Tinea Capitis: Symptoms, Types, Causes and Treatment

Tinea capitis, commonly known as scalp ringworm, is a contagious fungal infection that primarily targets the scalp and hair shafts. Though often associated with children, it can affect individuals of all ages. If left untreated, it can lead to discomfort, social stigma, and even permanent hair loss. In this comprehensive article, we’ll explore the symptoms, types, causes, and treatment options for tinea capitis, helping you understand how to recognize, prevent, and manage this persistent scalp condition.

Symptoms of Tinea Capitis

Tinea capitis can present in multiple ways, sometimes making it hard to distinguish from other scalp conditions. Understanding the key symptoms is crucial for early recognition and prompt treatment, especially to prevent spread in schools and households. Whether it’s subtle flaking or more dramatic hair loss, knowing what to look for can make all the difference.

Symptom	Description	Age Group Most Affected	Sources
Hair Loss	Patchy or diffuse loss, may show "black dots"	Children (3–12 years)	1, 4, 8, 7
Scalp Scaling	Fine, adherent white or grey scales	Children	4, 8
Itching	Mild to moderate pruritus	All ages	3, 4, 8
Inflammation	Redness, swelling, pustules (esp. in kerion)	Children	4, 6, 8
Broken Hairs	Short, brittle, broken close to scalp	Children	2, 8, 7

Table 1: Key Symptoms

Common Presentations

Tinea capitis most often affects children under 12, although adults can also be impacted, usually to a lesser extent 1 4 8. The earliest signs may be subtle, such as mild scalp scaling that resembles dandruff. As the infection progresses, patches of hair loss become noticeable. These may be:

• Grey Patch: Circular areas of partial hair loss with fine, greyish scaling.
• Black Dot: Well-demarcated areas studded with broken-off hairs at scalp level, giving a dotted appearance 8.

Itching is common, but not always severe. In some cases, the infection remains almost asymptomatic, making it easily transmissible within communities 6.

Inflammatory Symptoms

Some forms of tinea capitis present with more dramatic symptoms, such as:

• Kerion: A boggy, tender plaque covered by pustules or crusts, sometimes oozing pus. This severe reaction can lead to permanent scarring and hair loss if not promptly treated 4 6 8.
• Favus: Chronic, yellow, cup-shaped crusts (scutula) that can produce a distinctive odor 8.

Additional Signs

• Erythema (redness) and localized swelling
• Occasional lymph node enlargement (especially near the neck)
• Impetigo-like plaques or secondary bacterial infection 1

Recognizing these symptoms early enables timely diagnosis and treatment, minimizing the risk of complications and transmission.

Types of Tinea Capitis

Tinea capitis has several clinical types, each with distinct features and underlying causes. Understanding these types helps guide both diagnosis and management strategies, as some forms are more likely to lead to complications than others.

Type	Main Features	Severity	Sources
Non-inflammatory	Scaling, alopecia (grey patch, black dot)	Mild	2, 7, 8
Kerion	Painful, boggy plaque, pustules, possible scarring	Severe	4, 6, 8
Favus	Yellow crusts (scutula), odor, chronic hair loss	Variable	8
Mixed Forms	Combination of alopecic and inflammatory features	Variable	7, 4, 6

Table 2: Clinical Types of Tinea Capitis

Non-inflammatory Types

The most common presentations are non-inflammatory. These include:

• Grey Patch: Round, scaly patches of alopecia with broken hairs, giving a “tonsure” appearance (like a monk’s shaved patch) 2 7 8.
• Black Dot: Patches with black dots (broken hairs at scalp level), minimal inflammation, and subtle scale 8.

These forms are often caused by anthropophilic (human-adapted) dermatophytes and tend to be chronic but less likely to scar 2 4 8.

Inflammatory Types

• Kerion: This is a hypersensitivity reaction to the fungus, producing a swollen, tender, boggy lesion with pus and crusting. Kerion is more likely with zoophilic (animal-adapted) fungi and can result in permanent scarring if untreated 4 6 8.
• Favus: Characterized by yellow, cup-shaped crusts (scutula) and matted hair. Favus can lead to chronic infection and patchy baldness, and is more common in some geographic regions 8.

Mixed and Atypical Forms

A single pathogen can produce various clinical types. Sometimes, patients present with a mix of alopecia, scaling, and inflammation, making diagnosis tricky 7 4. Immunocompromised patients and adults may exhibit atypical forms or more extensive disease 4.

Causes of Tinea Capitis

Tinea capitis is caused by a group of fungi called dermatophytes, which thrive in keratin-rich environments like hair and scalp. Understanding the organisms involved, their modes of transmission, and risk factors is crucial for effective prevention and treatment.

Cause Type	Examples/Details	Transmission	Sources
Anthropophilic	Trichophyton tonsurans, T. violaceum, T. soudanense, T. rubrum	Human-to-human	2, 9, 11, 12
Zoophilic	Microsporum canis, T. mentagrophytes	Animal-to-human	2, 9, 6, 10
Geophilic	Microsporum gypseum	Soil-to-human	2, 10
Risk Factors	Young age, crowded living, poor hygiene, sharing combs, animal contact	Various	1, 10, 9, 5

Table 3: Main Causes and Transmission Modes

Dermatophyte Species

The main fungal genera responsible are:

• Trichophyton (e.g., T. tonsurans, T. violaceum, T. mentagrophytes, T. rubrum)
• Microsporum (e.g., M. canis, M. gypseum)
• Epidermophyton (less commonly implicated) 2 9 10

Anthropophilic Fungi

• Adapted to humans and spread mainly by direct contact or via contaminated objects (combs, hats, pillows).
• Usually cause milder, chronic forms with minimal inflammation 2 9 14.

Zoophilic Fungi

• Originate from animals (pets, livestock).
• More likely to cause severe, inflammatory reactions (kerion) 2 6 9 10.

Geophilic Fungi

• Found in soil; less common, but can infect humans through soil contact 2 10.

Transmission and Risk Factors

Tinea capitis is highly contagious and spreads via:

• Direct person-to-person contact
• Contaminated objects (combs, brushes, bedding, hats)
• Contact with infected animals
• Environmental exposure to contaminated soil 1 10 5 12

Risk factors include:

• Children aged 3–12 years, especially in crowded or low-income settings
• Sharing hair care items
• Playing with animals
• Poor hygiene (not bathing with soap) 1 10 9 5

Socioeconomic factors and global migration have led to changing patterns of causative species in different regions 9 11 12.

Treatment of Tinea Capitis

Effective management of tinea capitis requires systemic therapy, as topical antifungals do not penetrate deeply enough to eradicate the infection from hair follicles. Early and appropriate treatment not only cures the infection but also prevents complications and limits transmission.

Treatment	Indication/Use	Main Agents	Sources
Systemic	First-line, required for cure	Griseofulvin, terbinafine, itraconazole, fluconazole	8, 13, 15, 16
Topical	Adjunct to reduce transmission	Antifungal shampoos	8, 6, 14
Duration	Varies by agent and fungus	2–8 weeks	13, 15, 16
Monitoring	Needed for side effects (esp. liver tests)	All systemic agents	4

Table 4: Treatment Overview

Systemic Antifungal Therapy

• Griseofulvin: Longstanding gold standard, especially effective for Microsporum infections. Typical duration is 6–8 weeks. Preferred in many regions due to cost and availability 8 13 15 16.
• Terbinafine: Shorter treatment course (2–4 weeks); highly effective for Trichophyton (especially T. tonsurans) infections. May be less effective for Microsporum species 15.
• Itraconazole and Fluconazole: Alternative agents with similar efficacy for Trichophyton. Used when griseofulvin or terbinafine are unsuitable. Often more expensive; optimal regimens still under study 13 15 16.

Recent studies suggest that griseofulvin is superior for M. canis, while terbinafine is preferred for T. tonsurans. However, both are generally effective for mixed infections 15 16.

Topical Therapy

• Antifungal shampoos (e.g., ketoconazole, selenium sulfide) may help reduce fungal spore shedding and transmission, but are not curative alone 8 6.
• Topical agents are used alongside oral medications, particularly during outbreaks in schools or households 8 14.

Treatment Duration and Monitoring

• Treatment length varies by drug and pathogen, often 2–8 weeks 13 15.
• Regular laboratory monitoring (especially liver function tests) is recommended for prolonged systemic therapy 4.
• Adherence is crucial to prevent relapse and reduce the risk of resistant carriers.

Special Considerations

• Kerion: May require longer or combined therapy due to severity; sometimes adjunctive corticosteroids are used for severe inflammation 6.
• Asymptomatic Carriers: Screening and treating close contacts may be necessary during outbreaks 5 14.
• Children: All systemic agents have reasonable safety profiles but may not be available in all pediatric formulations 13.

Conclusion

Tinea capitis is a common and highly contagious scalp infection, especially among children. Prompt recognition, early diagnosis, and appropriate therapy are essential to limit its spread and prevent complications such as permanent hair loss. Here’s a summary of the main points:

• Symptoms: Include patchy hair loss, scalp scaling, broken hairs, itching, and—in severe cases—inflammation with pus or crusts.
• Types: Range from mild non-inflammatory forms (grey patch, black dot) to severe inflammatory types (kerion, favus).
• Causes: Predominantly dermatophyte fungi, transmitted via humans, animals, or soil; risk factors include young age, crowding, poor hygiene, and animal contact.
• Treatment: Requires systemic antifungals (griseofulvin, terbinafine, etc.); topical agents are adjuncts to limit spread, not cure. Treatment duration and choice depend on the causative fungus and clinical severity.

Understanding these aspects empowers patients, caregivers, and healthcare providers to effectively identify, manage, and prevent tinea capitis in their communities.