Journal of the European Academy of Dermatology and Venereology (JEADV): Published on November, 2021

Tinea capitis is a highly contagious scalp condition that is common in children 3-7 years of age but can be found in all ages. It can present with a spectrum ranging from scaly, patchy alopecia with or without "blackdots" to purulent inflammation or keroin, to a mild infection with no obvious findings or "carrier state."

The asymptomatic carrier poses a specific threat to controlling tinea capitis burden in a population, as these patients act as persistent reservoirs precipitating further spread and re-infection of their surrounding environment.

When evaluating the asymptomatic carrier, it is imperative to consider the close contacts, such as family members and pets in the household, who may also pose as potential vectors. If the scalp culture points to anthropophilic fungus, treatment of household members with topical antifungals as described above should be recommended.

Additionally, if zoophilic fungus is cultured, it is important to investigate and recommend treatment for the suspected animal vector as well.

Furthermore, spread through fomites on household or personal objects, such as that of contaminated bed sheets, hairbrushes, toys, or clothing should be addressed and counseling on decontamination measures provided. This is of utmost importance to prevent perpetuation in a household and communal environments.

TAKE-HOME MESSAGE

The authors included 10 studies with low to moderate evidence in this systematic review concerning asymptomatic carriers (ACs) of tinea capitis.

Treatment of tinea capitis generally requires oral antifungals for 4 to 6 weeks. As outlined by this article, topical medications may be an effective treatment of asymptomatic carriers. Such topicals include ketoconazole, povidine-iodine, miconazole, selenium sulfide, and econazole that are available as shampoos and various other preparations. Systemic antifungals may also be required.

Three studies investigating the success of ketoconazole shampoo twice weekly reported 100% mycologic cure rates.

A South African study of topical treatments showed the highest cure rates with povidone-iodine 4% shampoo (94%) and cure rates equal to control with econazole nitrate 1% foam and selenium sulphide 2.5% shampoo (~50%).

A US study evaluating the efficacy of oral griseofulvin for Trichophyton tonsurans eradication showed that only 10 of 44 patients (23%) converted to culture negative.

A study of 96 ACs in the Japanese wrestling community showed cure rates >80% with each of the following treatments: itraconazole 400 mg daily for 1 week, terbinafine 125 mg daily for 6 weeks, terbinafine 500 mg pulsed for 1 week, and miconazole 0.75% shampoo daily.

Importantly, culture results should direct the dermatologist’s selection of systemic agents. For example, griseofulvin is less effective in treating Trichophyton species and thus terbinafine is preferred. Alternatively, in treating Microsporum species, griseofulvin is the treatment of choice but fluconazole can also be affective.

The evidence for the treatment of asymptomatic carriers of scalp dermatophytes is scarce, but both topical and systemic antifungals show efficacy.