Ringworm on Scalp (Tinea Capitis)

Scalp Ringworm (Tinea Capitis) is most common in children between the ages of 3 and 7, and is less often found in adults.

What Is Ringworm on the Scalp?

Scalp ringworm (tinea capitis) is a very common scalp infection among children throughout the world. It is one of the most common skin problems seen in children. It is not caused by a worm, but by a fungus and is named for the ring-like or circular appearance of the infection on the skin.

Where Do Ringworm Infections Appear?

Fungal organisms known as dermatophytes superficially infect certain types of tissue found in hair, skin, and nails. The different types of fungal infections are named based on location and may differ in how they are treated. Certain dermatophytes forms the crusty, scaly patches commonly associated with scalp ringworm.

Does Ringwom Spread to Others?

Some people (mostly adults) can be carriers of the organism and spread it to others in the household without having symptoms.

Who Gets Ringworm of the Scalp?

Children 4-14 years of age are most likely to develop ringworm of the scalp, although it can occasionally appear in adults and may occur in younger children.

Scalp ringworm occurs most frequently in urban areas among people with poor hygiene, those living in overcrowded quarters, or those living in warm, damp climates. This disease tends to be more severe in people with weakened immune systems, such as those with diabetes, AIDS, or cancer.

Ringworm found on the body (tinea corporis) differs from scalp ringworm and is caused by a separate organism.

How Can You Get Rid of Ringworm on the Scalp Fast?

Home remedies sometimes can heal scalp ringworm without treatment; but consulting with a doctor is recommended.

Can Your Hair Grow Back after Curing Ringworm?

It make take weeks to months for the hair to grow back after ringworm is cured.

The appearance of scalp ringworm can vary among affected individuals, but the most common signs are reddening, crusting, and scaling of the scalp. Intense itching usually occurs as well. Scalp ringworm can cause up to 50% of hair loss among children. Lymph nodes in the neck region may become enlarged with all types of scalp ringworm organisms, and some children may have high fevers. The specific pattern depends on the infecting organisms and how the immune system responds to the infection.

• Black dot ringworm: The organism Trichophyton (T. tonsurans), which has become the most common fungus (causing most tinea capitis in the United States), causes black dot ringworm. This organism causes infections within the hair shaft. The hair becomes extremely brittle and breaks off at the surface of the scalp. The remaining portion of the hair is left behind in the follicle, creating the "black dot" appearance. Patches of hair loss commonly result.
• Gray patch ringworm: The organism Microsporum, which was the most common fungus in the United States in the 1940s and 1950s but now is a rare cause of ringworm of the scalp, causes gray patch ringworm. Today, it is much less common in North and Central America but continues to be the dominant cause of scalp ringworm in Southern and Eastern Europe. In this pattern, the lesions start as small, red bumps around the hair shaft. The lesions then grow outward, forming red, scaly, and circular "rings" that are dry but not inflamed. All hairs in the infected area appear gray and dull, and they frequently break off. Numerous areas of hair loss result. Intense itching is common.
• Inflammatory ringworm: Fungi from animals or soil commonly cause this inflammatory form of ringworm, which can look like areas containing small pustules or abscesses or kerion formations. Kerions are elevated boggy masses oozing pus and studded with broken hairs. Fever, pain, itchiness, and tender, enlarged lymph nodes are common. Inflammatory ringworm can result in permanent scarring and hair loss. Oral or topical steroids may sometimes be prescribed for treatment, depending upon the severity, although this has not been shown to reduce permanent hair loss.
• NOTE: Once effective antifungal therapy has started, the child may develop a widespread "id" reaction. This involves itchy, raised blister-like bumps that begin on the face and then spread to the trunk. The body's immune response causes this reaction to the dermatophyte and is probably not an allergic reaction to the medication. Usually, the medication treatment does not need to be changed or discontinued. However, a person who notices these changes should talk with the doctor to make sure cause of the reaction is not potentially dangerous.

Ringworm of the scalp usually appears within seven to 14 days of contact with an infected object or person. Not all people exposed to ringworm by contact will develop ringworm themselves.

Dermatophytes can be found in humans, other animals (most common household pets such as cats, dogs, and farm animals such as cattle), and soil.

• Fungal spores can be transmitted through contact with an infected person, fallen infected hairs, or contaminated objects. These may include objects such as combs and brushes, hats, movie theater seats, bedding, and clothing.
• Contact alone with one of these carriers may not be enough to cause an infection.
• However, coupled with minor trauma to the scalp, such as scratches or tight braiding, spores can enter the skin or hair shaft through the stratum corneum (a layer of the skin). Here, dermatophytes invade and digest the tissue's keratin (a type of protein) as the organisms grow.

A doctor should examine any child with scalp itch, scaling, or areas of hair loss for evidence of scalp ringworm as many other skin conditions such as psoriasis and dandruff (seborrheic dermatitis) can look like scalp ringworm and are treated differently.

Treatment occurs over a course of weeks to months, so generally, scalp ringworm infections are not emergencies, but should be examined by a doctor to start appropriate treatment.

Yes, ringworm of the scalp is contagious. Fungal spores can be transmitted through contact with an infected person or animal, fallen infected hairs, or contaminated objects. Ringworm stays contagious until about 48 hours after appropriate treatment has started.

• Any primary care doctor (family physician, general internist, or pediatrician) will be able to diagnose and treat ringworm of the scalp.
• Rarely, a skin specialist (dermatologist) would need to be involved in the diagnosis or treatment.

• In many cases, the doctor can diagnose scalp ringworm by examining the patient and asking questions.
• When the scalp is examined with a Wood lamp that transmits ultraviolet light, the base of the hair shaft will light up a blue-green fluorescent band if Microsporum species is present. This is due to deposits of metabolic byproducts that this species leaves. Because this species is no longer common in the United States, this technique is less useful and not routinely performed.
• More commonly, the doctor can diagnose scalp ringworm with a visual inspection and by observing the symptoms present. However, scrapings examined in the laboratory are sometimes needed to confirm the diagnosis and may be helpful if repeated to make sure the ringworm is treated.
• The following are methods of collecting tissue samples for microscopy:
  • Scraping the scalp with a surgical blade and removing the hair with a needle and forceps
  • Running a toothbrush over the scalp about 10 times to collect the scales and hair (this is the best method)
  • Cotton swabs
  • Moistened gauze
• Once tissues have been collected, a 10%-15% solution of KOH (potassium hydroxide) is added and the slide is studied under a microscope to look for fungal spores. This method is fast, but it is effective in demonstrating fungal spores only 50% of the time.
• The best method of diagnosis is culture. The collected specimen is placed in a medium that provides fungal food to see if growth takes place. This method naturally takes more time, and an answer takes seven to 10 days.

Sometimes, scalp ringworm can heal without treatment, but consulting a doctor is advised. To ensure timely management of the infection, it must be treated with a course of oral antifungal medications. Shaving the scalp is unnecessary.

• Shampoo with selenium sulfide (1%-2.5%), zinc pyrithione (1%-2%), or ketoconazole used two to three times weekly at home can help decrease shedding of spores, decrease spread of the infection to other people, and should be used together with the oral medications. Shampoos include Head & Shoulders Intensive Treatment, Selsun, Selsun Blue, Selsun Gold for Women, and Nizoral. Stronger medicated shampoos are sometimes prescribed by doctors, but in general, over-the-counter shampoos can be used.
• Because family members may be carriers, some doctors recommend that family members should also use the medicated shampoo to reduce the number of spores and prevent the infection from returning.

Hairbrushes and combs should be replaced or cleansed with disinfectant such as bleach solution. Bleach solution can be made by combining one part bleach to one part water, then soak the hairbrushes or combs for one hour daily for the first three days after using the shampoo and oral medication.

Home remedies such as vinegar (acetic acid) and tea tree oil have not been shown to improve scalp ringworm and may further irritate the skin and worsen the condition. They will also not prevent the spread of the disease.

Scalp ringworm must be treated with oral antifungal medications to penetrate the hair follicle and eliminate the scalp ringworm. Children may return to school once they have started oral therapy.

• Griseofulvin (Fulvicin, Grisactin) has been the drug of choice since 1958 because of its safety. This medication also comes in a liquid formula which makes it easier to administer to children. The usual dose involves taking the medicine every day with a fatty meal to enhance absorption for six to eight weeks. Therapy should continue until the ringworm is gone and you are told to stop by your physician. Occasionally a scalp culture may be performed to confirm that no fungi are present. Side effects caused by griseofulvin, such as headaches and GI disturbances, are rare. Routine liver and other blood test monitoring is not necessary for healthy children with scalp ringworm.
• The following are available to those who are allergic to or not responsive to griseofulvin:
  • Itraconazole (Sporanox)
  • Fluconazole (Diflucan)
  • Terbinafine (Lamisil)
• For inflammatory scalp ringworm: Prednisone during the first 10-15 days of treatment can be added for symptom relief, but no data have shown an increase in cure rate.
• Many physicians recommend adding an antifungal shampoo during the early period of the treatment.

• For the infection to be completely cured, the hair needs to grow out. With average hair growth, this process could take weeks to months.
• Continuing to take all the medications prescribed for the entire course of treatment is important.
• The medicated shampoo can help but should not replace the oral medications.
• Routine follow-up with the doctor is advised to measure the effect of the treatment and to monitor the potential side effects.

• Daily oral griseofulvin in combination with medicated shampoo has been the most common treatment of scalp ringworm over the last several decades.
• Generally, this combination is successful, but new antifungal drugs are being studied due to increasing resistance to griseofulvin and the desire for faster treatment.
• If ringworm treatment is started early and if the medications are taken as prescribed, scalp ringworm can be successfully cured, and the hair in bald spots will likely grow back.

A person can prevent scalp ringworm by keeping skin clean and dry, not sharing hats, combs, brushes, and avoiding contact with infected people or objects.