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Baby Cradle Cap and Tinea Capitis (Scalp Ringworm)

Tinea capitis and tinea capitis treatment, and how it is different to baby cradle cap.


Making the Diagnosis of Tinea Capritis: Testing for Tinea Capritis

One of the disorders that parents sometimes confuse with cradle cap is tinea capitis. Both cradle cap and tinea capitis occur on children’s scalps, though cradle cap occurs in infants while tinea capitis is seen more often among primary or elementary school children. The skin lesions can look the same in both disorders, especially to the untrained eye. In fact, physicians have been known, on occasion, to confuse Baby Cradle Cap and Tinea Capitis.

Cradle cap treatment

Another point of confusion between cradle cap and tinea capitis is that cradle cap can sometimes be complicated with impetigo. Impetigo, a bacterial infection of the skin, can look very much like the scaly lesions seen in tinea capitis. Again, the major distinction between the two diseases is that hair does not fall out or break off in cradle cap or cradle cap with impetigo. Hair does break off with tinea capitis. Also, impetigo can be overtly painful, a symptom that is not common in tinea capitis or cradle cap.

To be sure about diagnosis, doctors have a few diagnostic tests for tinea capitis at their disposal. Often the skin lesion is scraped or rubbed onto a test device which can then be examined under a microscope by a pathologist. If tinea capitis is the culprit, one of the many types of fungi that cause tinea capitis will be present in high concentration in the scraping. Another diagnostic clue that can be quite helpful for the pathologist is to be able to examine one of the broken hairs. Generally the physician will use a magnifying glass and forceps (tweezers) to pull out one or a few of the hairs that have broken. These hairs are already abnormal, come out quite easily, and without pain.

The scraping can be sent to the laboratory to be cultured. This means that the sample is placed in an environment (like a Petri dish) which facilitates the growth of the fungus. The fungus, if it exists in the scraping, will multiply and grow in culture. This growth is important for definitive diagnosis and to determine the precise genus and species of the fungus.

There are a large number of different fungi that can cause tinea capitis. Knowing the precise type of fungi that is causing a particular case of tinea capitis is not critically important; however it could direct the choice of medicine if the particular type of fungus is known. Certain genus and species of fungus that cause tinea capitis are found more often in certain regions of the world. If a culture is not performed, the type of fungus can be assumed based on geographical region.

The dermatologist may examine the scalp lesion with a special light called a Wood lamp. A Wood lamp is essentially a special ultraviolet light. When the Wood lamp is used to illuminate the infected hairs in tinea capitis, they may fluoresce. Unfortunately, some species of fungus that cause tinea capitis do not fluoresce under a Wood lamp, which makes correct diagnosis more difficult.

Rarely a skin biopsy is necessary to diagnose tinea capitis and to direct the choice of treatment. In a skin biopsy, a small chunk of scalp is removed and sent to the pathologist for analysis. This process is reserved for very difficult diagnoses or when standard tinea capitis treatment has failed.


What is tinea capitis? What causes tinea capitis?

Tinea capitis is the name given to a particular fungal infection of the scalp. Capitis denotes an infection of the head or scalp. This type of infection is known as a dermatophytosis. Tinea can affect many sites of the body. Tinea barbae, for example, is a fungal infection of the beard while tinea corporis affects the body. Tinea cruris (groin) and tinea pedis (feet) are the most common and well known dermatophytoses known as “jock itch” and“athlete’s foot,” respectively. Tinea capitis is also known colloquially as ringworm of the scalp.

Tinea capitis is particularly prevalent in urban areas and is most prominent in children of African and Caribbean descent. Tinea capitis is fairly common across the African and Indian continents but relatively rare in North America. Tinea is the second most common skin infection after acne, though it should be stated that most cases of dermatophytoses are tinea pedis (athlete’s foot) and tinea cruris (jock itch).


Tinea capitis symptoms and progression

Tinea capitis can appear in several different ways. One of the most common presentations is a red mark with a raised ring at the border. This appearance is the main reason that tinea capitis is called ringworm of the scalp. In fact, the early notion of the disease was that an actual worm, curled in a ring, burrowed its way under the skin (hence ringworm). We now know that tinea capitis is caused by a number of related, but different fungi.

The skin lesions of tinea capitis usually begin with a small, red bump. Since tinea capitis often first appears in the hair line, the bump is barely noticeable at first. The red bump may first appear on the eyebrow or even the eyelash. Over the course of days, the red bump gets bigger, flattens, and changes from red to more of a white color. As the lesion turns white, it becomes scaly and crusty. These scales and crust are what make the disease look like cradle cap.

In tinea capitis, the hair in the affected area loses color and shine. It also becomes quite brittle and tends to break off close to the scalp. In fact, it is common for the hair that is covered by the tinea capitis lesion to fall out completely. The black dots that are sometimes associated with tinea capitis are actually individual hairs that have become infected and have broken off from the hair shaft. This hair loss is the main feature that distinguishes tinea capitis from cradle cap—hair does not usually fall out during a case of cradle cap. Physicians (and parents) can use this symptom to distinguish between the two conditions.

Often, tinea capitis will spread to more than one location of the scalp; the head will have multiple, ringed lesions, each with scales and crust. If left untreated, the individual “islands” will grow together and form large skin lesions.

In general, tinea capitis is only mildly itchy but some people have reported intense itchiness. It is this itchiness that can be particularly troubling to children. In fact, some of the therapy for tinea capitis is directed at relieving this intense itchiness.

All tinea capitis lesions cause a certain amount of inflammation in the surrounding skin. Since it is a fungal infection, the body reacts to it by sending representatives (white blood cells) from the immune system to attack it. In some cases, however, the immune system response can be quite intense. In this case, the inflammation can be severe. The pale tinea capitis lesion will again become red and swollen. The puffy lesion will feel spongy to the touch.

When tinea capitis becomes severely inflamed, pus-filled bumps may form. Pus, which is essentially a massive collection of white blood cells (immune system cells), collects in response to the skin infection. These pus-filled bumps or pustules are called kerions. Kerions, unfortunately, can lead to scarring of the scalp and permanent hair loss. Therefore, prompt treatment of tinea capitis in necessary to prevent this complication.

Another severe form or complication of tinea capitis is called favus. Favus, also known as tinea favosa, is a chronic fungal infection of the scalp. It occurs most commonly in Africa and the Mediterranean region and is relatively rare in other parts of the world. In addition to the pale, scaly lesions that normally occur in tinea capitis, favus is characterized by yellow lesions that may be raised and bumpy. The favus lesions can appear waxy and “stuck on.” In favus, the affected hairs turn yellow.

Since tinea capitis is caused by a fungus, it is a rather pesky microorganism. Fungi are traditionally harder to destroy than bacteria and viruses. Also, people can pass fungi to one another - tinea capitis is contagious. It is this person to person transmission that is the primary means by which tinea capitis is spread. Good personal hygiene and cleanliness can reduce the severity and spread of tinea capitis (unlike cradle cap, which is not related to cleanliness nor is cradle cap contagious). Unfortunately, the fungi that cause tinea capitis can live on hair brushes, bed sheets and pillow cases, even furniture. Therefore it is difficult to get rid of tinea capitis once it has taken root.

Cradle cap treatment


Tinea capitis treatment

In contrast to cradle cap, tinea capitis is not treated topically. Tinea capitis, once it has taken hold, must be treated with an oral (systemic) medication. Studies have shown that putting antifungals directly on the scalp does not control the disease. There are a number of oral antifungal medications that can be used to treat tinea capitis. Griseofulvin was the first treatment for tinea capitis, historically, and is still effective in tinea capitis; however, newer medicines have been developed and are used more often today. Some of the more common antifungals used to treat tinea capitis are ketoconazole (Nizoral), fluconazole (Diflucan), itraconazole (Sporanox), and terbinafine (Lamisil) though the last two medications listed are most often used.

Oral treatment with antifungals may last four to six weeks depending on the drug and the type of fungus that is causing the infection. Since the treatment of tinea capitis takes a relatively long time and the disease usually occurs in children, it is important to choose a drug that is safe and well tolerated in young patients. The newer antifungals used to treat tinea capitis have a reasonably good safety profile.

Antihistamines can be given to reduce itchiness if children are scratching the lesions. Antihistamines, like Benadryl, can cause drowsiness and should be used prudently in kids during the day. If a topical antihistamine can be used, it will not caused drowsiness.

While topical treatment is not enough to fully treat tinea capitis, it can be combined with oral therapy to speed healing. There are a few therapeutic shampoos that are particularly good. Perhaps the best therapeutic shampoo for tinea capitis is one that contains povidine-iodine. Povidine-iodine shampoos are better than baby shampoo or even antifungal shampoo in treating tinea capitis.

Treatment of tinea capitis extends beyond the patient and, if the offending fungus is not mostly eliminated for the environment, re-infection of the same patient can occur and the disease can spread to other people. In regions where tinea capitis is quite prevalent, classrooms are screened for cases of tinea capitis, even among children that are not showing any symptoms. Once tinea capitis has been diagnosed in one person, close personal contacts, friends, and family should be screened for presence of the fungus. If present, these contacts should be treated as well.

Since toys and personal items can carry the offending fungi, these items should be sterilized as well as possible. Some materials cannot be satisfactorily cleaned and sterilized once they have been colonized or infected with the fungus. If the tinea capitis is not effectively treated with four to six weeks of treatment, and repeated infections occur or the disease is being spread to other people, items that are likely to contain the fungus should be discarded and/or destroyed.

While tinea capitis is contagious, the treatment takes more than a month in most cases. Therefore it is not practical to keep children home from school during this period of time. The American Academy of Pediatrics currently recommends that children be allowed to attend school during treatment as to not disrupt learning. A reasonable amount of precaution should be taken though, to prevent infection. Certain interventions, like wearing a hat or shaving the scalp do not prevent spread of the fungus.

Sadly and especially when tinea capitis is itchy, the process can be psychologically difficult for children. Children afflicted with the disease have large, obvious lesions on their scalp. Other children tend to ostracize kids that have tinea capitis for the duration of the infection, at least. Also, since contact precautions are sometimes put in place, this inhibits the amount of social interaction that children with tinea capitis can have. This psychological trauma can be prolonged and intensified if the tinea capitis becomes complicated and leads to scarring and permanent hair loss.

While the current recommendation is to allow students with tinea capitis to attend school, if parents have the resources, it may be reasonable to keep kids at home for home schooling while treatment for tinea capitis is ongoing. This option should be discussed with the child’s pediatrician.

Cradle cap treatment


ABOUT THE AUTHOR: Michael T. Spako is an M.D. who chose to pursue a medical writing career instead of a doctors practice. I am pleased to have him as the principal writer for this cradle cap treatment site, and look forward to his further contributions. Donald Urquhart, Psychologist, Editor.

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