The evolving role of itraconazole, fluconazole and terbinafine in the treatment of tinea capitis.

Tinea capitis has become an increasing public health concern in the last decade. The increased incidence of the disease; its sometimes subtle, nonspecific clinical presentation; and the development of tolerance to griseofulvin therapy have led to the need for alternative safe, efficacious, inexpensive therapies that work rapidly. Itraconazole, fluconazole and terbinafine all possess pharmacologic and pharmacokinetic characteristics that theoretically would make them ideal therapies for tinea capitis. However, few randomized double blind controlled studies using these agents have been published. Thus far none have been conducted in the United States. The best available data support the utility and safety of the new antifungals in the treatment of tinea capitis. However, one must keep in mind that they are not yet approved by the Food and Drug Administration for this indication. Safety and cost considerations favor terbinafine for the treatment of T. tonsurans infections. M. canis infections may respond better to itraconazole, but good controlled studies to confirm this speculation have not been conducted. Short course and pulse dosing are particularly exciting options that may decrease cost and lower the risk of adverse side effects. Further useful information will hopefully come from future randomized double blind studies that will include patients from the United States. Studies using standardized definitions of disease, cure and appropriate follow-up evaluation of clinical and mycologic cure will best identify the optimal therapy for pediatric tinea capitis infections. The new systemic antifungals may provide more therapeutic options for fungal infections of the scalp. Note added in proof A recent trial comparing short course terbinafine and intraconazole therapy demonstrated that 2-week therapy with either drug provided good results and high cure rates (Jahangir M, et al. Br J Dermatol 1998;139:672-4).