Tinea capitis (scalp ringworm)

Key takeaways

• Tinea capitis is a fungal infection of scalp skin and hair shafts. It mostly affects children but also adults; 3 to 11% of cases worldwide are adults, mainly postmenopausal women, and Black women are particularly at risk (Hill 2024).
• It looks like many other things: flaky "dandruff", black dots where hairs break, scaly bald patches, or a boggy swelling called a kerion. In 91 older adults reviewed in 2025, 37.4% were misdiagnosed, commonly as seborrhoeic dermatitis, and topical steroid use (40.7%) was frequent (Valdez-Martinez 2025).
• Shampoo or cream alone does not cure it. Oral antifungals are the standard, and topical products are only an add-on (Hill 2024; Mayser 2026).
• Confirm the organism first. Terbinafine works well against Trichophyton but is clearly weaker against Microsporum; griseofulvin (20 to 25 mg/kg/day in the trials reviewed) works for both. Treating without confirmation risks lower cure rates (Tyson 2026).
• Drug choices are shifting. Griseofulvin has become unavailable in some markets, pushing use of terbinafine, itraconazole and fluconazole (Bonifaz 2024). The 2026 German guideline recommends terbinafine first-line for adults, and for children terbinafine (off-label) for Trichophyton and itraconazole (off-label) or griseofulvin for Microsporum (Mayser 2026).
• Delay can scar. Prompt, adequate treatment gives an excellent outlook in adults, but late or inadequate treatment may cause scarring alopecia (Hill 2024).
• It spreads between household contacts and through asymptomatic carriers, so the guideline covers carrier treatment, hygiene and outbreaks (Mayser 2026).

What it is and how it is diagnosed

Europe has seen a shift toward human-to-human species, particularly Trichophyton tonsurans and T. violaceum. In older adults the leading species were M. canis, T. rubrum and T. tonsurans, with pet exposure, diabetes and topical steroids common backgrounds (Valdez-Martinez 2025). Fungal culture and microscopy are the commonly used tests, with scalp microscopy as an aid (Gupta 2022).

Treatment

All systemic antifungals are prescription-only, and some uses are off-label in children. Terbinafine and griseofulvin are the best-supported options, itraconazole and fluconazole are effective alternatives with liver risk flagged, antifungal shampoo is an adjunct that may reduce spore shedding, and home remedies or oils have no data. Liver monitoring practice varies (Gupta 2022).

Hair type notes

• In textured, braided or tightly coiled hair, scale and redness are hard to see, wash days are often spaced out, and scalp oils or tight styles can hide patches, so diagnosis is often delayed. Black children and adult Black women are over-represented in reviews (Hill 2024).
• In straight or fine hair, patches are visible earlier but easily mistaken for dandruff.
• Do not share combs, brushes, hats, headwraps, bonnets or clippers when anyone has scalp flaking with hair loss.
• A flaky scalp that does not respond to dandruff shampoo in 2 to 4 weeks is a reason to stop self-treating and get a swab or hair sample.

Bottom line

Scalp scale with patchy loss, black dots, a swollen tender area or enlarged neck nodes needs a clinician within days, with a fungal culture or PCR. In children it is urgent, particularly with a boggy swelling. Steroid cream can mask and worsen it. Household contacts may need treatment, and combs and towels should be washed hot. Hair usually regrows after cure unless scarring occurred. See when to see a dermatologist. Discuss with a doctor.