A randomized comparison of 4 weeks of terbinafine vs. 8 weeks of griseofulvin for the treatment of tinea capitis

Exploring treatment and antifungal resistance in an outbreak of tinea caused by Microsporum audouinii

BACKGROUND

Microsporum audouinii has resurged recently. Infections with the dermatophyte are difficult to treat, which raises the question if we treat M. audouinii infections with the most effective antifungal (AF) agent.

OBJECTIVES

The aims of this study was to investigate an outbreak of tinea capitis (TC) in Denmark, address the challenges in outbreak management and to conduct two reviews regarding previous outbreaks and minimal inhibitory concentration (MIC).

METHODS

We used Wood's light, culture, direct microscopy, and PCR for screening and antifungal susceptibility testing (AFST) for treatment optimization. We performed two reviews to explore M. audouinii outbreaks and MIC values using broth microdilution method.

RESULTS

Of 73 screened individuals, 10 had confirmed M. audouinii infections. Clinical resistance to griseofulvin was observed in 4 (66%) cases. While previous outbreaks showed high griseofulvin efficacy, our study favoured terbinafine, fluconazole and itraconazole in our hard-to-treat cases. AFST guided the choice of AF. Through the literature search, we identified five M. audouinii outbreaks, where differences in management included the use of Wood's light and prophylactic topical AF therapy. Terbinafine MIC values from the literature ranged from 0.002 to 0.125 mg/L.

CONCLUSION

Use of Wood's light and preventive measurements were important for limiting infection. The literature lacked MIC data for griseofulvin against M. audouinii, but indicated sensitivity for terbinafine. The clinical efficacy for M. audouinii treatment was contradictory favouring both terbinafine and griseofulvin. AFST could have a key role in the treatment of difficult cases, but lack of standardisation of AFST and MIC breakpoints limits its usefulness.

Loop-mediated isothermal amplification-microfluidic chip for the detection of Trichophyton infection

Trichophyton is the most pathogenic type of fungal skin infection. It often invades and grows in a keratin-rich matrix, and lesions include human skin, hair, and fingernails (toenails). We designed LAMP primers for Trichophyton and developed a LAMP-Microfluidic chip detection system for Trichophyton. This system detects six common species of Trichophyton in the genus Trichophyton, including Trichophyton rubrum, Trichophyton mentagrophyte, Trichophyton violaceum, Trichophyton tonsurans, Trichophyton verrucosum, and Trichophyton schoenleinii. The specificity reached 100%, and the sensitivity could reach about 1 × 10² copies/μl. The entire detection process can be completed within 60 min and does not cross-react with other dermatophytes. The established LAMP-Microfluidic chip detection system has the advantages of simple operation, high specificity, and high sensitivity, and has the potential for clinical application.

Tinea capitis asymptomatic carriers: what is the evidence behind treatment?

Tinea capitis is a fungal infection mostly affecting children. Epidemiology is changing over time due to migration, and it has been estimated that up to 40% of children from certain developing countries are affected. The mechanism of transmission is still unclear although asymptomatic carriage seems to have an influence in establishing persistent reservoirs that can cause or fuel epidemics. Screening and prophylactic treatment of close contacts of tinea capitis patients are therefore recommended by several international guidelines, but vaguely and not consistent. The treatments involved can be expensive, hard to integrate in everyday life, have well-known side effects and some are not approved for the treatment of children. The aim of this review was to clarify the evidence behind treatment of human asymptomatic carriers of tinea capitis. Databases were searched for the 'tinea capitis', 'carriers' and 'treatment'. Inclusion criteria were clinical trials, observational and interventional studies including case series (10+ cases) and case reports in English, Danish, Swedish, Norwegian and French. Reviews, guidelines, unclear reports and in vitro trials were excluded. A systematic review identified 10 studies with low to moderate evidence levels. The topical treatments ketoconazole, povidone-iodine, miconazole and the systemic antifungals terbinafine and itraconazole have all shown significant effects in the mycological eradication of fungal conidia. General prophylactic hygienic measures may have a benefit. The scientific evidence behind the treatment of asymptomatic carriage of scalp dermatophytes is sparse and not of high quality. Yet, both topical and systemic antifungal agents show treatment efficacy. Considering the possible adverse effects, topical agents are preferable, but with necessary attention to the compliance of asymptomatic contacts with treatment.

S1 guidelines: Tinea capitis

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Treatment of tinea capitis with topical 1% encapsulated terbinafine hydrochloride gel: A pilot study

BACKGROUND/OBJECTIVE

Oral antifungal agents are the mainstay of the therapy of pediatric tinea capitis. No approved topical medications for tinea capitis are found. We evaluated the therapeutic efficacy, safety, and tolerability of topical 1% encapsulated terbinafine hydrochloride gel for the treatment of pediatric tinea capitis.

METHODS

An open-label clinical trial was performed on 10 children with clinical and mycologically confirmed diagnosis of tinea capitis. Each child was prescribed topical 1% encapsulated terbinafine hydrochloride gel to be applied twice daily to the full scalp for 4 weeks. Clinical and mycological examinations were assessed 2 weeks after completion of treatment. Monitoring was performed for associated side effects during the treatment and follow-up periods.

RESULTS

Ten male patients were enrolled with a mean age of 10.3 years. A cure rate of 80% (n = 8) was noted 2 weeks after treatment completion. An additional 20% (n = 2) had mycological cure with incomplete, but significant clinical improvement. No significant side effects were reported.

CONCLUSIONS

This preliminary study demonstrated that topical 1% encapsulated terbinafine hydrochloride gel was an effective treatment for tinea capitis in children.

A network meta-analysis on the efficacy and safety of monotherapies for tinea capitis, and an assessment of evidence quality

Various monotherapies exist for tinea capitis; however, their relative efficacies have never been determined using a statistical approach which compares treatments' efficacy simultaneously. The goal of this study was to determine the relative efficacy (mycologic and complete cure rates) of monotherapies for the treatment of tinea capitis. On October 5, 2019, searches were performed in Scopus, PubMed, EMBASE, MEDLINE (Ovid), and CINAHL; there were no date restrictions. For the main network meta-analysis, eligible studies were randomized trials that investigated the effect of tinea capitis monotherapies on subjects' mycological and complete cure rates. Network meta-analyses were conducted in accordance with the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for network meta-analyses. Mycological cure rate was the primary outcome; complete cure rate and adverse events were secondary outcomes. Twelve studies met the eligibility criteria for the main network; five systemic monotherapies were identified, griseofulvin, ketoconazole, terbinafine, itraconazole, and fluconazole. When the causative species was of the Microsporum genus, griseofulvin was most efficacious in terms of mycological cure (SUCRA = 66.1%) and complete cure (SUCRA = 80.6%). For tinea capitis caused by the Trichophyton species, terbinafine was the most efficacious in terms of both mycological and complete cure (SUCRA values of 75.2% and 78.2%, respectively). Risk of adverse events did not significantly differ across the interventions. Our results are congruent with those of previous pairwise meta-analyses; our findings also corroborate clinical experience and anecdotal evidence.

Laboratory monitoring during antifungal treatment of paediatric tinea capitis

Griseofulvin and terbinafine are considered effective first-line therapies for tinea capitis (TC). Haematological dyscrasias and hepatic injury are possible adverse effects with both drugs. There is a debate in the literature regarding the necessity of laboratory monitoring during griseofulvin and terbinafine treatment. We aimed at assessing the prevalence and severity of haematological and hepatic laboratory test abnormalities in a paediatric cohort of African immigrants in Tel-Aviv with TC who were treated with Terbinafine or Griseofulvin. We conducted a retrospective study of all TC cases diagnosed and treated at the paediatric dermatology clinic, Tel-Aviv Medical centre, between June 2013 and March 2019. Epidemiologic, clinical and laboratory data were collected. Our cohort included 321 patients of whom 225 (70%) were treated with Griseofulvin and 96 (30%) with Terbinafine. We identified a total of 64 (20%) patients with haematological or hepatic laboratory test abnormalities that in most cases (96.3%) were considered as mild. No difference in laboratory abnormalities prevalence was identified between the griseofulvin and terbinafine groups (21.3% and 16.6%, respectively). Only one patient treated with Griseofulvin revealed significantly increased levels of hepatic aminotransferases that required discontinuation of treatment. Mild elevation in hepatic transaminases is relatively common among paediatric patients treated with systemic antifungal treatment for TC. However, significant laboratory abnormalities are extremely rare and may be diagnosed and addressed early through periodic laboratory tests monitoring.

Treatment of Tinea Capitis

Tinea capitis is a common fungal infection of the hair of the scalp affecting predominately prepubertal children. In the US, griseofulvin has been considered a first-line therapy agent for tinea capitis since the 1960s. However, it has been falling out of favor due to significant treatment failure, high cost, and long duration of treatment. Other antifungal agents have been researched as an alternative to griseofulvin. This paper will review the relevant pharmacologic properties, dosing, cost, efficacy, and adverse events profile for griseofulvin, terbinafine, itraconazole, fluconazole, and some adjuvant therapy options such as selenium sulfide shampoos and topical ketoconazole.

Infectious Diseases Associated With Organized Sports and Outbreak Control

Participation in organized sports has a variety of health benefits but also has the potential to expose the athlete to a variety of infectious diseases, some of which may produce outbreaks. Major risk factors for infection include skin-to-skin contact with athletes who have active skin infections, environmental exposures and physical trauma, and sharing of equipment and contact with contaminated fomites. Close contact that is intrinsic to team sports and psychosocial factors associated with adolescence are additional risks. Minimizing risk requires leadership by the organized sports community (including the athlete's primary care provider) and depends on outlining key hygiene behaviors, recognition, diagnosis, and treatment of common sports-related infections, and the implementation of preventive interventions.

The kerion: an angry tinea capitis

Tinea capitis has a high incidence with a global changing pathogen distribution, making this condition a public health concern around the world. As the infection is initially asymptomatic, it is easily spread. Moreover, it is present in many fomites, including hairbrushes, pillows, and bedding. Prompt recognition and treatment is necessary for kerion, an inflammatory subtype characterized by tender boggy plaques with purulent drainage. Kerion is usually associated with infection by zoophilic dermatophytes, although other sources have been described. Treatment for this severe form of dermatophytic infection can be challenging. In addition to the use of topical treatments, oral administration of griseofulvin, terbinafine, itraconazole, or fluconazole is often required. Griseofulvin, the first-line treatment, may not completely eradicate pathogen colonization of the host and may contribute to reinfection and prevalence of infective but asymptomatic carriers. This review highlights new agents that are being evaluated for the treatment of kerion and typical tinea capitis, enhanced diagnostic criteria, and a grading system for kerion evaluation.

Systemic antifungal therapy for tinea capitis in children

BACKGROUND

Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review.

OBJECTIVES

To assess the effects of systemic antifungal drugs for tinea capitis in children.

SEARCH METHODS

We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies.

SELECTION CRITERIA

RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update.Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence).Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence).This update provides new data: in children with Microsporum infections, a meta-analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6-12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence).One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans, terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence).The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible.All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect.

AUTHORS' CONCLUSIONS

Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton. With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower.New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection.However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles.

Cutaneous infectious diseases: Kids are not just little people

The changes in immune response that occur with age play a significant role in disease presentation and patient management. Evolution of the innate and adaptive immune systems throughout life, influenced partly by hormonal changes associated with puberty, plays a role in the differences between pediatric and adult response to disease. We review a series of manifestations of dermatologic infectious diseases spanning bacterial, viral, and fungal origins that can be seen in both pediatric and adult age groups and highlight similarities and differences in presentation and disease course. Therapeutic options are also discussed for these infectious diseases, with particular attention to variations in management between these population subgroups, given differences in pharmacokinetics and side effect profiles.

Tinea capitis in Botswana

Background

Tinea capitis (TC) is a common dermatophyte infection of the scalp that can also involve the eyebrows and eyelashes.

Aim

This study aimed to find the causative fungus responsible for TC in Botswana and determine its association with the clinical types of TC.

Methods

Samples for potassium hydroxide 10% mounts and fungal cultures were collected in a microbiology laboratory at the National Health Laboratory, Gaborone, Botswana. Dermasel agar and Sabouraud dextrose agar were inoculated with the samples. Lactophenol cotton blue mounts were prepared from the culture-positive samples to study the morphological characteristics.

Results

Trichophyton violaceum was found to be the predominant causative organism of TC. Trichophyton tonsurans was isolated from one patient. Both are anthropophilic species.

Conclusion

TC was found to be most common in those aged 1–15 years (81%). Of 17 patients in this age group, 16 were younger than 10 years old and one was 14 years old. T. violaceum was the most common dermatophyte species isolated.

Meta-analysis of randomized, controlled trials comparing particular doses of griseofulvin and terbinafine for the treatment of tinea capitis

Two oral antifungal agents, griseofulvin and terbinafine, have regulatory approval in the United States, but it is unknown whether one has superior overall efficacy. Genus-specific differences in efficacy are believed to exist for the two agents. It is not clear at what doses and durations of treatment these differences apply. The goals of this meta-analysis were to determine whether a statistically significant difference in efficacy exists between these agents at a given dose and duration of each in tinea capitis infections overall and to determine whether a genus-specific difference in efficacy exists for these two treatments at a given dose and duration of each. We performed a literature search for clinically and methodologically similar randomized controlled trials comparing 8 weeks of griseofulvin (6.25-12.5 mg/kg/day) to 4 weeks of terbinafine (3.125-6.25 mg/kg/day) in the treatment of tinea capitis. A meta-analysis was performed using the Mantel-Haenszel method and random effects model; results were expressed as odds ratios with 95% confidence intervals. Meta-analysis of randomized controlled trials did not show a significant difference in the overall efficacy of the two drugs at the doses specified, but specific efficacy differences were observed based on the infectious species. For tinea capitis caused by Microsporum spp., griseofulvin is superior (p = 0.04), whereas terbinafine is superior for Trichophyton spp. infection (p = 0.04). Our results support species-specific differences in treatment efficacy between griseofulvin and terbinafine and provide a clinical context in which this knowledge may be applied.

A random comparative study of terbinafine versus griseofulvin in patients with tinea capitis in Western China

OBJECTIVE

To compare the efficacy and safety of terbinafine with griseofulvin in the treatment of tinea capitis in Western China.

METHODS

Children (2-14 years of age) with clinically diagnosed and potassium hydroxide microscopy-confirmed tinea capitis were randomized into three groups: group GRI4 received 4 weeks of griseofulvin; group TBF2 received 2 weeks of terbinafine; and Group TBF4 received 4 weeks of terbinafine. Clinical and mycological evaluations were done in 0, 2, 4, and 8 weeks and 1 year after therapy started. The isolated pathogenic fungi were evaluated for in vitro susceptibility by detecting the minimal inhibitory concentration (MIC) against terbinafine, griseofulvin, itraconazole, and ketoconazole.

RESULTS

The clinical effectiveness rate of GRI4, TBF2, and TBF4 were 100% (95% CI-confidence interval: 82-100%), 96.3% (95% CI: 81-100%), and 100%(95% CI: 85-100%), respectively, at week 8 and 100% after 1 year for the 3 groups; clinical cure rates were 84.2%(95% CI: 77-99%), 85.2%(95% CI: 71-98%), and 78.3%(95% CI: 61-95%), respectively, at week 8 and 100% after 1 year for all agents; mycological cure rates were 100%(95% CI: 74-100%), 95.0%(95% CI: 74-100%), and 94.1%(95% CI: 50-93%) at week 8 and 100% after 1 year for the 3 groups. In vitro, all patient-derived cultures were sensitive to the four antifungal agents.

CONCLUSION

Data from the clinical trial and in vitro antifungal activity indicated that terbinafine is efficacious and well tolerated in the treatment for Trichophyton infections (T. violaceum; Arthroderma vanbreuseghemii; and T. tonsurans) of the scalp, i.e., a 2- to 4-week course of terbinafine is as effective as a 4-week course of griseofulvin; in fact, a 2-week course of terbinafine is sufficient. Terbinafine is an effective alternative to griseofulvin against tinea capitis of Trichophyton infections.

Microsporum audouinii tinea capitis in a Swiss school: assessment and management of patients and asymptomatic carriers

We report three cases involving 7- to 8-year-old children from a Swiss school who had refractory tinea capitis due to an unusual strain of Microsporum audouinii which perforates hair in vitro. The patients showed no response to modern oral antifungal drugs like terbinafine and fluconazole. After switching to oral griseofulvin, two of the patients had a complete recovery, while the third was cured after the introduction of oral itraconazole. Given the high potential for contagion of this anthropophilic dermatophyte, all family members and three entire school classes were screened using the 'toothbrush technique'. Three family members and five class-mates were found to be asymptomatic carriers of M. audouinii and were consequently treated to avoid further transmission or reinfection of the treated patients. This is the first report of an outbreak of M. audouinii in Switzerland and underlines the importance of screening all contacts of patients with M. audouinii tinea capitis. Further, the effectiveness of griseofulvin in Microsporum tinea capitis has been corroborated, while newer antimycotic drugs like fluconazole or terbinafine failed.

Management of tinea capitis in childhood

Tinea capitis (TC) is a common dermatophyte infection affecting primarily prepubertal children. The causative pathogens belong to only two genera: Trichophyton and Microsporum. Although there is a great local variation in the epidemiology of TC worldwide, T. tonsurans is currently the most common cause of TC with M. canis second. Even though there is an emerging number of anthropophilic scalp infections, M. canis remains the predominant causative organism in many countries of the Mediterranean basin, the most important dermatophyte carriers being stray cats and dogs as well as pet puppies, kittens and rabbits. TC always requires systemic treatment because topical antifungal agents do not penetrate down to the deepest part of the hair follicle. Since the late 1950s, griseofulvin has been the gold standard for systemic therapy of TC. It is active against dermatophytes and has a long-term safety profile. The main disadvantage of griseofulvin is the long duration of treatment required which may lead to reduced compliance. The newer oral antifungal agents including terbinafine, itraconazole, ketokonazole, and fluconazole appear to have efficacy rates and potential adverse effects similar to those of griseofulvin in children with TC caused by Trichophyton species, while requiring a much shorter duration of treatment. They may, however, be more expensive.

Guidelines for the management of tinea capitis in children

Practice guidelines for the treatment of tinea capitis (TC) from the European Society for Pediatric Dermatology are presented. Tinea capitis always requires systemic treatment because topical antifungal agents do not penetrate the hair follicle. Topical treatment is only used as adjuvant therapy to systemic antifungals. The newer oral antifungal agents including terbinafine, itraconazole, and fluconazole appear to have efficacy rates and potential adverse effects similar to those of griseofulvin in children with TC caused by Trichophyton species, while requiring a much shorter duration of treatment. They may be, however, more expensive (Grading of recommendation A; strength of evidence 1a). Griseofulvin is still the treatment of choice for cases caused by Microsporum species. Its efficacy is superior to that of terbinafine (Grading of recommendation A; strength of evidence 1b), and although its efficacy and treatment duration is matched by fluconazole (Grading of recommendation A; strength of evidence 1b) and itraconazole (Grading of recommendation A; strength of evidence 1b), griseofulvin is cheaper. It must be noted, however, that griseofulvin is nowadays not available in certain European countries (e.g., Belgium, Greece, Portugal, and Turkey).

Tinea capitis: predictive value of symptoms and time to cure with griseofulvin treatment

OBJECTIVES

To describe (a) the predictive value of symptoms for diagnosis of tinea capitis and (b) the rate and timing of cure with high-dose griseofulvin treatment.

METHODS

This prospective open-label study enrolled children aged 1 to 12 years with clinical tinea capitis. Participants with a positive dermatophyte culture received oral griseofulvin (20-25 mg/kg/day) and topical selenium sulfide shampoo for 6 weeks. Main outcome measures. The rate of symptoms of tinea capitis, and rates of mycologic and clinical cure.

RESULTS

The positive predictive values of any 1, 2, 3, or 4 symptoms for a positive culture were 88%, 82%, 78%, and 77%, respectively. The observed rates of mycologic, clinical, and complete cure were 89%, 66%, and 49%, respectively. conclusion: In a high-risk population it is reasonable to diagnose tinea capitis using one or more cardinal symptoms. Oral griseofulvin at 20 to 25 mg/ kg/day with adjunctive shampooing for 6 weeks is moderately successful as treatment.

Safety and efficacy of terbinafine in a pediatric Iranian cohort of patients with Tinea capitis

BACKGROUND AND OBJECTIVES

Tinea capitis is a common infection of the scalp and hair shaft caused by dermatophyte fungi that mainly affects prepubescent children. Systemic therapy is required for treatment and to prevent spread. The aim of present study was to assess the effect of terbinafine for Tinea capitis treatment in children.

METHODS

Thirty Iranian pediatric patients with a clinical diagnosis of Tinea capitis were enrolled in the study. The Study was conducted in a general and referral teaching hospital (Imam Medical Centre - Tehran, Iran) from 2006 to 2007. Eligible patients with less than 20 kg of body weight were given 62.5 mg terbinafine, and for patients between 20 and 40 kg the dose was 125 mg, on the first visit. All patients had the second clinical visit and second samples for microscopic study were taken. For each patient, direct mycology test (KOH test) and mycological culture were carried out before the study was started and after second, fourth, fifth, sixth and eighth weeks. Probable drug's adverse effects were also recorded.

RESULTS

Based on the results of mycological culture of patients' lesions, Microsporum canis and Trichophyton sheonlini were considered as major causes of Tinea capitis in these children. Out of 30 study patients, KOH test of 93% in the 5th week and 100% in the 6th week was negative. All patients healed completely from signs of infection, after six weeks. Also, no severe side effects were seen in any patients.

CONCLUSION

According to the results of this study, the use of terbinafine is an effective therapy in Iranian cases of Tinea capitis in children without severe side effects.

Update on terbinafine with a focus on dermatophytoses

Since terbinafine was introduced on the world market 17 years ago, it has become the leading antifungal for the treatment of superficial fungal infections, aided by unique pharmacologic and microbiologic profiles. This article reviews mode of action, antimycotic spectrum and disposition profile of terbinafine. It examines the data, accumulated over 15 years, on the comparative efficacy of terbinafine (vs griseofulvin, itraconazole, fluconazole) in the management of the infections for which it is primarily indicated (eg, dermatophytoses) and provides a brief discussion on its use for the treatment of non-dermatophyte infections. Finally, the available data on the newest topical and systemic formulations are introduced.

Systemic antifungal therapy for tinea capitis in children

BACKGROUND

Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread.

OBJECTIVES

To assess the effects of systemic anti-fungal drugs for tinea capitis in children.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (2003 to June 2005), EMBASE ( 2003 to June 2005), LILACS (1982 to July 2005), CINAHL (1982 to July 2005), the ACP journal club (1991 to July 2005) and Healthstar (1975 to July 2005).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated systemic antifungal therapy in people with normal immunity under the age of 18 who had tinea capitis confirmed by microscopy or growth of dermatophytes in culture or both.

DATA COLLECTION AND ANALYSIS

At least two authors independently examined each retrieved trial for eligibility and quality.

MAIN RESULTS

We included 21 studies (1812 participants). Infections involving Trichophyton species: Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy in 3 studies involving 382 participants (RR 1.09; 95% CI 0.95 to 1.26). Cure rates following treatment with itraconazole and griseofulvin for 6 weeks were similar in 1 study of 35 children (RR 1.06; 95% CI 0.81 to 1.39). Another study of 100 children did not show any significant difference in cure between itraconazole for 2 weeks compared with griseofulvin for 6 weeks (RR 0.89; 95% CI 0.76 to 1.04). There was no difference between itraconazole and terbinafine for treatment periods lasting 2 to 3 weeks in 2 studies involving 160 children (RR 0.93; 95% CI 0.72 to 1.19). Two studies that included 140 children found similar cure rates between 2 to 4 weeks of fluconazole with 6 weeks of griseofulvin (RR 0.92; 95% CI 0.80 to 1.05). Microsporum infections: There was no significant difference in cure between terbinafine and griseofulvin in children with Microsporum infections in 1 small study of 29 children (RR 0.64; 95% CI 0.19 to 2.20).

AUTHORS' CONCLUSIONS

The best evidence suggests that newer treatments including terbinafine, itraconazole and fluconazole may be similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Newer treatments may be preferred because shorter treatment durations may improve treatment adherence, although they may be more expensive. There is not enough evidence on the use of systemic treatments in children with Microsporum infections. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles.

Dermatophytosis: the management of fungal infections

Dermatophytosis is an infection of the hair, skin, or nails caused by a dermatophyte, which is most commonly of the Trichophyton genus and less commonly of the Microsporum or Epidermophyton genera. Tinea capitis, tinea pedis, and onychomycosis are common dermatologic diseases that may result from such an infection. The treatment of fungal infections caused by a dermatophyte has been successful when treated with oral or topical antifungal agents. Terbinafine, itraconazole, and fluconazole are oral antimycotics that are effective in the treatment of superficial mycoses, although, depending on the severity of the infection, a topical antifungal may be sufficient.

Tinea capitis: a treatment update

Currently, many experts consider griseofulvin to be the drug of choice for tinea capitis. It is FDA approved for this indication, highly efficacious, and has an excellent long-term safety record. Nonetheless, there is now ample evidence documenting the efficacy and safety of other antifungal agents. Terbinafine, itraconazole, and fluconazole have been used off-label in the United States and United Kingdom for tinea capitis. Several studies have shown that short-term terbinafine, itraconazole, or fluconazole each are comparable in efficacy and safety to griseofulvin. High-dose griseofulvin is still the first-line therapy for tinea capitis in our practice, but a large-scale, multicenter trial of higher dose terbinafine is now ongoing, and positive efficacy and safety results from that study may lead to a change in our standard of care. Terbinafine, itraconazole, or fluconazole currently are used in patients who have either failed griseofulvin or developed adverse reactions to this medication. Families must be informed that these other antifungal agents are not FDA-approved for this indication when they are used. Guidelines for therapy with each of these agents are summarized in Table 5. In addition, the adjuvant use of antifungal shampoos is recommended for all patients in order to decrease the viability of fungal spores present on the hair, as well as for all household contacts to prevent infection or eliminate the carrier state.

Optimal management of fungal infections of the skin, hair, and nails

Superficial fungal infections are chronic and recurring conditions. Tinea capitis is a scalp infection, primarily affecting prepubescent children. Ringworm infections, such as tinea corporis and tinea cruris, involve the glabrous skin. Tinea nigra is a rare mycotic infection that may be related to travel abroad. Piedra, black or white, is limited to the hair shaft without involvement of the adjacent skin. Pityriasis (tinea) versicolor and seborrheic dermatitis are dermatoses associated with yeasts of the genus Malassezia that affect the lipid-rich areas of the body. The taxonomy of the Malassezia yeasts has been revised to include nine species, eight of which have been recovered from humans. Tinea pedis, an infection of the feet and toes, is one of the most common forms of dermatophytosis. Onychomycosis is a fungal infection affecting the nail bed and nail plate; it may be chronic and can be difficult to treat. In instances where the superficial fungal infection is severe or chronic, an oral antifungal agent should be considered. Terbinafine, itraconazole, and fluconazole are oral antifungals that are effective in the treatment of superficial mycoses.

Griseofulvin versus terbinafine in the treatment of tinea capitis: a meta-analysis of randomized, clinical trials

OBJECTIVE

Tinea capitis, a common pediatric infection in the United States, is caused mainly by Trichophyton species and affects many urban children. Although the current treatment of choice is oral griseofulvin, terbinafine has been shown to be variably effective in several comparative, randomized trials. The purpose of this study was to perform a meta-analysis of randomized, clinical trials comparing the efficacies of oral terbinafine and oral griseofulvin for the treatment of childhood tinea capitis.

METHODS

The Medline database was searched for randomized, clinical studies comparing griseofulvin and terbinafine for the treatment of tinea capitis. Acceptance criteria included oral administration of griseofulvin for at least 6 weeks and the identification of a pathogenic dermatophyte from the scalp at the time of enrollment in the study. Scalp culture status at least 8 weeks after enrollment was used as the outcome. The common odds ratio (OR) with 95% confidence intervals (CIs), the Cochran-Mantel-Haenszel test for significance, and the Breslow-Day test for homogeneity were calculated.

RESULTS

Six articles that satisfied all inclusion criteria were identified. These studies were combined by using outcomes at 12 to 16 weeks after enrollment. The common OR was 0.86 (95% CI: 0.57-1.27). When the 5 studies that identified Trichophyton species as the predominant pathogen were combined, using outcomes 12 weeks after enrollment, the results nearly favored terbinafine (OR: 0.65 [95% CI: 0.42-1.01]). For outcomes at 8 weeks after enrollment, no difference was found between the agents (OR: 0.84 [95% CI: 0.54-1.32]). Consclusions.A 2- to 4-week course of terbinafine is at least as effective as a 6- to 8-week course of griseofulvin for the treatment of Trichophyton infections of the scalp. Griseofulvin is likely to be superior to terbinafine for the rare cases caused by Microsporum species.

Itraconazole in the treatment of tinea capitis caused by Microsporum canis: experience in a large cohort

Mycotic scalp infection caused by Microsporum canis is one of the more recalcitrant disorders, with increasing incidence during the last decade. We report our experience with administration of itraconazole in 163 children (86 girls, 77 boys) with M. canis tinea capitis. Fifty-five patients had previous treatment with terbinafine without success. In all children, the dosage of itraconazole was adjusted according to body weight, with 5 mg/kg/day given in a continuous regimen either as a capsule (116 patients) or an oral suspension (47 patients). In all children, there was both clinical and mycologic cure after a mean treatment period of 39 +/- 12 days (range 10-77 days). Eleven children (6.7%) had side effects: diarrhea in five children, cutaneous eruption in four, and abdominal pain in two. Itraconazole was effective and safe for the treatment of M. canis tinea capitis.

New treatments for tinea capitis

PURPOSE OF REVIEW

Tinea capitis, a dermatophyte infection involving the hair shaft on the scalp, is primarily a disease of preadolescent children. The predominant pathogen varies according to the geographical location. Trichophyton tonsurans and Microsporum canis account for the majority of infections in north America and certain parts of Europe. The current standard of care for the treatment of tinea capitis in the USA is oral griseofulvin, but evidence is accumulating that some of the newer antifungal agents may also be useful.

RECENT FINDINGS

The newer oral antifungal agents such as terbinafine, itraconazole and fluconazole seem to be effective, safe, and have the advantage of a shorter treatment duration. Although a significant number of clinical studies and reports have documented experience with terbinafine and itraconazole for the treatment of tinea capitis, it should be noted that only a few trials have been conducted utilizing fluconazole. Both 2% ketoconazole and 1% selenium sulfide shampoos are often recommended as adjuvant topical therapy.

SUMMARY

Currently, many experts consider griseofulvin to be the drug of choice for tinea capitis. Short-term terbinafine, itraconazole and fluconazole therapy have been shown to be comparable in efficacy and safety with griseofulvin. Regular epidemiological surveillance of causative fungal organisms in the community and their antifungal susceptibility is an essential component in the management of this condition.

Efficacy and tolerability of 8 weeks' treatment with terbinafine in children with tinea capitis caused by Microsporum canis: a comparison of three doses

BACKGROUND

Tinea capitis caused by Microsporum canis is the most common mycosis of the scalp in preschool and school-aged children in Greece.

OBJECTIVE

To compare the efficacy, safety and tolerability of an 8-week course of oral terbinafine at different doses.

METHODS

Patients received oral terbinafine at doses ranging from 3.3 to 12.5 mg/kg/day for 8 weeks, as follows: group A, terbinafine 3.3 to </= 6.0 mg/kg/day (40 patients); group B, terbinafine > 6.0 to 7.0 mg/kg/day (23 patients); group C, terbinafine > 7.0 to 12.5 mg/kg/day (37 patients). Fungal microscopy and cultures were performed 4 weeks before the start of the treatment, at the end of the treatment (week 8) and at a follow-up visit at week 16.

RESULTS

At week 8 mycological cure was achieved in one patient (2.7%) in group A, in 21 patients (91.3%) in group B and in 34 patients (97.1%) in group C. At week 16 mycological cure was achieved in one patient (2.7%) in group A, in 22 patients (95.7%) in group B and in 35 patients (100%) in group C. There was a statistically significant difference (P < 0.0005) between dose level and efficacy of terbinafine at the end of the treatment period and also at the follow-up visit at week 16. Five patients (three in group A and two in group C) discontinued treatment because of adverse events.

CONCLUSIONS

The administration of terbinafine at a dose of either 6-7 or 7-12.5 mg/kg/day for 8 weeks is safe and effective for the treatment in children of tinea capitis caused by M. canis.

The efficacy and safety of terbinafine in children

Terbinafine is an allylamine antifungal agent that has been effective and safe in the treatment of superficial and some deep mycotic infections in adults. An increasing amount of data is available where terbinafine has been used in the paediatric population to treat superficial fungal infections, in particular tinea capitis. The data suggest that terbinafine is effective and safe using treatment regimens that involve short duration therapy, leading to an increased compliance and providing a cost-effective means of treating paediatric superficial fungal infections such as tinea capitis. Terbinafine has been approved for the treatment of tinea capitis in many countries worldwide, and provides good efficacy rates for Trichophyton tinea capitis using shorter regimens than the gold standard griseofulvin. The adverse events profile for children is similar to that in adults with few adverse effects associated with its use. The evidence favours the use of terbinafine in the treatment of superficial infections in children.

The efficacy and safety of terbinafine in children

In summary, terbinafine is a broad-spectrum allylamine, which has been used to treat superficial fungal infections including onychomycosis, and some systemic mycoses in adults. With a fungicidal activity, low minimum inhibitory concentration value, and high selectivity for fungal squalene epoxidase, terbinafine has demonstrated good efficacy in superficial fungal infections. Its lipophilic nature provides excellent, widespread absorption into hair, skin, and nails where it can eradicate fungal infection. Terbinafine has been shown to be effective and safe in several studies of the treatment of tinea capitis and onychomycosis in children. When treating Trichophyton tinea capitis the length of therapy may be 2 or 4 weeks. Microsporum tinea capitis may require somewhat higher or longer doses of terbinafine for adequate efficacy. These regimens still tend to be shorter than treatment with griseofulvin, and terbinafine may provide a higher compliance and a more cost-effective means of managing tinea capitis. It is possible that even higher cure rates and a shorter duration of therapy may be achieved following further optimization of treatment regimens that use a higher daily dosage of terbinafine than is currently recommended. The evidence is strongly in favor of using terbinafine to treat superficial fungal infections in children.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.