungal treatment if there is a confirmed diagnosis and sufficient prescribing experience in primary care, or seeking specialist advice before initiating treatment.
    • Co-prescribing a topical antifungal agent to reduce the risk of transmission to other people.
    • Reviewing the person 4–8 weeks after completing the course of oral antifungal therapy to assess the response to treatment.
  • If oral antifungal treatment is initiated in primary care, either oral griseofulvin (licensed) or oral terbinafine (off-label) should be prescribed empirically, until culture results are available.
    • If the person lives in an urban area, terbinafine should be started (and continued if the infecting organism is Trichophyton tonsurans).
    • If the person lives in a rural area, griseofulvin should be started (and continued if the infecting organism is Microsporum species). Oral itraconazole use (off-label indication) can be considered if griseofulvin is not tolerated or is contraindicated.
  • If there are signs of treatment failure:
    • Repeat skin and hair sampling for fungal microscopy and culture should be arranged, and first-line oral antifungal therapy may be continued for a further 2–4 weeks if there are signs of clinical improvement but ongoing positive mycology.
  • Referral to a dermatology specialist should be arranged if:
    • The person has a suspected kerion (urgent referral).
    • Oral antifungal treatment is being considered for a child, and there is insufficient experience and expertise to initiate this in primary care.
    • The diagnosis is uncertain.
    • Treatment in primary care is unsuccessful.
    • There is a suspected complication which is not responding to treatment in primary care.
  • If a person is a known contact of a person with confirmed fungal scalp infection:
    • Skin and hair sampling for fungal culture should be arranged to determine if the contact has confirmed infection or is an asymptomatic carrier.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the diagnosis and management of fungal infection of the scalp (tinea capitis), and the management of contacts.

This CKS topic does not cover the diagnosis and management of other fungal infections of the skin and nails.

There are separate CKS topics on Candida - skin, Fungal nail infection, Fungal skin infection - body and groin, and Fungal skin infection - foot.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

February 2025 — minor update. Information about selenium sulfide shampoo has been removed from this topic as it has been discontinued. 

Previous changes

March to April 2023 — reviewed. A literature search was conducted in March 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to recommendations have been made. 

July 2022 — minor update. Added drug interaction between clotrimazole and tacrolimus.

March to April 2018 — reviewed. A literature search was conducted in March 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. Complications and Prognosis nodes have been added to the Background information section. A Differential diagnosis node has been added to the Diagnosis section. The management recommendations have been updated in line with the current literature. The Prescribing Information section has been updated and expanded in line with current CKS style.

September 2014 — minor update. Update to the prescribing information text on terbinafine, to state that a baseline liver function test is required before starting treatment with terbinafine.

August 2014 — minor update. The Basis for recommendation text on why itraconazole and fluconazole are not recommended has been amended in response to user feedback.

December 2013 — minor update. Text updated to reflect that the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) has suspended the marketing authorisation for oral ketoconazole, and it should not be prescribed for the treatment of fungal infections (MHRA 2013).

September 2013 — reviewed. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made. Prescribing information has been added to support the prescribing of topical and oral antifungal treatments.

August 2013 — minor update to the text to reflect recent guidance from the European Medicines Agency (EMA) regarding the use of oral ketoconazole.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

January to May 2009 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Together with the CKS topics on Fungal skin infection - body and groin and Fungal skin infection - foot, this CKS topic replaces the former topic on Fungal skin infections. There have been minor changes to the recommendations on choice of antifungal drug and on managing contacts.

September 2008 — minor correction to the Changes section. 

August 2008 — minor update. Text amended as nystatin cream and ointment discontinued. 

April 2008 — minor update to the text for oral ketoconazole, which now reflects the most recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance.

March 2008 — minor update. New text inserted regarding rare cases of changes in international normalized ratio (INR) when warfarin and oral terbinafine have been given concomitantly. 

October to December 2005 — written. Validated in March 2006 and issued in May 2006.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2023.

New policies

No new national policies or guidelines since 1 March 2023.

New safety alerts

No new safety alerts since 1 March 2023.

Changes in product availability

No changes in product availability since 1 March 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Be aware of when to suspect fungal scalp infection and exclude similar conditions.
  • Assess suspected fungal scalp infection.
  • Offer appropriate treatment in primary care.
  • Arrange referral to secondary care if appropriate.
  • Provide advice and information to people with fungal scalp infection and any contacts.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Fungal infection of the scalp is also known as 'tinea capitis' or 'scalp ringworm', and it describes infection of scalp hair follicles and the surrounding skin caused by dermatophytes.
    • In the UK, infection is usually caused by the anthropophilic (spread from human to human) dermatophyte Trichophyton tonsurans or the zoophilic (spread from animals to human) dermatophyte Microsporum canis [BMJ Best Practice, 2022; Elsaie, 2022].
    • Elsewhere Trichophyton violaceum is predominant [Kassem, 2021] but this can change over time [Zhi, 2021]. 
      • Transmission is usually from contact with an infected child, either directly or via fomites (objects or materials which carry infection such as hairbrushes or hats) [Heath, 2022].
      • Fungal spores or infected hairs are transferred by contact or airborne dissemination onto the epidermis between hair follicles. The spores germinate, producing chains of cells or hyphae, which grow down into the hair shaft and penetrate the hair.
  • A 'contact' is defined as a household member or other person closely associated with the index case.
  • A 'carrier' is defined as a person who is asymptomatic without clinical signs of infection, but who is culture positive.

Prevalence

  • Fungal scalp infection predominantly affects prepubertal children with a peak incidence between 3–7 years [BMJ Best Practice, 2022; Elsaie, 2022].
    • It occurs more commonly in Afro-Caribbean than white children [Heath, 2022].
    • A London-based school survey in the 1990s (n = 1057) found a mean infection rate of 2.5%, and 4.9% of children were asymptomatic carriers [Hay, 1996].
  • The reported prevalence is higher in hot, humid climates [Al Aboud, 2022] and may be as high as 40% in some communities worldwide [Hay, 2017].
  • The infection spreads through households and school friends [Kassem, 2021].
  • The incidence in adults is generally low, but infection may be seen in people who are immunosuppressed [BMJ Best Practice, 2022].
  • Males and females are equally affected overall but Microsporum canis predominates in girls and Trichophyton tonsurans predominates in boys [Al Aboud, 2022].

What are the complications?

  • Complications of fungal scalp infection may include:
    • Secondary bacterial infection — see the CKS topics on Cellulitis - acute and Impetigo for more information.
    • Skin pigmentation changes.
    • Kerion  — an inflammatory, boggy scalp mass which is painful [BMJ Best Practice, 2022].
    • Scarring and damage to the scalp, alopecia (hair loss) [Kassem, 2021].
    • A dermatophytid (id) reaction — a reactive phenomenon to the dermatophyte causing a disseminated itchy, papular or vesicular eruption, commonly affecting around the outer helix of the ear, which may also affect the trunk or limbs. This may accompany the start of oral antifungal treatment, and may be misinterpreted as a widespread fungal infection.
    • Erythema nodosum — this is a rare association with fungal scalp infection.

What is the prognosis?

The prognosis after receiving effective treatment is excellent for most people [Al Aboud, 2022].

  • Communities without access to effective healthcare, including diagnosis, treatment and follow-up, will see a larger proportion of complications [Kassem, 2021].
  • Individuals with comorbidities (such as immunosuppression) may struggle to clear the infection [BMJ Best Practice, 2022].

Diagnosis of fungal skin infection - scalp

When should I suspect fungal scalp infection?

The clinical features of fungal scalp infection vary depending on the causal organism, type of hair invasion, and degree of inflammatory response.

  • Non-inflammatory involvement is characterized by:
    • Scaling and itch of the scalp. This may be generalized and diffuse.
    • Single or multiple circular patches of hair loss (alopecia) which is usually asymmetrical.
      • There may be a 'black dot' appearance of the scalp, caused by broken-off, swollen hair stubs within the follicles, which is typically caused by Trichophyton tonsurans infection.
  • Inflammatory involvement may also present with:
    • Erythema, scattered pustules, crusting.
    • Painful, pustular boggy masses, which may have a thick crust (kerion).
    • Permanent alopecia and scarring of hair follicles.
    • Lymphadenopathy which may be painful (usually post-auricular and cervical).
  • Be aware that infection may present atypically in people who are immunosuppressed.

Basis for recommendation

The recommendations on when to suspect fungal scalp infection are based on expert opinion in the British Association of Dermatologists' Guidelines for the management of tinea capitis 2014 [Fuller, 2014], and expert opinion in review articles on fungal scalp infection [Ankad, 2020; Elsaie, 2022; Heath, 2022] and in review articles on fungal infections [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].

  • A kerion represents a delayed aggressive host inflammatory response to the causative dermatophyte [Kassem, 2021].
  • The recommendation that people who are immunosuppressed may present atypically is based on expert opinion in a review article [BMJ Best Practice, 2022].

How should I assess suspected fungal scalp infection?

If fungal scalp infection is suspected on the basis of clinical features:

  • Ask the person about:
    • The nature and duration of any symptoms, such as an itchy or painful scalp.
    • Any previous treatments, including over-the-counter preparations.
    • Any family or close contacts affected.
    • Any household pets affected or contact with animals.
    • Any co-morbidities such as underlying causes of immunosuppression.
  • Examine the person to assess:
  • Arrange for skin and hair sampling for fungal microscopy and culture, to confirm the diagnosis and identify the underlying cause.
  • Be aware that Wood's light examination is not routinely needed to aid diagnosis in primary care.

Skin and hair sampling

  • When taking skin and hair samples for fungal microscopy and culture:
    • Wipe off any creams from the scalp before sampling.
    • Scrape affected areas with a blunt scalpel blade to collect affected hairs and/or broken-off hair stubs, and scalp scale. Sampling the edge of lesions may provide a higher yield of dermatophyte.
    • Collect at least 5 mm2 of skin flakes and hair into folded dark paper squares secured with a paper clip. Alternatively, commercially available packs are available. Label the sample clearly.
    • Keep the samples at room temperature and do not refrigerate (dermatophytes are inhibited at low temperatures, and humidity facilitates the growth of contaminants).
    • Ensure clinical details provided on the microbiology request form include any treatment used, animal contacts, and overseas travel.
    • Inform the person microscopy results (to identify hyphae or spores) should be available within 1–2 days; culture results (to identify the causative organism) within 2–3 weeks.
    • Be aware that testing for antifungal susceptibilities is not required.
  • If sampling is not possible or tolerated, or the person is a suspected carrier:
    • Brush the scalp with an unused, soft toothbrush or cytobrush (normally used to take cervical smears), passing the brush through the hair several times in the abnormal skin area. If the person is a suspected carrier, pass the brush through different areas of the scalp to obtain a good sample. Send the brush for culture (microscopy is not possible on brush samples).
  • Dermoscopy is a non-invasive method of initial diagnosis in appropriately trained clinicians.
    • Dermoscopy can also be used to monitor treatment progress.

Basis for recommendation

The recommendations on assessment are based on expert opinion in the British Association of Dermatologists' (BAD) Guidelines for the management of tinea capitis 2014 [Fuller, 2014]  the Public Health England publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017], and expert opinion in review articles on fungal scalp infection [Al Aboud, 2022; Elsaie, 2022] and review articles on fungal infections [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].

Screening family members and close contacts

  • The recommendations on screening are based on expert opinion in the PHE publication [UKHSA, 2017] and in the BAD guidelines, which state that Trichophyton scalp infections are highly infectious and more than 50% of family members may be affected. If this is undetected and contacts are not treated, high recurrence rates are likely [Fuller, 2014]. Expert opinion in a review article supports this approach of screening family members (especially siblings) and close contacts and possible animal reservoirs of infection [Elsaie, 2022].

Advice on skin and hair sampling

  • The recommendation to perform skin and hair sampling on any person considering oral antifungal treatment in primary care is based on expert opinion in the publications [UKHSA, 2017; BMJ Best Practice, 2022] and from expert opinion in guidelines [Mochizuki, 2019].
    • The detailed information on sampling technique is based on the fact that obtaining good quality specimens for fungal culture gives the maximal chance of identifying the causative organism, which guides the choice of oral antifungal agent used [Kovitwanichkanont, 2019].
  • The recommendation that antifungal susceptibility testing is not needed is based on the fact that antifungal resistance is rare, and there is no known correlation between antifungal susceptibilities and outcome [UKHSA, 2017].
  • The recommendation to use a cytobrush is based on the fact that this has soft bristles which may cause less discomfort to children [Mochizuki, 2019].

Dermoscopic examination

  • There is evidence that clinicians trained in dermoscopy can readily examine the scalp to identify diagnostic markers [Ankad, 2020].

Wood's light examination not needed

  • Wood's light examination can be useful in identifying Microsporum canis and Microsporum audouinii as they fluoresce blue-green , however, the majority of dermatophyte organisms which currently cause fungal scalp infection in the UK, such as Trichophyton tonsurans, do not fluoresce under Wood's light [Fuller, 2014; BMJ Best Practice, 2022].

Differential diagnosis

Other conditions that may present similarly to fungal scalp infection include:

  • Seborrhoeic dermatitis — typically causes greasy scaling of the scalp without significant hair loss. Other typical sites include the nasolabial folds, hairline, eyebrows, and chest. See the CKS topic on Seborrhoeic dermatitis for more information.
  • Atopic eczema — typically causes a scaling and itchy scalp and hair loss is less commonly associated; may be a personal or family history of atopy. See the CKS topic on Eczema - atopic for more information.
  • Alopecia areata — usually presents with sudden-onset of discrete patchy hair loss of the scalp with little or no scaling or inflammation. There may be 'exclamation mark hairs' (short broken hairs which taper proximally) which should be distinguished from the 'black dot' broken-off, swollen hair stubs of fungal scalp infection. See the CKS topic on Alopecia areata for more information.
  • Traction alopecia — hair loss secondary to pulling on the roots, commonly caused by hair styling techniques (for example tight braids or ponytails), and usually involving the scalp margins causing temporal hair thinning.
  • Trichotillomania — a psychiatric condition where people pull their own hair out. Hair loss is typically incomplete, asymmetrical, has an unusual shape with no associated scale. There are usually multiple broken hairs of varying length. Single or multiple areas may be affected, including eyebrows and eyelashes. See the CKS topic on Obsessive-compulsive disorder for more information.
  • Psoriasis — scalp involvement is usually a variant of chronic plaque psoriasis with typical silver scale. The whole scalp can be affected, or individual plaques may be visible. It may be associated with areas of non-scarring alopecia. There may be nail involvement or lesions at other sites. See the CKS topic on Psoriasis for more information.
  • Discoid lupus erythematosus — typically causes persistent, scaly plaques on the scalp, face, and ears which may cause pigmentary changes, scarring, and permanent alopecia.
  • Lichen planus — typically causes a very itchy scalp mainly affecting the vertex, with redness and scaling around the base of the hair follicles, and may lead to patches of scarring alopecia.
  • Folliculitis — a superficial infection of the hair follicles, which develop into small inflammatory papules or pustules. This may mimic the inflammatory form of fungal scalp infection. See the CKS topic on Boils, carbuncles, and staphylococcal carriage for more information.
  • Scalp abscess — this often presents as a swollen, painful collection of pus on the scalp; alopecia is less likely and hair plucking is painful. This may mimic the boggy, localized swelling of an inflammatory kerion.

Basis for recommendation

The information on the differential diagnosis of fungal scalp infection is based on expert opinion in the British Association of Dermatologists' Guidelines for the management of tinea capitis 2014 [Fuller, 2014], and expert opinion in a review article on fungal scalp infection [Al Aboud, 2022] and in review articles on fungal infections [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].

Management

Scenario: Management of fungal skin infection - scalp

From age 1 month onwards.

How should I manage a person with fungal scalp infection?

The management of fungal scalp infection depends on the site and severity of scalp and hair involvement, the causative organism, the person's symptoms, and any co-morbidities.

  • If the person has a suspected kerion, arrange urgent referral to a dermatology specialist.
  • Advise on self-care management strategies:
    • Soften any surface crusts (for example, by applying moistened dressings to affected areas), and then gently tease away.
    • Discard or disinfect objects that can transmit fungal spores, such as hats, scarves, hairbrushes, combs, pillows, blankets, and scissors, to prevent re-infection or transmission of infection to others.
    • Do not share towels, and ensure they are washed frequently.
    • Parents or carers should inspect the scalps of other children and household contacts regularly for clinical signs of infection, and manage appropriately.
    • If a household pet is suspected of being the source of infection, it should be assessed and treated by a vet.
  • Provide information on sources of advice and support, such as:
  • In adults, offer treatment with an oral antifungal agent if there is:
    • A positive skin and hair sample microscopy or culture result.
    • A negative mycology result, but clinical features are very suggestive of infection.
    • A strong clinical suspicion of fungal scalp infection before mycology results are back, depending on clinical judgement.
  • In children, consider offering treatment with an oral antifungal agent in primary care:
    • Prescribe an oral antifungal agent if the diagnosis is certain and there is appropriate experience and expertise in prescribing treatment in primary care, or
    • Seek specialist advice from a paediatric dermatologist before starting treatment.
    • Advise that once appropriate treatment is started, they should attend school or nursery as normal.
  • If oral antifungal treatment is offered in primary care:
    • Prescribe either oral griseofulvin (licensed) or oral terbinafine (off-label) empirically until culture results are available.
      • If the individual lives in an urban area (Trichophyton tonsurans more likely), start treatment with terbinafine for 4 weeks.
      • If the individual lives in a rural area (Microsporum canis more likely), start treatment with griseofulvin for 4–8 weeks.
      • See the sections on Oral terbinafine and Oral griseofulvin in Prescribing information for more detailed information on drug doses, contraindications and cautions, adverse effects, and drug interactions.
    • When the culture results are available:
      • If the infective organism is Trichophyton tonsurans, continue terbinafine (if taking already), or switch to treatment with terbinafine.
      • If the infective organism is a Microsporum species, continue griseofulvin (if taking already), or switch to treatment with griseofulvin.
      • Consider the use of itraconazole (off-label indication) for 4 weeks if griseofulvin is not tolerated or is contraindicated. See the section on Oral itraconazole in Prescribing information for more detailed information on drug doses, contraindications and cautions, adverse effects, and drug interactions.
  • Consider co-prescribing a topical antifungal agent during initial oral antifungal treatment, to reduce the risk of transmission to others.
    • Options include ketoconazole shampoo to be used at least twice weekly for 2–4 weeks, or an imidazole cream (in children less than 5 years of age) to be used daily for one week. NB: selenium sulfide shampoo is no longer available.
  • Assess and manage any possible complications:
    • If there is suspected secondary infection, see the CKS topics on Cellulitis - acute and Impetigo for more information.
      • Be aware that pustule formation may represent an inflammatory response to the dermatophyte itself ('Id reaction') rather than a secondary bacterial infection.
    • If there is a suspected Id reaction, advise the person to continue oral antifungal treatment as prescribed.
  • Review the person 4–8 weeks after completing the course of oral antifungal treatment to assess the response to treatment:
    • Assess for signs of normal hair regrowth suggesting clearance of infection, or for signs of treatment failure.

Basis for recommendation

The recommendations on the management of index cases are largely based on expert opinion in the British Association of Dermatologists' (BAD) Guidelines for the management of tinea capitis 2014 [Fuller, 2014], the Guidelines committee of the Japanese Dermatological Association's Guidelines for the management of dermatomycosis [Mochizuki, 2019], the Public Health England (PHE) publications Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and Health protection in children and young people settings, including education [UKHSA, 2023a], a Cochrane systematic review Systemic antifungal therapy for tinea capitis in children [Chen, 2016], two meta-analyses comparing griseofulvin and terbinafine treatments [Gupta, 2018; Gupta, 2020], and expert opinion in review articles on fungal scalp infection [Al Aboud, 2022; Elsaie, 2022] and in review articles on fungal infections [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].

Advice on self-care strategies
  • The recommendations on self-management are largely based on the BAD guidelines [Fuller, 2014] and expert opinion in review articles [BMJ Best Practice, 2022; Elsaie, 2022].
    • Removal of surface crusts may relieve itching and discomfort, and may help to reveal and manage any underlying secondary bacterial infection[Hay, 2017; BMJ Best Practice, 2022].
    • If a person has a confirmed zoophilic infection such as Microsporum canis, it is important to identify and treat the animal source of infection [Hay, 2017; Elsaie, 2022].
Management of children
  • The recommendation on considering treating children with oral antifungal therapy in primary care is extrapolated from expert opinion in the BAD guidelines, from the Japanese guidelines [Mochizuki, 2019] and advice on tinea capitis management from the Centers of Disease Control and Prevention (CDC) [CDC, 2021], as griseofulvin is the only drug licensed for the treatment of fungal scalp infection in children in the UK, however, it notes that off-label prescribing is well established [Fuller, 2014]. This recommendation is also pragmatic, based on the expert opinion of previous external reviewers of this CKS topic.
  • The recommendation on attending school or nursery is based on the UK Health Security Agency document on health protection in children and young people settings, including education [UKHSA, 2023b], which states that exclusion is not needed once appropriate antifungal treatment has been started.
Prescribing oral antifungal treatment
  • The recommendation to offer oral antifungal treatment to adults before culture results are available if there is a strong clinical suspicion of infection is based on expert opinion in the PHE publication [UKHSA, 2017], and is also extrapolated from the BAD guidelines [Fuller, 2014] and expert opinion in review articles [BMJ Best Practice, 2022; Elsaie, 2022].
    • In high-risk populations, a delay in starting treatment may increase the risk of spread of infection [Fuller, 2014; Kassem, 2021]. Treatment for clinically obvious or severe cases should not be delayed until culture results are available [BMJ Best Practice, 2022].
  • The recommendation to use oral antifungal treatment (and not topical antifungal monotherapy) for fungal scalp infection is based on expert opinion in the BAD guidelines [Fuller, 2014], and expert opinion in review articles [Mochizuki, 2019].
  • Oral antifungal treatments can penetrate and eradicate hair shaft infection , whereas topical antifungal agents do not penetrate down to the deepest part of the hair follicle [Hay, 2017].
    • The BAD and Japanese guidelines highlight that the optimal treatment regimen varies according to the causative dermatophyte organism, which will vary geographically [Fuller, 2014; Mochizuki, 2019].
First-line treatment - oral terbinafine or griseofulvin
  • The recommendation to consider prescribing terbinafine first-line for Trichophyton infections is based on the fact it is has high fungicidal activity against this dermatophyte compared with Microsporum species, has similar efficacy to griseofulvin treatment, requires a shorter duration of treatment , and is generally well tolerated [BMJ Best Practice, 2022].
    • A 2018 meta-analysis of twenty-one randomized controlled trials (RCTs) found that griseofulvin and terbinafine has the highest rates of complete clinical cure (72% and 92% respectively) [Gupta, 2018].
    • A 2020 network meta-analysis of monotherapy treatment options found that griseofulvin gave the highest complete cure rates with Trichophyton infection and terbinafine gave the highest cure rates with Microsporum infections [Gupta, 2020].
    • These findings are supported by a 2016 Cochrane systematic review of three RCTs (n = 328) of oral antifungal treatment in children, which found low-quality evidence that 4 weeks of terbinafine and 8 weeks of griseofulvin treatment showed similar efficacy for the primary outcome of complete cure in Trichophyton infections. A further RCT (n = 1006) provided moderate-quality evidence that terbinafine was more effective than griseofulvin in clearing infection. There was no significant difference in tolerability or adverse effects between the two agents [Chen, 2016].
    • The use of shorter treatment regimens with terbinafine potentially also improves compliance rates [Fuller, 2014].
    • The recommendation on the duration of terbinafine treatment is extrapolated from expert opinion in the BAD guidelines [Fuller, 2014], Japanese guidelines [Mochizuki, 2019], and expert opinion in a review article [BMJ Best Practice, 2022].
    • The recommendation on the duration of griseofulvin treatment is based on the Electronic Medicines Compendium Summary of Product Characteristics (SPC) for griseofulvin [EMC, 2021] and is extrapolated from expert opinion in the BAD guidelines [Fuller, 2014].
Second-line treatment - oral itraconazole
  • The recommendation to consider itraconazole as an alternative to griseofulvin is based on expert opinion in the BAD guidelines [Fuller, 2014], a Cochrane systematic review of oral antifungal treatment in children [Chen, 2016], and expert opinion in review articles [BMJ Best Practice, 2022; Elsaie, 2022].
    • Itraconazole has both fungicidal and fungistatic activity against dermatophytes, depending on the concentration of the drug in the tissues [Fuller, 2014].
    • It has the advantage of potentially shorter treatment courses than griseofulvin [Fuller, 2014; BNF, 2023].
    • The Cochrane systematic review found very-low-quality evidence that complete cure rates were similar in two studies (n = 134) of children with confirmed fungal scalp infection which compared 2–6 weeks treatment with itraconazole to a 6-week course of griseofulvin [Chen, 2016].
    • The recommendation on the duration of itraconazole treatment is extrapolated from expert opinion in the BAD guidelines [Fuller, 2014] and expert opinion in review articles [Al Aboud, 2022; BMJ Best Practice, 2022].
Prescribing topical antifungal adjuvant treatment
  • The recommendation to consider co-prescribing a topical antifungal as an adjunct at the start of oral antifungal treatment to prevent spread of infection, is extrapolated from expert opinion in the BAD guidelines [Fuller, 2014], the Japanese guidelines [Mochizuki, 2019] and expert opinion in review articles [Hay, 2017; BMJ Best Practice, 2022; Elsaie, 2022].
    • The BAD guidelines recommend the use of ketoconazole, or povidone-iodine shampoos, and cite limited evidence from a small, randomized double-blind study (n = 40) which compared different antifungal shampoos as adjunctive treatments for fungal scalp infection in children [Chen, 2010].
      • It found that topical antifungal shampoos in addition to oral griseofulvin are sporicidal and can reduce the carriage and transmission of fungal spores to others, as well as physically removing adherent scale and spores from the scalp when applied. It noted, however, that the study had a small sample size and high rate of loss to follow-up.
    • Expert opinion in Japanese guidelines recommends ketoconazole shampoo twice weekly for 2–4 weeks, or antifungal creams or lotions applied once daily for a week, which decrease the carriage of viable spores, and may shorten the oral antifungal time to cure [Mochizuki, 2019]. Expert opinion in review articles also recommends this management approach [Hay, 2017; BMJ Best Practice, 2022; Elsaie, 2022].
Management of complications
  • The recommendation on the management of suspected secondary bacterial infection is pragmatic, based on what CKS considers to be good medical practice.
  • The recommendation on the management of a suspected Id reaction is based on expert opinion in the BAD guidelines [Fuller, 2014] and in a review article [Bennassar and Grimalt, 2010].
Assessing response to treatment
  • The recommendation on follow-up is extrapolated from expert opinion in review articles which recommend that oral antifungal treatment is stopped in children after repeat fungal culture is negative, or when there is clinical evidence of hair regrowth, to allow treatment to be tailored to each person depending on their individual response[Hay, 2017; Kovitwanichkanont, 2019; BMJ Best Practice, 2022; Elsaie, 2022].

When should I follow-up and refer?

Review the person 4–8 weeks after completing first-line oral antifungal therapy to assess the response to treatment.

  • If normal hair regrowth does not occur and there are signs of persistent or recurrent infection:
    • Consider and, if possible, manage any underlying cause of treatment failure. This may include:
      • Non-adherence to self-care advice or the treatment regimen.
      • Drug-resistant or multiple organisms.
      • Drug interactions or adverse effects.
      • Reinfection from close contacts or recurrence of infection.
      • An immunocompromised host.
      • An alternative diagnosis.
    • Arrange for repeat skin and hair sampling for fungal microscopy and culture.
      • If there are signs of clinical improvement but ongoing positive mycology, consider continuing current oral antifungal treatment for a further 2–4 weeks and then reassess the person.
      • If repeat mycology is negative, no further oral antifungal treatment is needed.
  • Arrange referral to a dermatology specialist, the urgency depending on clinical judgement, if:
    • The person has a suspected kerion — urgent referral should be arranged.
    • Oral antifungal treatment is being considered for a child, and there is insufficient experience and expertise to initiate this in primary care.
    • The diagnosis is uncertain.
    • Treatment in primary care is unsuccessful.
    • There is severe, extensive, or recurrent infection.
    • There is a suspected severe Id reaction which is not responding to treatment in primary care.
    • The person is immunocompromised, depending on clinical judgement.

Basis for recommendation

The recommendations on follow-up and referral are largely based on expert opinion in the British Association of Dermatologists' (BAD) Guidelines for the management of tinea capitis 2014 [Fuller, 2014], the Guidelines committee of the Japanese Dermatological Association's Guidelines for the management of dermatomycosis [Mochizuki, 2019], the Public Health England (PHE) publications Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and the UK Health Security Agency Health protection in children and young people settings, including education [UKHSA, 2023a], and expert opinion in review articles on fungal scalp infection [Al Aboud, 2022; Elsaie, 2022] and in review articles on fungal infections [Kovitwanichkanont, 2019; BMJ Best Practice, 2022].

Managing treatment failure
  • The recommendation on follow-up is based on expert opinion in review articles which recommend that oral antifungal treatment is stopped in children after repeat fungal culture is negative, or when there is clinical evidence of hair regrowth, to allow treatment to be tailored to each person depending on their individual response [Hay, 2017; Kovitwanichkanont, 2019; Al Aboud, 2022; BMJ Best Practice, 2022].
  • CKS notes that the BAD guidelines recommend post-treatment sampling for fungal microscopy and culture for all people with fungal scalp infection, to ensure clearance of infection [Fuller, 2014]. CKS has taken a more pragmatic approach to target people where there is suspected treatment failure, which is supported by expert opinion in a review article [Ely, 2014] and the expert opinion of previous external reviewers of this CKS topic.
  • The recommendations on prescribing a prolonged course of first-line oral antifungal treatment if there are signs of clinical improvement but ongoing refractory infection are extrapolated from expert opinion in the BAD guidelines [Fuller, 2014] and the Electronic Medicine's Compendium Summary of Product Characteristics (SPC) for griseofulvin [EMC, 2021]. Expert opinion in a review article also recommends this approach [Bennassar and Grimalt, 2010].
Arranging referral to dermatology
  • The recommendation to arrange urgent referral for a suspected kerion is based on the fact that this needs a rapid diagnosis; may require high-dose oral antifungal treatment; may require specialist removal of thick superficial crust; and may need oral corticosteroid treatment in severe cases with widespread Id reactions [Fuller, 2014; Hay, 2017; BMJ Best Practice, 2022]. In addition, expert opinion in review articles notes that children with kerion have a high false-negative culture rate, and if not treated promptly, it can lead to scarring and permanent hair loss [Ely, 2014; Kassem, 2021].
  • Referral to a dermatologist may allow examination with a Wood's lamp, which may help to clarify the diagnosis and causative organism. Microsporum species demonstrate bright green fluorescence of infected hairs, whereas Trichophyton infection is generally non-fluorescent [Fuller, 2014; BMJ Best Practice, 2022].
  • The recommendation on referral of a suspected severe Id reaction is extrapolated from the BAD guidelines, as this may occasionally need oral corticosteroid treatment to provide symptom relief [Fuller, 2014].

How should I manage contacts?

If a person is a known contact of a person with confirmed fungal scalp infection:

  • Arrange for skin and hair sampling for fungal culture, to determine if the contact has confirmed infection or is an asymptomatic carrier.
    • If infection is confirmed and the person is symptomatic, offer self-care advice and oral antifungal treatment.
    • If the person is an asymptomatic carrier, seek specialist advice from a dermatologist regarding ongoing management and follow-up.
      • If there is a heavy growth or high spore count on brush culture, oral antifungal treatment may be needed.
      • If there is a low spore load, topical antifungal treatment with ketoconazole shampoo may be appropriate.

Basis for recommendation

The recommendations on the management of contacts are largely based on expert opinion in the British Association of Dermatologists' (BAD) Guidelines for the management of tinea capitis 2014 [Fuller, 2014], the Public Health England (PHE) publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017], and expert opinion in review articles on fungal scalp infection [Hay, 2017; BMJ Best Practice, 2022].

  • The recommendations on screening and treating positive contacts are based on expert opinion in the PHE publication [UKHSA, 2017] and in the BAD guidelines, which state that Trichophyton scalp infections are highly infectious and more than 50% of family members may be affected. If this is undetected and contacts are not treated, high recurrence rates are likely [Fuller, 2014].
  • The recommendations on the management of asymptomatic carriers is extrapolated from the BAD guidelines [Fuller, 2014] and expert opinion in review articles [Hay, 2017; BMJ Best Practice, 2022], as management options depend on the fungal spore load and underlying dermatophyte causative organism.
    • It is important to fully treat asymptomatic carriers, as these people are responsible for fungal shedding and may be a reservoir for disease transmission and continued reinfection of index cases if they are untreated or partially treated [Elsaie, 2022].
    • Carriers with a high spore count may need oral antifungal treatment as they are more likely to develop an overt clinical fungal scalp infection, and are unlikely to respond to topical antifungal monotherapy [BMJ Best Practice, 2022].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Oral terbinafine

Dosing schedule

Terbinafine is available in tablet form but not liquid or suspension.

  • For children aged 1–17 years:
    • Bodyweight 10–19 kg, prescribe 62.5 mg once daily for 4 weeks.
    • Bodyweight 20–39 kg, prescribe 125 mg once daily for 4 weeks.
    • Bodyweight 40 kg and above, prescribe 250 mg once daily for 4 weeks.
  • For adults, prescribe 250 mg once daily for 4 weeks.

[BNF, 2023; BNFC, 2023]

Contraindications and cautions

Do not prescribe terbinafine to people with:

  • Hepatic impairment — the manufacturer recommends that terbinafine should not be prescribed in people with chronic or active hepatic disease. It recommends for other people, liver function tests (LFTs) should be performed. Hepatotoxicity may occur in people with and without pre-existing hepatic disease, therefore periodic monitoring of LFTs (after 4–6 weeks of treatment) is recommended. Terbinafine should be stopped immediately if LFTs are deranged.
  • Severe renal impairment.

Prescribe terbinafine with caution to people with:

  • Autoimmune disease — risk of lupus erythematosus-like effect.
  • Psoriasis — increased risk of exacerbation of psoriasis.
  • Renal impairment — the BNF recommends that half the normal dose of terbinafine should be used if estimated glomerular filtration rate (eGFR) is less than 50 mL/min/1.73 m2 and there is no suitable alternative. However, the manufacturer does not recommend using terbinafine in these people, as it has not been adequately studied.

[EMC, 2020a; BNF, 2023]

Adverse effects

Adverse effects of terbinafine include:

  • Gastrointestinal — abdominal distension, dyspepsia, nausea, abdominal pain, diarrhoea, feeling of fullness (very common); pancreatitis (unknown frequency).
  • Nervous system — headache (common); taste disturbance (uncommon). Dizziness, paraesthesia, and hypoaesthesia (rare).
  • Skin and subcutaneous tissue — rash, urticarial (very common). Very rarely Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, skin eruption, dermatitis exfoliative, dermatitis bullous, photosensitivity reaction, and alopecia.
  • Other common or very common adverse effects include arthralgia, myalgia, decreased appetite.
  • Other rare or very rare adverse effects include:
    • Anaphylaxis.
    • Hepatic dysfunction, jaundice, hepatitis, cholestasis — people taking terbinafine tablets should be warned to report immediately any signs and symptoms of unexplained persistent nausea, decreased appetite, fatigue, vomiting, right upper abdominal pain, jaundice, dark urine, or pale faeces. If these symptoms develop, terbinafine treatment should be stopped, and liver function tests (LFTs) should be immediately performed.
    • Malaise, neutropenia, agranulocytosis, thrombocytopenia, vertigo.

 [EMC, 2020a; BNF, 2023]

Drug interactions

Possible drug interactions with terbinafine include:

  • Codeine — the analgesic effect may be reduced or abolished by terbinafine. Monitor for analgesic efficacy.
  • Rifampicin — levels of terbinafine are reduced. Dose increases of terbinafine may be necessary.
  • Tamoxifen — avoid concurrent use. Metabolism to an active metabolite of tamoxifen may be inhibited by terbinafine. 
  • Terbinafine levels may be increased by the following drugs if taken concomitantly:
    • Amiodarone.
    • Fluconazole, ketoconazole.
  • Terbinafine may increase levels of the following drugs if taken concomitantly, thereby increasing or prolonging their effects, including adverse effects:
    • Anti-arrhythmics (flecainide, mexiletine, and propafenone).
    • Aripiprazole, risperidone.
    • Beta-blockers (carvedilol, metoprolol, nebivolol, propranolol, and timolol).
    • Dextromethorphan.
    • Monoamine oxidase inhibitors Type B (MAOIs-B, such as selegiline).
    • Selective serotonin reuptake inhibitors (sertraline, paroxetine).
    • Tramadol — terbinafine may increase levels of tramadol, but not the active metabolite, which cause an increase in adverse effects, but not in analgesic effect.
    • Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline). 

[EMC, 2020a; BNF, 2023; Preston, 2019]

Oral griseofulvin

Dosing schedule

Griseofulvin is the only licensed oral antifungal agent for the treatment of fungal scalp infection in children in the UK.

  • For children aged 1 month to 11 years:
    • Prescribe usual dose 10 mg/kg daily (maximum per dose 500 mg), increased if necessary to 20 mg/kg daily (maximum per dose 1 g), for severe infections.
      • Reduce the dose when clinical response occurs; daily dose may be taken once daily or in divided doses.
  • For children aged 12–17 years:
    • Prescribe 500 mg daily, increased if necessary to 1 g daily, for severe infections.
      • Reduce the dose when clinical response occurs; daily dose may be taken once daily or in divided doses.
  • For adults, prescribe 1000 mg once a day or 500 mg twice a day for 4–8 weeks.

[EMC, 2021; BNFC, 2023]

Contraindications and cautions

  • Do not prescribe griseofulvin to people with:
    • Acute porphyria.
    • Severe liver disease.
    • Systemic lupus erythematosus — increased risk of exacerbation.

 [EMC, 2021; BNFC, 2023]

Adverse effects

  • Possible adverse effects of griseofulvin include:
    • Gastrointestinal — such as nausea, vomiting, diarrhoea, abdominal pain, dyspepsia, anorexia.
      • Advise the person to take griseofulvin after a high-fat meal to increase systemic absorption and reduce the risk of adverse effects.
    • Hepatobiliary — alteration in liver function tests (LFTs), intrahepatic cholestasis, and hepatitis.
    • Neuropsychiatric — headache, dizziness, confusion, taste disturbance, impaired co-ordination and hearing, peripheral neuropathy, sleep disturbances, agitation, and irritability.
      • Advise the person that griseofulvin may enhance the effects of alcohol and impair the performance of skilled tasks, such as driving.
    • Skin — rashes such as erythema multiforme, toxic epidermal necrolysis, photosensitivity, bullous reactions (including Lyell's syndrome), urticarial reactions.
    • Other — fatigue, leucopenia, neutropenia, anaemia (usually resolve on stopping treatment).

 [EMC, 2021; BNFC, 2023]

Drug interactions

Possible drug interactions with griseofulvin include:

  • Alcohol — concurrent use of alcohol and griseofulvin may cause a disulfiram-like reaction (flushing, tachycardia). Warn people about the possibility of this reaction.
  • Oral contraceptives — the efficacy of oral contraceptives may be reduced with concurrent griseofulvin use. The clinical significance of this effect is unknown.
    • The Faculty of Sexual and Reproductive Healthcare (FSRH) recommends avoiding use of combined oral contraceptives (COCs) and progestogen-only contraceptives (POPs), the progestogen-only implant, and ulipristal acetate, and using an alternative method of contraception when using griseofulvin, and within 28 days of stopping treatment.
      • If a woman wishes to use the COC when taking griseofulvin, consider an increased ethinylestradiol dose (at least 50 micrograms) during treatment and for a further 28 days after stopping griseofulvin, with a continuous or tricycling regimen plus pill-free interval of four days.
      • See the CKS topic on Contraception - assessment for more information.
  • Warfarin — griseofulvin potentially decreases the efficacy of warfarin. Monitor the international normalized ratio (INR), and adjust the anticoagulant dose accordingly. 
  • Phenobarbital — may result in a decreased plasma level of griseofulvin, leading to a reduction in efficacy.
  • Primidone — may result in a decreased plasma level of griseofulvin, leading to a reduction in efficacy.

[EMC, 2021; CoSRH, 2022; BNFC, 2023; Preston, 2019]

Oral itraconazole

Dosing schedule

Itraconazole is not licensed for the treatment of fungal scalp infection in the UK. Adult doses have been extrapolated from treatment doses for tinea pedis.

  • For children aged 1–17 years, prescribe 3–5 mg/kg once daily (maximum per dose 200 mg) for 4 weeks.
  • For adults, prescribe 100 mg daily for 4 weeks.

 [BNF, 2023; BNFC, 2023]

Contraindications and cautions

Do not prescribe itraconazole to people with:

  • Acute porphyria.
  • Ventricular dysfunction or a history of heart failure — itraconazole has been shown to have a negative inotropic effect.

Prescribe itraconazole with caution in people:

  • At high risk of heart failure, including people on treatment with negative inotropic drugs (such as calcium-channel blockers).
  • Who are immunocompromised (for example people with AIDS, on chemotherapy, have neutropenia, or previous organ transplants).
  • With acute liver disease, or a history of hepatotoxicity with other drugs — consider monitoring liver function tests (LFTs). Advise immediate LFTs if symptoms of possible liver toxicity develop, such as anorexia, nausea, vomiting, fatigue, abdominal pain, or dark urine.
  • With renal impairment.
  • Taking drugs such as astemizole, pimozide, quinidine, or terfenadine that may prolong the QT interval, as there is a risk of cardiac arrhythmias.

[ABPI, 2018; BNF, 2023]

Adverse effects

Adverse effects of itraconazole include:

  • Gastrointestinal — nausea, abdominal pain (common); vomiting, diarrhoea, constipation, dyspepsia, taste disturbance, flatulence (uncommon). Rarely pancreatitis.
  • Hepatobiliary — hyperbilirubinaemia (uncommon). Rarely hepatotoxicity (including acute liver failure).
  • Nervous system — headache, dizziness, paraesthesia (uncommon).
  • Skin and subcutaneous tissue — rash (common); alopecia, urticaria, pruritus (uncommon).
  • Other — arthralgia, myalgia, heart failure, erectile dysfunction, menstrual disorders, oedema, tinnitus, visual disturbance.

[ABPI, 2018; BNF, 2023]

Drug interactions

Itraconazole is metabolized by the cytochrome p450 3A4 (isoenzyme CYP34A) and it interacts with a number of liver enzyme-inducing and liver enzyme-inhibiting drugs.

  • Itraconazole levels may be reduced by the following drugs:
    • Carbamazepine, phenobarbital, phenytoin — monitor itraconazole efficacy and increase dose if necessary.
    • Rifampicin, rifabutin — monitor itraconazole efficacy and increase dose if necessary.
    • St John’s wort — avoid concurrent use.
  • Itraconazole levels may be increased by the following drugs:
    • HIV protease inhibitors (ritonavir, indinavir) — monitor for adverse effects.
    • Clarithromycin and erythromycin — monitor for adverse effects.
  • Itraconazole may increase levels of the following drugs:
    • Aliskiren — monitor for adverse effects.
    • Aripiprazole, quetiapine, risperidone — dose reductions may be necessary.
    • Quetiapine — concurrent use with itraconazole is contraindicated. If considered necessary, monitor for adverse effects and adjust dose.
    • Phospodiesterase-5 inhibitors (avanafil, sildenafil, vardenafil) — avoid concurrent use with avanafil; reduce dose of sildenafil or vardenafil.
    • Benzodiazepines (alprazolam, triazolam, midazolam) — dose reductions may be required.
    • Calcium-channel blockers (amlodipine, verapamil) — monitor for adverse effects.
    • Colchicine — dose adjustment may be necessary.
    • Corticosteroids (budesonide, dexamethasone) — avoid concurrent use.
    • Digoxin — monitor the effects of digoxin; digoxin dose may need to be reduced by 50–75%.
    • Disopyramide — avoid concurrent use.
    • Domperidone — possible increased risk of ventricular arrhythmias. Avoid concurrent use.
    • Eplerenone — concurrent use is contraindicated.
    • Ergot alkaloids (such as ergotamine and ergometrine) — increased risk of ergotism. Concurrent use is contraindicated.
    • Ivabradine — concurrent use is contraindicated.
    • Mizolastine — monitor for adverse effects.
    • Oral anticoagulants (warfarin, apixaban, dabigatran). Monitor for adverse effects and adjust doses if required.
    • Pimozide — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Quinidine — increased risk of torsades de pointes. Concurrent use is contraindicated, but if considered necessary, monitor for adverse effects and reduce dose if required.
    • Ranolazine — increased risk of QT interval prolongation. Concurrent use is contraindicated.
    • Reboxetine — monitor for adverse effects and adjust dose if required.
    • Solifenacin — restrict dose of solifenacin to 5 mg daily.
    • Statins (lovastatin, simvastatin) — avoid concurrent use.

[ABPI, 2018; BNF, 2023; Preston, 2019]

Topical antifungals

Contraindications and cautions

The use of topical antifungal agents for treatment of fungal scalp infection is an off-label indication.

  • Ketoconazole 2% shampoo is licensed for use in adults and young people aged 12 years and over.
    • Advise the person to avoid contact with the eyes and mucous membranes during use.
  • Clotrimazole 1% cream is licensed for use in children and adults.
    • Advise the person to avoid contact with the eyes and mucous membranes during use.
  • Miconazole 2% cream is licensed for use in children and adults.
    • Advise the person to avoid contact with the eyes and mucous membranes during use.
  • Econazole 1% cream is licensed for use in children and adults.
    • Advise the person to avoid contact with the eyes and mucous membranes during use.

 [BNF, 2023; BNFC, 2023]

Adverse effects

  • Possible adverse effects with topical antifungals are uncommon and may include erythema, hypersensitivity reactions, itching, mild burning sensation, occasional local irritation.

 [BNF, 2023; BNFC, 2023]

Drug interactions

  • Topical ketoconazole shampoo — no drug interaction studies have been performed for ketoconazole shampoo, and there are no known significant drug interactions.
  • There is an interaction between topical clotrimazole and tacrolimus with an increase in plasma tacrolimus levels with concurrent prescribing.
  • Topical miconazole and econazole cream — oral miconazole and econazole are known to interact with oral anticoagulants, but due to the limited systemic availability of topical preparations, clinically relevant drug interactions are rare. The manufacturer advises, however, that caution should be exercised and the anticoagulant effect should be monitored during concurrent use with an oral anticoagulant.

[EMC, 2020b; ABPI, 2020; ABPI, 2021; EMC, 2022]

Supporting evidence

This CKS topic is largely based on expert opinion in the British Association of Dermatologists' (BAD) Guidelines for the management of tinea capitis 2014 [Fuller, 2014], the Public Health England (PHE) publication Fungal skin and nail infections: Diagnosis and laboratory investigation [UKHSA, 2017] and the UK Health Security Agency (UK HSA) Managing specific infectious diseases A-Z [UKHSA, 2023c], a Cochrane systematic review Systemic antifungal therapy for tinea capitis in children [Chen, 2016], together with expert opinion in review articles [Gupta, 2018; Kovitwanichkanont, 2019; Al Aboud, 2022; BMJ Best Practice, 2022; Heath, 2022]. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of fungal skin infection of the scalp.

Search dates

March 2018 - March 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Dermatomycoses/, dermatomycos?s.tw., exp Tinea Capitis/, tinea capitis.tw., scalp ringworm.tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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