Tinea capitis asymptomatic carriers: what is the evidence behind treatment?

Abstract

Tinea capitis is a fungal infection mostly affecting children. Epidemiology is changing over time due to migration, and it has been estimated that up to 40% of children from certain developing countries are affected. The mechanism of transmission is still unclear although asymptomatic carriage seems to have an influence in establishing persistent reservoirs that can cause or fuel epidemics. Screening and prophylactic treatment of close contacts of tinea capitis patients are therefore recommended by several international guidelines, but vaguely and not consistent. The treatments involved can be expensive, hard to integrate in everyday life, have well-known side effects and some are not approved for the treatment of children. The aim of this review was to clarify the evidence behind treatment of human asymptomatic carriers of tinea capitis. Databases were searched for the 'tinea capitis', 'carriers' and 'treatment'. Inclusion criteria were clinical trials, observational and interventional studies including case series (10+ cases) and case reports in English, Danish, Swedish, Norwegian and French. Reviews, guidelines, unclear reports and in vitro trials were excluded. A systematic review identified 10 studies with low to moderate evidence levels. The topical treatments ketoconazole, povidone-iodine, miconazole and the systemic antifungals terbinafine and itraconazole have all shown significant effects in the mycological eradication of fungal conidia. General prophylactic hygienic measures may have a benefit. The scientific evidence behind the treatment of asymptomatic carriage of scalp dermatophytes is sparse and not of high quality. Yet, both topical and systemic antifungal agents show treatment efficacy. Considering the possible adverse effects, topical agents are preferable, but with necessary attention to the compliance of asymptomatic contacts with treatment.

Tinea capitis: An update

“…From a safety perspective, topical treatment is more prudent and effective at reducing fungal detection, allowing patients to safely return to activities between follow-ups until negative cultures are achieved. 4,18,20 In a recent review, Aharaz et al 28 evaluated the evidence for treatment of asymptomatic carriers as conventional treatments for tinea capitis are costly and have well-known side effects. Unfortunately, only a small number of studies (n = 10) met the criteria of Aharaz et al, and the diversity of these studies made meta-analysis impossible.…”

“…Unfortunately, only a small number of studies ( n = 10) met the criteria of Aharaz et al, and the diversity of these studies made meta‐analysis impossible. The authors acknowledged the discrepancy between the individual patient and written guidelines as many asymptomatic carriers were mycologically cured without intervention; however, the use of topical shampoos containing povidone‐iodine or ketoconazole offered a higher rate of mycological cure (94% and 100%, respectively), which better serves the general population 28 . Given the paucity of data, the authors recommend topical antifungal shampoos as a treatment that possesses an acceptable risk–benefit ratio.…”

Pediatric Tinea Capitis: A Retrospective Cohort Study from 2010 to 2021

“…For example, children attending a public school are at a higher risk for tinea capitis as compared to children attending a private school [ 5 ]. The constant spread of the disease in highly populated areas is also affected by the rates of asymptomatic carriers which constitute a persistent reservoir [ 6 ].…”

Tinea capitis caused by Trichophyton tonsurans among adults: Clinical characteristics and treatment response

“…12 Moreover, asymptomatic carrier state can also occur. 10,13 The gold standard for treatment is oral antifungal medication. 12,14 Early and appropriate antifungal therapy can help avoid disfiguring scarring alopecia and reduce infection spread.…”

“…Despite the fact that T. tonsurans is an antropophilic dermatophyte, it may cause a wide range of clinical scalp manifestations, including both inflammatory and non‐inflammatory tinea capitis 12 . Moreover, asymptomatic carrier state can also occur 10,13 . The gold standard for treatment is oral antifungal medication 12,14 .…”