When scalp mycology or fungal culture confirms a Trichophyton species and no Microsporum species are detected, the treatment protocol is driven by that specific identification. Organism identity directly shapes which antifungal approach is appropriate.
Scalp mycology or culture has returned positive for a Trichophyton species. Microsporum species have not been identified.
This distinction is clinically meaningful: as a general rule, terbinafine is more efficacious against Trichophyton species, whereas griseofulvin is more effective against Microsporum species. Confirmed Trichophyton on culture therefore informs the agent of choice.
An oral antifungal with established activity against Trichophyton species is used as first-line therapy. Dosing is weight-based.
The targets are clinical improvement of scalp lesions and mycological clearance. Critically, the endpoint is mycological rather than clinical cure — repeat mycology sampling is recommended to confirm clearance before stopping treatment.
Both griseofulvin and terbinafine have good evidence of efficacy and remain the most widely used first-line treatments.
As a general rule, terbinafine is more efficacious against Trichophyton species (T. tonsurans, T. violaceum, T. soudanense), and griseofulvin more effective against Microsporum species (M. canis, M. audouinii).
The end point of treatment is mycological rather than clinical cure; therefore repeat mycology sampling is recommended until mycological clearance is achieved.
In cases of clinical improvement but ongoing positive mycology, continue current therapy for a further 2–4 weeks.
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