Disease Management

Tinea Capitis: Diagnostic Criteria and

Treatment Options
Mikki Meadows-Oliver

Tinea capitis is a fungal

infection involving the hair shaft
of the scalp. It is commonly
referred to as ringworm and
occurs primarily in children.
Treatment with a systemic antifungal rather than topical
treatment is required. Currently,
two medications, griseofulvin
(Grifulvin) and terbinafine
(Lamisil Granules), are FDAapproved to treat tinea capitis.
Treatment with griseofulvin is
usually 6 to 8 weeks, while
treatment with terbinafine
requires 6 weeks. There are other
medications currently not FDAapproved to treat tinea capitis
that have similar cure rates and
shorter durations of treatment
for tinea capitis, and as a result,
are being used off-label. The
research-based literature related
to the treatment of tinea capitis
with various pharmacologic
agents is reviewed.

inea capitis is a fungal infection

involving the hair shaft of the
scalp and hair follicles caused
by dermatophyte fungi (Ali,
Graham, & Forgie, 2007). While it
may affect any age group, tinea capitis
is particularly common among
s chool-aged children (Alvarez &
Silverberg, 20 06). To treat tinea capitis, systemic anti-fungal rather than
topical treatment is required. Topical
anti-fungal treatments are not able to
adequately penetrate the hair shaft to
eliminate the infection (Ali et al., 2007;
Chan & Friedlander, 2004). Because
of the prevalence of tinea capitis, it is
essential that nurses are aware of this
condition and current available treatment regimens. The recent researchbased publications on the diagnosis
and treatment of tinea capitis, and
valuable evidence for nursing practice
are reviewed.
Currently, griseofulvin (Grifulvin)
and terbinafine (Lamasil Granules)
are the only two medications
approved by the United States Food
and Drug Administration (FDA) for
the treatment of tinea capitis (FDA,
20 07; Roberts & Friedlander, 20 05 ) .
There are newer anti-fungal agents
available that have been shown to be
safe and effective with a shorter
duration of treatment, but are not yet
approved by the FDA for the treatment of tinea capitis. Medications

Mikki Meadow s -Oliver, PhD, RN, is an

Assistant Professor, Yale University School of
Nursing, New Haven, CT.
Acknowledgment: The author would like to
thank Pat Jackson-Allen for her assistance in the
preparation of this article.
Note: This article is reprinted with permission from Pediatric Nursing, 35(1), 53-57.

DERMATOLOGY NURSING/September-October 2009/Vol. 21/No. 5

such as fluconazole and itraconazole

are currently being prescribed offlabel for tinea capitis.
Off-label use refers to the use of
legally available medications being
prescribed for a function outside of the
medications approved label. For
example, fluconazole (Diflucan) is
currently FDA approved to treat vaginal yeast infections but is sometimes
used in pediatrics to treat tinea capitis
(off-label use). Prescribing off-labelapproved medications is common and
often necessary in pediatric practice
(Moonestime-Williams, Dick e r s o n ,
& Basco, 2007; Novak & JacksonAllen, 20 07). According to the FDA
(1998), the off-label use of medication cannot significantly increase the
risk or decrease the acceptability of
the risks associated with use of the
medication. Care must be used
when prescribing and administering
off-label medications in pediatrics
because the pharmacokinetics of
medications may be different in children than in adults (Novak &
Jackson-Allen, 2007). Pediatric
providers should consider consulting
specialists for guidance on treatment
with non-approved medications
until a community standard of practice with the non-approved drug is
attained. Parents should also be
informed when a medication is
being used in an off-label manner
(Moonestime-Williams et al., 20 07).

Epidemiology
Fungi that cause tinea capitis
infections are from geophilic,
zoophilic, and anthropophilic organisms. Geophilic fungi inhabit the soil,
zoophilic organisms (Microsporum
canis) live on animals, and anthropophilic fungi (Trichophytan tonsurans)

281

Figure 1.
Tinea capitis caused the Trichopyhtan species. Note the
thinning hair and broken hair shafts sometimes known
as black dot alopecia.

Figure 2.
An inflammatory kerion caused in this case by the
Microsporum species. Note the inflammation,
scaling, broken hair shafts, and alopecia.

Source: Photo from Centers of Disease Control and Prevention,

Public Health Image Libra ry.

Source: Photo from Centers of Disease Control and Prevention,

Public Health Image Libra ry.

live on humans (Fuller, Child,

Midgley, & Higgins, 20 03). In the
past, most pediatric tinea capitis
infections in the United States were
caused by zoophilic fungi after exposure to an infected animal (usually
cats and dogs). Although the reasons
for the change in infective fungi are
not known, more recently, the most
prevalent organisms causing tinea
capitis infections in children are
anthropophilic organisms, w h i ch
spread directly from person to person (Fuller et al., 20 03). Most cases
tend to occur in children from the
age of 4 to 7 years, although it does
occur in adolescents, with both boys
and girls appearing to be infected
equally (Chen & Friedlander, 20 01).
In the United States, the spread of T.
tonsurans has predominantly (but not
exclusively) been seen in AfricanAmerican children. It is unknown
whether this is related to hair type or
ethnicity. African Americans may
have a higher risk of developing
tinea capitis, but it is important to
realize that all children are susceptible to tinea capitis infections regardless of their ethnic backgrounds
(Hay, 20 01).

Clinical Manifestations
Tinea capitis infections have
been called the great masquer-

282

aders (Roberts & Friedlander, 20 05,

p. 191). Tinea capitis infections present in an assortment of ways that
may cause them to be confused with
other skin disorders of the scalp (see
Figure 1). It may present as either a
non-inflammatory or inflammatory
condition. Symptoms may be subtle
with non-inflammatory presentation,
such as dandruff-like scaling of the
scalp, slight pruritus, and minimal
hair loss (Ali et al., 2007). Hair
growth will return as the fungal
infection clears. With the inflammatory form of the disease (kerions), the
infected area may be boggy, oozing,
and have pustular masses. Kerions
may sometimes be incorrectly diagnosed as bacterial abscesses leading
to inappropriate and ineffective
treatment (Roberts & Friedlander,
2005). Permanent scarring may
result from kerions (Ali et al., 20 07).
Figure 2 shows a child with an
inflammatory kerion.
The clinical triad of scalp scaling,
alopecia, and lymphadenopathy
(occipital and/or posterior cervical)
is typically associated with tinea
capitis (Roberts & Fr i e d l a n d e r ,
20 05). A differential diagnosis of
tinea capitis should include other
common scalp disorders that may
present with scalp scaling and head
and neck adenopathy, such as atopic

dermatitis, psoriasis, and seborrheic

dermatitis (Roberts & Freidlander,
20 05). It is important to keep in
mind that not all individuals with
tinea capitis will display symptoms.
In the general population of the
United States, the asymptomatic carrier state is estimated to be 5%.
However, in urban school-age populations, the percentage increases to
nearly 15% (Chen & Friedlander,
20 01).

Diagnosis
The clinical diagnosis of the
infection is notoriously unreliable...
(Hay, 2001, p. 122). Microscopic
examination and/or fungal culture
should be used to confirm the clinical diagnosis of tinea capitis because
of the extended nature of most treatment regimens (Ali et al., 20 07).
Microscopic examination consists of
scraping the scales of the lesions
onto a slide and viewing the sample,
which is prepared with a 20% potassium hydroxide (KOH) solution,
under the microscope to look for the
presence of hyphae (Chen &
Friedlander, 20 01). This test may be
difficult to interpret or may be falsely negative with early or inflammatory lesions. Therefore, the final diagnosis of tinea capitis should be made
by culture. Culture documentation

DERMATOLOGY NURSING/September-October 2009/Vol. 21/No. 5

Table 1.
Medications Used to Treat Tinea Capitis
Medication

D o s age

Duration of Treatment

Labs

Other Considerations

Griseofulvin
(Grifulvin)

20 to 25 mg/kg/day

6 to 8 weeks (up to 16
weeks)

Consider baseline CBC,

liver function tests, renal
function tests

Should be taken with

food or milk to
enhance medication
absorption.

Fluconazole*
(Diflucan)

6 mg/kg/day

3 we e k s

Needs baseline CBC,

liver function tests, renal
function tests

May be taken with food

if GI symptoms occur.

Itraconazole*
(Sporanox)

5 mg/kg/day

4 we e k s

Needs baseline CBC,

liver function tests, renal
function tests

Capsules should be
taken with food; c a psules may be opened
and sprinkled on food;
liquid preparation
should be taken on
an empty stomach.

Terbinafine
(Lamisil Gra nu l e s)

125 mg/day
(25 kg weight)

6 we e k s

Needs baseline CBC,

liver function tests, renal
function tests, potassium level

May be taken with nonacidic, non-fruit based

foods, such as pudding
or mashed potatoes, if
GI symptoms occur.

187.5 mg/day
(25 to 35 kg weight)
250 mg/day (greater
than 35 kg weight)
*Medications not currently FDA-approved for the treatment of tinea capitis.

of the infection is a crucial component to treatment of tinea capitis

(Roberts & Friedlander, 20 05). If the
clinical index of suspicion is high,
therapy should be initiated after the
culture is obtained because it may
take at least 2 weeks for culture
results to return. However, oral antifungals should be deferred if there is
low index of clinical suspicion until
positive culture results have been
obtained (Roberts & Friedlander,
20 05).
Traditional scalp culture methods
include a scalp scraping with a scalpel
and removal of hairs; however, culturing the scales and hair of tinea
capitis lesions with a cotton swab or
cytobrush is a reliable, inexpensive,
and less-traumatic means of gathering
a sample for the fungal culture
(Bonifaz et al., 20 07; Friedlander,
Pickering, Cunningham, Gibbs, &
Eichenfeld, 1999). Culturing the suspected fungal lesion with a cotton
applicator involves rubbing and
rotating a moistened swab over the
affected area and placing the swab in
the appropriate culture medium.
Hubbard and de Triquet (1992)

determined that using a toothbrush

in a manner similar to that of the cotton swab is also a reliable manner of
gathering a scalp sample for fungal
culture in the diagnosis of tinea capitis. While this technique has been
shown to be easy to perform and
painless, one disadvantage of this
method is that it requires an office to
be stocked with toothbrushes, which
are more expensive than cotton
swabs (Friedlander et al., 1999 ) .
Historically, when the majority of
tinea capitis infections in the United
States were caused by the
Microsporum species, a Woods lamp
examination was helpful in assisting
providers in diagnosing tinea capitis;
the Microsporum species would fluoresce when examined using a
Woods lamp due to the formation of
a sheath by fungal spores on the outside of the hair shaft (ectothrix).
However, with tinea capitis infections that are caused by the
Trichophytan species, the fungal
spores form on the inside of the hair
shaft (endothrix), and there is no fluorescence (Fuller et al., 2003).
Therefore, the Woods light exami-

DERMATOLOGY NURSING/September-October 2009/Vol. 21/No. 5

nation is not a reliable method for

diagnosing tinea capitis caused by
the Trichophytan species because this
species does not fluoresce.

Available Treatments for the

Management of Tinea Capitis
There are several pharmacologic
treatments for managing tinea capitis, as shown in Table 1 and discussed in detail below.
Griseofulvin (Grifulvin). Griseofulvin (Grifulvin) is currently the
standard treatment for tinea capitis
infections in the pediatric population. However, griseofulvin has a
restricted spectrum of action and is
only effective against a small number
of dermatophyte species (Tricho phytan, Microsporum, and Epider mophyton). A meta-analysis of studies
researching the efficacy of grisefulvin
noted that after 6 to 8 weeks of treatment, griseofulvin was nearly 68 %
effective
when
treating
the
Trichophytan species and 88% effective when treating the Microsporum
species (Gupta, Cooper, & Bowen,
20 08 ) .
Re s e a r chers have been con-

283

cerned with the observed troublesome decrease in the sensitivity of

tinea capitis infections to this agent
(Chen & Friedlander, 20 01, p. 332 ) .
This concern over the decrease in
sensitivity of tinea infections to griseofulvin is supported by changes in
the initial response and cure rates,
and increases in recommendations
for dosages and duration of treatment with griseofulvin (Chen &
Friedlander, 2001; Roberts &
Friedlander, 20 05). Mycologic cure
rates with griseofulvin have been
shown to range from 71% to 92 %
(Fuller, Smith, & Cerio, 20 01; Gupta,
Adam, & Dlova, 20 01) depending on
the infective organism, the dose of
medication, and the duration of therapy.
There is an apparent relationship
between the dose of medication and
recurrence rate of infection.
Absorption of griseofulvin is
increased by microsizing or reducing the particle size of the medication. The medication is even more
rapidly absorbed with the ultramicrosized form of griseofulvin that
allows for a dosage reduction of 33 %
to 50%. The microsized formulation
of the medication should be administered at a dose of 20 to 25 mg/kg
per day, while the ultramicrosized
preparation should be dosed at 10 to
15 mg/kg/day. The normal duration
of treatment is 6 to 8 weeks (up to 16
weeks) depending on clinical and
mycological cure. It has poor water
solubility and should be taken with
food or milk to enhance absorption
( Roberts & Friedlander, 2005).
Currently, only the microsized
preparation is available in liquid
form (Roberts & Friedlander, 20 05 ) .
The most common side effects
associated with griseofulvin are
headaches and gastrointestinal complaints. Increased sensitivity to the
sun may occur. Patients should be
advised to use sunscreen with at least
SPF 15 and avoid tanning booths.
Griseofulvin may affect the efficacy
of oral contraceptives. Adolescent
girls taking griseofulvin should be
instructed to use a different or an
additional form of contraception
while taking griseofulvin. BUN, creatinine, and liver function tests

284

should be monitored after 8 weeks of

therapy with griseofulvin (Wynne,
Woo, & Olyaei, 20 07).
Terbinafine (Lamasil Granules).
Terbinafine (Lamisil Granules) is
currently FDA-approved to treat
tinea capitis in children 4 years of
age and older. A meta-analysis of
randomized clinical trials comparing
terbinafine to griseofulvin for the
treatment of tinea capitis was conducted, and results favored terbinafine after 12 weeks of treatment
(Fleece, Gaughan, & Aronoff, 20 02 ) .
More recent randomized controlled
trials comparing griseofulvin to
terbinafine oral granules supported
the results of the earlier meta-analysis in patients infected with tinea
from the Trichophytan species. Rates
of mycological and clinical cure
were significantly higher for
terbinafine than for griseofulvin for
patients with Trichophytan tonsurans.
For patients with Microsporum canis,
mycological and clinical cure rates
were significantly higher for patients
treated with griseofulvin than those
treated with terbinafine oral granules
(Elewski et al., 20 08).
The approved terbinafine granules dose for the treatment of tinea
capitis is 125 mg/day (25 kg weight),
187.5 mg/day (25 to 35 kg weight),
and 250 mg (greater than 35 kg
weight). The maximum dose is 250
mg/day. Children should be treated
once daily for 6 weeks. The oral
granules should be taken with nonacidic foods, such as pudding or
mashed potatoes. The oral granules
should not be taken with applesauce
or other fruit-based foods (Deglin &
Vallerand, 20 09 ) .
The most common side effects
reported when using terbinafine are
headache, nasopharyngitis, rash, and
gastrointestinal symptoms. Because
there is a risk of hepatotoxicity when
using terbinafine oral granules, this
medication should not be used in
patients with a pre-existing liver condition. Pre-treatment serum liver
transminases (ALT and AST) and a
potassium level should be obtained.
If treatment is to continue beyond 6
weeks, liver transaminases and a
potassium level should be reobtained along with a complete

blood count (CBC) with differential

to monitor the absolute neutrophil
count. The medication should be
continued if abnormal values occur
(Deglin & Vallerand, 20 09 ) .
Fluconazole (Diflucan). Fluconazole
(Diflucan) is FDA-approved to treat
candidiasis and systemic fungal infections (Deglin & Vallerand, 20 09) but
not tinea capitis. It is available in
both liquid and tablet formulations,
and greater than 90% of the medication is absorbed regardless of presence of food in the stomach. The recommended dose for treatment of
fungal infections in children is 6
mg/kg/day for 3 weeks depending
on the clinical response, and this
dose has been proposed for the treatment of tinea capitis (Roberts &
Friedlander, 20 05). At 6 mg/kg/day
for 2 to 3 weeks of treatment, studies
have shown mycological cure rates of
between 84% to 89% (Gupta et al.,
20 01; Solomon, Collins, & Sharma,
1997).
Gastrointestinal symptoms and
headaches are the most common side
effects. The medication is cleared primarily by renal excretion. BUN and
creatinine levels should be obtained
prior to treatment with fluconazole.
Liver tests (ALT, AST, alkaline phosphatase, bilirubin) should also be
obtained prior to treatment (Deglin &
Vallerand, 20 09 ) .
Itraconazole (Sporanox). Itraconazole (Sporanox) is currently not
FDA-approved to treat tinea capitis,
but it is approved to treat onychomycosis and fungal infections of the
esophagus and mouth (Deglin &
Vallerand, 20 09). There are different
formulations of itraconazole capsules and liquids. The capsules
should be taken with food, and can
be opened and mixed with food. The
liquid form of the medication should
be taken on an empty stomach and
may cause some gastrointestinal disturbances, such as diarrhea. The liquid form of the medication is given at
a lower dose due to its greater
bioavailability.
For the Trichophytan species,
mycological cure has been shown to
be 86% with continuous dosing for 2
to 3 weeks (Gupta et al., 20 01), and
mycological cure rates range from

DERMATOLOGY NURSING/September-October 2009/Vol. 21/No. 5

67% to 81% after receiving 3 to 5

medication pulses (Gupta, Hofstader,
& Summerbell, 1998; Gupta,
Solomon, & Adam, 1998). Pu l s e
medication regimens usually consist
of administering the medication daily
for 1 week, with no medication being
administered during the following 2
to 3 weeks. After the 2 to 3 week
respite period, the medication is
restarted for 1 week.
The recommended dose for itraconazole in treating tinea capitis
depends on the chosen medication
administration regimen. For a continuous medication regimen with capsules, the recommended dose is 5
mg/kg/day for 4 weeks (Roberts &
Friedlander, 20 05). If using pulse
therapy, the dosing should be 5
mg/kg/day for 1 week each month
for 2 to 4 months. The recommended dose for oral solution is 3
m/kg/day for 4 weeks (Roberts &
Friedlander, 20 05 ) .
The most common side effects
are gastrointestinal symptoms, headaches, and rash. As with fluconazole,
e l evated transaminase levels may
occur. Pre-therapy laboratory studies
of hepatic function tests and a potassium level should be obtained
(Deglin & Vallerand, 20 09). Co n s u ltation with a specialist prior to prescribing itraconazole for tinea capitis
is recommended.

Adjunct Therapies
Transmission of tinea capitis
between individuals may be reduced
when anti-fungal shampoos are used
in conjunction with oral therapy.
Selenium sulfide shampoos have
been shown to have success in eliminating the shedding of viable tinea
capitis spores (Wynne et al., 20 07).
In a prospective, randomized, nonblinded clinical trial of 54 pediatric
patients with culture-proven tinea
capitis, Givens, Murray, and Baker
(1995) found that when used twice
weekly, both the 1% and 2.5%
preparations of selenium sulfide
shampoos were superior to a nonmedicated control shampoo in terms
of the time required to eliminate the
shedding of viable spores. When the
1% and 2.5% preparations of selenium sulfide were compared to each

other, there was no difference

between the two in the time required
to produce a negative culture. This
finding led the researchers to conclude that the 1% selenium sulfide
shampoo, which is commercially
available, is an equally effective but
less expensive alternative sporicidal
adjunct to the oral treatment of tinea
capitis.
Similarly, Greer (2000) found
that 2% ketoconazole shampoo
reduced the number of viable spores
in a sample of 16 children with culture-proven tinea capitis infections
caused by Trichophytan tonsurans. The
children were treated daily for 8
weeks without any oral medication.
Greer noted that marked clinical
improvement occurred in all children within the first 2 weeks of therapy; after 8 weeks of therapy, 93% of
the children were clinically healed.
Complete culture cure was obtained
in 33% of cases using 2% ketoconazole shampoo as a treatment for
tinea capitis, and these ch i l d r e n
remained culture negative for at least
1 year after treatment.
No studies were located researching alternative therapies for tinea
capitis. However, one article discussed alternative treatments for fungal skin infections, such as tinea corporis and tinea cruris, using a 1:1:1
mixture of honey, olive oil, and
beeswax. Al-Waili (20 04) found that
71% of individuals with tinea cruris
and 61% of those with tinea corporis
obtained a mycological cure after 4
weeks of treatment.

Other Considerations
Families with children with infections should be cautioned against
sharing personal items, such as
combs, brushes, and hats. Fungal
spores may attach themselves to
these items and be transmitted from
person to person if these items are
shared. Children with tinea capitis
may return to school once treatment
with an anti-fungal shampoo or an
anti-fungal agent has been started.

Conclusion
This evidence-based review
sought to provide nurses with current information on the diagnosis

DERMATOLOGY NURSING/September-October 2009/Vol. 21/No. 5

and treatment of tinea capitis. While

griseofulvin and terbinafine remain
the only FDA-approved medications
for the treatment of tinea capitis in
children, the evidence presented
indicates that other anti-fungal
agents, such as itraconozole and fluconazole, are effective in the treatment of tinea capitis infections.
Itraconozole and fluconazole are
not, however, currently approved
for use in treating tinea capitis by the
FDA, and therefore, should not be
used as first-line therapy but considered for use with consultation with a
dermatologist for infections resistant
to standard approved therapy.
It is important for nurses and
other health care providers to
remember that caution should be
used when prescribing or administering off-label medications to children
because the pharmacokinetics of
medications may be different in children than in adults (Novak & JacksonAllen, 20 07). A specialist should be
consulted for guidance on treatment
with non-approved medications, and
parents should be informed when a
medication is being used in an offlabel manner (Moonestime-Williams
et al., 20 07).
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