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Referral and warning signs
When to refer
Refer to Dermatologist/Specialist if: Diagnosis uncertain. Failure to respond to Griseofulvin after 6-8 weeks. Severe kerion (consider steroids). Need for alternative systemic antifungals.
Red flags
- Severe, boggy, inflamed kerion.
- Rapidly progressing hair loss.
- Signs of significant secondary bacterial infection.
- Failure to respond to appropriate first-line therapy.
Signs and symptoms
- Scaly patches on the scalp.
- Hair loss (alopecia) within patches.
- Broken hairs close to the scalp surface ('black dots').
- Itching.
- May have mild inflammation or significant inflammation with pustules, boggy swelling, and crusting (Kerion).
- Occipital or cervical lymphadenopathy may be present.
- Appearance varies depending on causative fungus (e.g., Trichophyton vs Microsporum).
Risk factors
- Age (pre-pubertal children most common).
- Close contact with infected individuals or animals (esp. Microsporum canis from cats/dogs).
- Sharing contaminated items (combs, hats, bedding).
- Crowded living conditions.
- Poor hygiene.
- Immunosuppression.
Diagnosis
Clinical assessment
Diagnosis often based on clinical appearance (scaly patches with alopecia/broken hairs +/- kerion).
Differential diagnosis
- Seborrhoeic dermatitis (greasy scales, less hair loss).
- Psoriasis (well-demarcated silvery plaques, often affects other areas).
- Alopecia areata (smooth, completely bald patches).
- Bacterial folliculitis / Scalp abscess.
- Lichen planopilaris / Discoid lupus (scarring alopecia - rare in children).
Investigations
- Fungal Examination (Confirmatory):
- - KOH Microscopy: Pluck affected hairs (broken stumps) and scrape scales. Examine under microscope with Potassium Hydroxide (KOH) solution to visualize fungal hyphae/spores within or around hair shaft (ectothrix/endothrix).
- - Fungal Culture: On Sabouraud's agar using hair/scales. Identifies specific species (takes weeks).
- Wood's Lamp Examination: Some Microsporum species fluoresce green (less common cause now in many areas).
Diagnostic criteria
Clinical suspicion supported by positive KOH microscopy or fungal culture.
Management
Non-pharmacological management
- Good hygiene.
- Wash contaminated items (combs, bedding, hats) - may need antifungal shampoo use by contacts.
- Avoid sharing personal items.
Pharmacological treatment
- Systemic Antifungal Therapy is REQUIRED (topicals alone are ineffective as infection is within hair shaft). (LOC: HC2/3)
- - First line: Griseofulvin (microsize) 10-20 mg/kg/day PO single dose (take with fatty meal for better absorption) for 6-8 weeks (or longer until cure confirmed).
- - UCG recommends 10mg/kg/day for 6 weeks.
- - Alternatives (often used if Griseofulvin fails/unavailable/specific fungi):
- - Terbinafine PO (dose by weight) for 4-6 weeks (effective for Trichophyton, less for Microsporum).
- - Itraconazole PO.
- - Fluconazole PO.
- Adjunctive Topical Therapy:
- - Antifungal Shampoos (Ketoconazole 2%, Selenium Sulfide 2.5%) used 2-3 times weekly can reduce spore shedding and transmission (does NOT cure alone).
- Kerion Management:
- - Continue systemic antifungal.
- - May require short course of oral corticosteroids (Prednisolone) to reduce severe inflammation and scarring risk (specialist advice).
- - Antibiotics if secondary bacterial infection suspected.
Monitoring
Monitor clinical response (reduction in scaling/inflammation, hair regrowth). Consider repeat fungal exam if poor response. Monitor LFTs if using terbinafine/itraconazole long-term.
Complications
- Permanent scarring alopecia (especially after severe kerion).
- Secondary bacterial infection.
- Psychosocial impact.
Prevention
- Treating infected individuals and household contacts.
- Treating infected pets.
- Avoiding sharing personal items.
- Good hygiene.
Patient education
- Explanation of scalp ringworm as a fungal infection.
- Need for ORAL antifungal medication for several weeks.
- Importance of taking Griseofulvin with fatty food.
- How to use antifungal shampoo.
- Measures to prevent spread (hygiene, not sharing items).
- Checking family members/contacts.
- Reassurance that hair usually regrows (unless severe scarring).
Uganda-specific notes
Very common, particularly in school-aged children. Griseofulvin is the standard first-line treatment when available. Access to KOH microscopy/culture limited. Topical treatments often used inappropriately as sole therapy.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 22, Section 22.3.1 (Tinea Capitis section)