J Am Board Fam Pract: first published as 10.3122/jabfm.12.3.236 on 1 May 1999. Downloaded from STEPPED CARE: AN EVIDENCE-BASED APPROACH TO DRUG THERAPY Pharmacotherapy of Tinea Capitis Mary E. Temple, PharmD, Milap C. Nahata, PharmD, and Katalin I. Koranyi, MD Editors' Note: This month we continue the new feature­ dans do. We will avoid making conclusions that are not sup­ STEPped Care: An Evidence-BasedApproach to Drug Ther­ ported by POEMs. Nevertheless, POEMs should be incorpo­ apy. These articles are designed to provide concise answers to rated into clinical practice. The rest is up to the reader. Blend­ the drog therapy questions that family physicians encounter in ing POEMs with rational thought, clinical experience, and their daily practice. The format ofthe feature will folhw the importantly, patient preferences can be the essence ofthe art mnemonic STEP: safety (an analysis ofadverse effects that ofmedicine. patients and providers care about), tolerability (pooled drop­ We hope you will find these new articles useful and easy to out rates from large clinical trials), effectiveness (how well the read. Your comments and suggestions are wekome. You may drogs work and in what patient population[sj), and price contact the editors through the editorial office ofJABFP or on (costs ofdrog, but also cost-effectiveness oftherapy). 1 Hence, the Internet (http://clinic.isu.edu/drogsteps/intro.html). the name STEPped Care. We hope the articles provide you with useful information that Since the informatics pioneers at McMaster University can be applied in everyday practice, and we look forward to introduced evidence-based medicine,2 Slawson and col­ your feedback. leagues3,4 have brought it to mainstream family medicine ed­ ucation and practice. This feature is designed to further the Rex W. Force, PhannD, STEPped Care Feature Editor mission ofsearchingfor the troth in medical practice. Authors John P. Geyman, MD, Editor will provide information in a stroctured format that allows Journal ofthe American Board ofFamily Practice the readers to get to the meat ofa therapeutic issue in a way References that can help physicians (and patients) make informed deci­ 1. Shaughnessy AF, Slawson DC, Bennett)H. Separating the wheat from the chaff: identifying fallacies in pharmaceutical sions. The articles will discourage the use ofdisease-oriented promotion.) Gen Intern Mea 1994;9:563-8. evidence (DOE) to make treatment decisions. Examples of 2. Evidence-based medicine: a new approach to teaching the DOEr include blood pressure hwering, decreases in hemoglobin practice of medicine. Evidence-Based Medicine Working Group.)AMA 1992;268:2420-5. A Ie, and SO on. We will include studies that are POEMs-pa­ 3. Slawson DC, Shaughnessy AF, Bennett )H. Becoming a tient-oriented evidence that matters (myocardial infarctions, medical information master: feeling good about not know­ ing everything.) Fam Pract 1994;38:505-13. pain, strokes, mortality, etc)-with the goal ofoffering our 4. Shaughnessy AF, Slawson DC, Bennett)H. Becoming an in­ http://www.jabfm.org/ patients the most practical, appropriate, and scientifically sub­ formation master: a guidebook to the medical information stantiated therapies. Number needed to treat to observe benefit jungle.) Fam Pract 1994;39:489-99. 5. Laupacis A. Sackett DL, Roberts RS. An assessment of clini­ in a single patient will also be included as a way ofdefining cally: useful measures of the consequences of treatment. N advantages in terms that are relatively easy to understand. ),6 Engl) Med 1988;318:1728-33. 6. Wtffen P), Moore RA. Demonstrating effectiveness-the At times this effort will be frustrating. Even as vast as the concept of numbers-needed-to-treat. J Clin Pharm Ther biomedical literature is, it does not always support what clini- 1996;21:23-7. on 27 September 2021 by guest. Protected copyright. Tinea capitis, or ringworm of the scalp, is the capitis is transmitted by humans (anthropophilic) most common dermatophyte infection in pedi­ or is acquired from animals (zoophilic). Trichophy­ atric populations throughout the world. 1-4 In the ton tonsurans and Microsporum audouinii are associ­ United States, 3 to 8 percent of the population can ated with anthropophilic infections, and Microspo­ be affected. 5-7 Additionally, 34 percent of house­ rum canis is associated with zoophilic infections.9•IO hold contacts of children with tinea capitis are In the United States T tonsurans has replaced asymptomatic carriers of the infection.8 Tinea M audouinii as the most common pathogen, and it causes up to 96 percent of tinea capitis infec­ tions. II Generally, Trichophyton infections are Submitted, revised, 3 February 1999. equally distributed between boys and girls and From the College of Pharmacy (MET, MCN) the Depart­ ment of Pediatrics, College of Medicine (MCN, KIK), and affect far more African-Americans than whites. Children's Hospital (MET, MCN, KIK), The Ohio State The infection is rare in adults and adolescents University, Columbus. Address reprints requests to Milap C. Nahata, PharmD, College of Pharmacy, The Ohio State Uni­ (who have reached puberty), although they can versity, 500 West 12th Ave, Columbus, OH 43210. be carriers. The rarity of infection is most likely 236 JABFP May-June 1999 Vol. 12 No.3 J Am Board Fam Pract: first published as 10.3122/jabfm.12.3.236 on 1 May 1999. Downloaded from attributed to the fungistatic activity of short- and approach. The STEP approach involves: safety long-chain fatty acids found in the sebum of (analysis of adverse events most concerning to pa­ these individuals.3.5.7 tients and physicians), tolerability (pooled drop­ Although griseofulvin is the only agent ap­ out rates from large clinical trials), effectiveness proved for the treatment of tinea capitis by the (the efficacy of medications and what patient pop­ Food and Drug Administration, (FDA) a variety ulations benefit most), and price (cost of drug, but of other systemic and topical agents, including ke­ also cost effectiveness of therapy). toconazole, itraconazole, fluconazole, terbinafine, corticosteroids, and selenium sulfide, are also be­ Safety and Tolerability ing used. Griseofulvin is fungistatic and acts by in­ Treatment of tinea capitis usually requires ex­ terfering with fungal nucleic acid synthesis. 12 Ke­ tended therapy with medications that can cause toconazole, itraconazole, and fluconazole are all adverse reactions in some patients. In a 12-week fungistatic and inhibit the biosynthesis of fungal randomized double-blind study, 79 patients (most ergosterol. 13 Terbinafine is the only systemic were African-Americans) were given griseofulvin agent that is fungicidal at low concentrations and microsize (n - 46) or ketoconazole (n - 33).16 Al­ acts by inhibiting squalene epoxide and thus er­ though 6 percent of patients taking griseofulvin gosterol biosynthesis.14 developed mild elevations in aspartate amino­ Adjunctive agents used in the treatment of transferase, these elevations were not of clinical tinea capitis include corticosteroids and selenium importance as patients continued on therapy. Two sulfide. Corticosteroids are used to alter the host patients (6 percent) in the ketoconazole group and immune-mediated responses in patients with 3 (6.5 percent) in the griseofulvin group withdrew complicated tinea capitis, whereas selenium sul­ for unknown reasons. An additional patient on ke­ fide is used as a topical sporicidal agent. 15 toconazole withdrew from the study because of The focus of tinea capitis literature has been nausea. largely disease oriented. Most studies have evalu­ A 6-week double-blind study comparing keto­ ated the microbiologic response to certain agents conazole (n - 24) with griseofulvin microsize (n - using disease-oriented evidence as surrogates. 23) in 47 children with dermatophyte infections There are some studies, however, that can provide found a twofold increase in serum alanine and as­ POEMs (patient-oriented evidence that matters, partate aminotransferase concentrations after 3 eg, compliance rates and clinical cure, such as hair weeks of treatment in 1 patient on griseofulvin; http://www.jabfm.org/ regrowth, decreased inflammation, and relapse however, concentrations returned to normal in rates) for comparative purposes. 16-30 subsequent visits. No adverse events were re­ ported in the ketoconazole group.17 Methods In a double-blind, randomized study of 35 pa­ MEDLINE and Metacrawler search engines en­ tients given ultramicronized griseofulvin (n - 17) compassing January 1966 through July 1998 were or itraconazole (n - 18), 12 percent of patients tak­ on 27 September 2021 by guest. Protected copyright. used to obtain clinical trials and general informa­ ing griseofulvin discontinued therapy because of tion regarding the treatment of tinea capitis. severe nausea, vomiting, and abdominal pain.ls Search terms included "tinea capitis," "griseoful­ These symptoms resolved after stopping griseo­ vin," "ketoconazole," "itraconazole," "flucona­ fulvin. Although no adverse events were noted zole," "terbinafine," "selenium," "corticosteroids," with itraconazole, 1 patient dropped out for an "antifungal," "trichophyton," and "microsporum." unstated reason. The searches were limited to human clinical trials, Although headache and gastrointestinal dis­ pediatric patients, and review articles published in tress are the most commonly reported adverse ef­ English language journals. Randomized, con­ fects of griseofulvin, rare cases of systemic lupus, trolled studies were included