If you have a patient who you think has tinea capitis:
- Culturing the lesion is important because sometimes it can be a more unusual, difficult to treat fungal pathogen.
- If the lesions are scaly, take a scraping (scrape off as many flakes as you can, and put them between 2 glass slides, tape up the edges of the glass slide, and label it). Send this to microbiology for KOH stain and fungal culture.
- If the scalp lesion is boggy and wet (as can happen with a kerion), use a regular culture swab (like for strep) and culture as much of the oozing stuff as possible. Send this for fungal culture (KOH cannot be done on this sample).
- Draw off a baseline CBC and LFTs (even though the risk of problems with Lamisil treatment is very low in children, Dermatology recommends this). Needs to be done in all cases (whether you are sure or unsure of the diagnosis), so that if we have to call the patient back to start the therapy after a positive culture, we don't have to bring them back to get this done.
- If you are not sure of the diagnosis, then just start the patient on Loprox cream for the lesion, and Nizoral shampoo for the rest of the family, pending the culture results. Keep in mind that tinea capitis can only be treated with oral therapy, therefore this is just a temporizing measure hoping to limit spread of the infection pending the culture result.
- If you are sure you are dealing with tinea capitis, then start the patient on oral Lamisil:
- Griseofulvin no longer exists
- Lamisil only comes in pill form, but it can be crushed and given in a puree or other food, and Dermatology uses the following dosing guideline in all patients
- < 20 kg, 62.5mg (1/4 pill) qday x 6 weeks
- 20-40 kg, 125mg (1/2 pill) qday x 6 weeks
- > 40 kg, 250mg (1 pill) qday x 6 weeks
- Follow-up CBC and LFTs are recommended 4 weeks into the therapy, Follow-up can with be done through the primary care physician, or the patient can be referred to Dermatology. If you send them to Dermatology, indicated that follow-up is requested in 4 weeks, and give the family a requisition to get the CBC and LFTs done prior to the appointment.
As an added note, tinea corporis is much easier to treat. If the lesion is scaly and can easily be cultured, do so as above for tinea capitis. If it is not easily cultured, do not worry, it is not as critical. Tinea corporis responds easily to topical therapy. Dermatology recommends Loprox cream BID for 2-4 weeks (they say better than Lamisil cream), and that it works every time!
Thank you to Dr. Jafarian, MCH Dermatology for her advice.
