When to Initiate Referral

• Recalcitrant and/or severe cases, such as those with kerion or severe alopecia

First Step

• A fungal swab culture should be taken prior to starting treatment. This may be obtained by moistening a fungal culture swab with the media bottom of the culture tube followed by vigorously rubbing of the affected area (results can take up to 4 weeks).

Treatments

• Griseofulvin 20-25 mg/kg/day po dosed once or twice daily for 6 to 8 weeks

OR

• Terbinafine (comes in a 250 mg tablet and is given po q day) for 6 to8 weeks as follows: <20 kg = 5 mg/day, 20-40 kg = 125 mg/day, or >40 kg = 250 mg/day

AND

• Ketoconazole 2% shampoo or otc selenium sulfide shampoo 2 to 3 times weekly

Points to Remember

• Testing of liver function with griseofulvin or terbinafine is unnecessary in otherwise healthy children and is usually done if treating for 8 weeks or longer.
• It may be appropriate to initiate treatment while waiting for initial culture results in highly suspicious cases.
• If signs of bacterial infection (pustules, oozing, etc.) please obtain a bacterial swab culture and treat appropriately.