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Tinea Capitis (Scalp Ringworm)

Dermatophyte infection of the scalp and hair shafts caused predominantly by Trichophyton tonsurans (anthropophilic, US/UK) and Microsporum canis (zoophilic, Mediterranean/Europe); the most common dermatophytosis in school-aged children, requiring oral antifungal therapy with griseofulvin or terbinafine.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Dermatoloji department. Book Appointment →

What is Tinea Capitis (Scalp Ringworm)?

Tinea capitis is a superficial fungal infection caused by dermatophytes of genera Trichophyton and Microsporum that invade the keratinized tissue of the scalp, hair follicles, and hair shafts. It is the most common dermatophytosis in pre-pubertal children worldwide. Three patterns of hair invasion: (1) endothrix — fungal arthroconidia within hair shaft (Trichophyton tonsurans, T. violaceum); (2) ectothrix — fungal arthroconidia outside hair shaft (Microsporum canis, M. audouinii, M. gypseum); (3) favus — air-filled tunnels and arthroconidia in shaft (T. schoenleinii, rare).

Epidemiology: 90 percent of US tinea capitis is T. tonsurans (anthropophilic, person-to-person spread, prevalent in inner-city children especially African American); in Europe and Mediterranean, M. canis from cats and dogs predominates; T. violaceum endemic in parts of Africa, Asia. Outbreaks occur in schools, daycares, households via direct contact with infected hairs, fomites (combs, brushes, hats, pillows, barber clippers), and from animal pets.

Clinical patterns: (1) Black dot — endothrix T. tonsurans causes patches of alopecia with broken hairs at follicular orifice (black dots), mild scaling, minimal inflammation; (2) Gray patch — ectothrix Microsporum causes scaly patches with hair broken close to scalp, fluoresces blue-green under Wood lamp; (3) Diffuse scaly — mimics seborrheic dermatitis or dandruff with patchy hair loss; (4) Kerion — severe inflammatory boggy mass with pustules, lymphadenopathy, fever, and risk of permanent scarring alopecia (T-cell mediated hypersensitivity); (5) Favus — yellow scutula and atrophic scarring (rare). Diagnosis: KOH preparation of scaly hairs / brushings (hyphae and arthroconidia inside vs around hair), fungal culture (Sabouraud / DTM, gold standard, takes 2–4 weeks), Wood lamp (only ectothrix Microsporum fluoresces), trichoscopy (corkscrew hairs, comma hairs, black dots, broken hairs).

Symptoms

Patchy hair loss with scaling on scalp
Black dots — broken hair stubs at follicular orifice (T. tonsurans endothrix)
Gray patches with hairs broken close to scalp (Microsporum ectothrix)
Inflammatory kerion: boggy tender mass with pustules, lymphadenopathy, fever
Diffuse fine scaling resembling dandruff or seborrheic dermatitis
Posterior cervical or occipital lymphadenopathy (helpful diagnostic clue in inflammatory tinea)
Pruritus (variable)
School outbreak history or pet exposure (cat, dog, rodent)

Risk Factors

Pre-pubertal age (3–7 years peak; rare in adults due to fungistatic sebum)
Crowded living conditions, daycare or school attendance
Sharing combs, brushes, hats, pillows, towels
Contact with infected pets (cats, dogs — Microsporum canis)
African American descent (higher T. tonsurans prevalence in US)
Immunosuppression (HIV, transplant, chemotherapy — adult tinea capitis)
Barber shop transmission via clippers, capes
Asymptomatic carrier state (especially T. tonsurans, may persist for years)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Patchy hair loss in child with scaling, black dots, or boggy swelling
  • Scaly itchy scalp not responding to dandruff treatment
  • Tender boggy mass on scalp with pustules — possible kerion (urgent)
  • Multiple cases in family or school — potential outbreak requires evaluation
  • Known tinea capitis with worsening or new symptoms despite therapy
  • Bacterial superinfection (impetiginization)
  • Pet diagnosed with ringworm (consider screening exposed children)

Treatment Methods

01
Diagnostic: KOH preparation of scaly hairs and brushings (look for hyphae inside or around hair shaft), Wood lamp examination (Microsporum ectothrix fluoresces blue-green), fungal culture on Sabouraud or DTM (gold standard, 2–4 weeks), trichoscopy (corkscrew, comma, zigzag hairs, black dots)
02
First-line systemic therapy mandatory (topical alone insufficient): griseofulvin (microsize 20–25 mg/kg/day or ultramicrosize 10–15 mg/kg/day) with fatty meal for 6–12 weeks (preferred for Microsporum, FDA-approved); OR terbinafine (62.5 mg/day < 25 kg, 125 mg/day 25–35 kg, 250 mg/day > 35 kg) for 4–6 weeks (preferred for Trichophyton, more convenient)
03
Alternative systemic agents for resistant cases or atypical species: itraconazole 5 mg/kg/day pulsed (1 week per month) or continuous, fluconazole 6 mg/kg/day for 6–8 weeks
04
Adjunctive topical antifungal shampoo (NOT alone): selenium sulfide 2.5 percent or ketoconazole 2 percent or ciclopirox 1 percent shampoo, used 2–3 times weekly during systemic therapy to reduce viable spores and transmission
05
Kerion management: continue systemic antifungal; short course of oral prednisone (1 mg/kg/day for 1–2 weeks) for severe inflammation to reduce scarring; gentle compresses, avoid surgical drainage; antibiotic if bacterial superinfection
06
Public health and contact measures: examine and treat household contacts; treat asymptomatic carriers with antifungal shampoo; clean shared items (combs, brushes, hats, pillowcases — wash, replace, or treat); evaluate and treat pets if zoophilic species (Microsporum canis from cats); school exclusion not required once treatment started
07
Follow-up: clinical response by 4 weeks, mycologic cure (negative KOH and culture) by end of therapy; longer treatment if Microsporum or persistent culture; document cure to prevent re-infection
08
In adult tinea capitis (rare), evaluate for immunosuppression and treat as in children with appropriate adult dosing

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You can visit our Dermatoloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.