Ringworm of the Scalp or Beard

Topic Overview

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This topic is about ringworm of the scalp or beard. For information about other fungal infections, see the topics:

What is ringworm of the scalp or beard?

Ringworm is an infection on your skin, hair, or nails. It is caused by a fungus. Ringworm of the scalp occurs in children and adults all over the world. It is most common in young children. Ringworm of the beard is not common.

What causes ringworm of the scalp or beard?

Ringworm is not caused by a worm. Ringworm infections are caused by a fungus. The kinds of fungi (plural of fungus) that cause ringworm live and spread on the top layer of the skin and on the hair.

Ringworm is contagious. It spreads when you come into close contact with a person or animal that has it. It can also spread when you share hats, combs, brushes, towels, clothing, and other items. Children get ringworm more often than adults.

If an adult gets ringworm, he or she will most likely become a carrier of the ringworm fungus. Carriers can pass ringworm on to others but do not have symptoms of the disease.

You can also get ringworm by touching an infected dog or cat, although this form of ringworm is rare.

What does ringworm of the scalp or beard look like?

Ringworm of the scalp or beard often looks like round, bald patches. Most often, the infection spreads outward while the inside of the circle clears up. This makes the infection look like a ring. The name "ringworm" comes from this pattern.

But ringworm of the scalp or beard doesn't always make a ring pattern. Sometimes it just looks like dandruff. In some cases the hair breaks off, leaving stubble that looks like black dots. Sometimes people get ringworm but do not have any symptoms

In the most severe cases, the infected area is swollen, red, crusty, and painful, with small bumps that look like blisters.

Ringworm is contagious, meaning it can spread from one person to another easily. If you or someone in your family has the symptoms listed above, see your doctor.

How is ringworm of the scalp or beard diagnosed?

If you have a ring-shaped rash, you very likely have ringworm. Your doctor will be able to tell for sure. He or she will probably look at a hair or skin sample under a microscope to check for the ringworm fungus. You may have other tests. But most of the time, none are needed.

How is it treated?

Your doctor will prescribe pills that will kill the fungus. And you can use special shampoo to keep ringworm from spreading to others.

Ringworm can come back, so be sure to throw away your combs and brushes and buy new ones that won't spread the infection. Try to keep your skin clean and dry. Don't share hats, combs, or brushes. If you treat ringworm early, the hair in the bald spots will probably grow back. If you don't treat it, the bald spots could be permanent.

A child who has ringworm can still go to school, as long as he or she is taking pills to kill the fungus. You do not need to shave your child's head.

Frequently Asked Questions

Learning about ringworm of the scalp or beard:	What is ringworm of the scalp or beard? What causes ringworm of the scalp or beard? How do I know if I have ringworm of the scalp or beard? How can I prevent ringworm of the scalp or beard?
Being diagnosed:	How is ringworm of the scalp or beard diagnosed?
Getting treatment:	How is ringworm of the scalp or beard treated? What medicines are used for ringworm of the scalp or beard?

Cause

Ringworm infection is caused by a fungus. Fungi that cause ringworm live and multiply on the upper layer of the skin and on the hair. Ringworm is not caused by a worm or other parasite.

The medical term for fungal infections is tinea, followed by a word that describes the location of infection. For example, tinea capitis is ringworm of the scalp, and tinea barbae is ringworm of the beard.

Ringworm of the scalp is most commonly caused by the fungus Trichophyton tonsurans, which is spread from one person to another. This fungus causes more than 90 out of 100 cases of ringworm of the scalp in North and Central America.¹ In the past, the fungus Microsporum canis was the most common cause, but it is a less frequent cause now. Microsporum canis is spread by cats and dogs.

Ringworm of the beard is caused by Trichophyton verrucosum and is spread by cattle, horses, or dogs.

You can catch ringworm by sharing contaminated hats, combs, brushes, towels, telephones, clothing, sports equipment, or even theater seats, and by direct contact with an infected person.

Children are more susceptible to the fungus and more likely to get an infection than adults. Adults often do not get an infection even after exposure to ringworm-causing fungi. Adults, and less commonly children, can be carriers for ringworm. Carriers do not have symptoms of ringworm but can pass the infection on to others.

Ringworm-causing fungi can live on people, objects (such as hats or brushes), or animals for several months.

Symptoms

Most commonly, ringworm appears as one or more round or oval patches of baldness or scaly skin on the scalp or beard. Typically, the circular patches spread along their outer borders while clearing at the center, which gives them a ringed appearance and the name "ringworm." But you don't always see this pattern.

Other patterns include:

Patchy dandruff.
Scalp hair that breaks off at the surface, resulting in a "black dot" appearance, with mild to moderate dandruff.
Inflamed, reddened, crusty, tender, and swollen areas with small bumps that look like blisters.

Sometimes swollen lymph nodes and fever occur with ringworm infections.

When fungal infections occur, other areas of skin may have a delayed allergic reaction in the form of a rash that looks like blisters, known as an "id" reaction. Id reactions from ringworm of the scalp usually appear on the face.

Early diagnosis and treatment of ringworm of the scalp or beard may stop the infection from becoming uncomfortable and prevent scarring and permanent hair loss.

Ringworm can be confused with other conditions with similar symptoms.

What Happens

At first, ringworm of the scalp or beard may look like dandruff with flakes of dead skin on the hair or beard. There may be round or oval patches of baldness. The skin under the hair or beard may be itchy, red, and peeling. The infection can spread gradually and cover a large area.

As fungi invade the hair, the hair becomes infected, brittle, and breaks off near the root, resulting in patches of baldness. If you treat ringworm early, hair loss is usually temporary.

The scalp or the skin under the beard may become very tender if swollen areas and bumps that look like blisters or nodules with pus (kerions) develop. Skin blisters can become infected.

Ringworm of the scalp or beard can cause scarring and permanent hair loss.

What Increases Your Risk

Things that increase a person's risk for ringworm include:

Being susceptible to fungal infection or having had a previous fungal infection on the scalp, beard, or other areas.
Having contact with people or animals with ringworm infections or with those who carry the ringworm fungus but do not have symptoms.
Having an impaired immune system (due to diseases, such as diabetes or cancer).
Living in a warm, damp climate.

When To Call a Doctor

Call your doctor if you suspect you have ringworm of the scalp or beard, and:

The skin on your scalp or beard area is scaling, peeling, itchy, red, or has swollen areas and bumps that look like blisters and that have pus.
You have hair loss that occurs in patches.
You have pain, swelling, redness, tenderness, or heat in the infected scalp or beard area.
You have a fever of 100°F (37.78°C) or higher with no other cause.
Your dandruff does not improve after 2 weeks of treatment with dandruff shampoo.

Watchful waiting

Symptoms such as flakes of dead skin on the scalp can be due to dandruff, which should go away in about 2 weeks if treated with dandruff shampoos. But if the symptoms are due to ringworm of the scalp or beard, you need to be treated with antifungal pills to completely destroy the fungi.

Who to see

The following health professionals can diagnose and treat ringworm of the scalp or beard:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Doctors can often easily recognize ringworm when there is a distinct ringworm-patterned rash. Your doctor will probably also look at a hair or skin sample (KOH preparation) under a microscope to find out whether a fungus is present.

Tests used for ringworm of the scalp or beard include:

A KOH (potassium hydroxide) preparation, which your doctor can use to find out whether the skin condition is caused by a fungus.
A fungal culture (skin culture), which your doctor usually will do only if diagnosis is difficult or the skin condition is not responding to treatment. The test results may take 4 to 6 weeks.

Early detection

If someone in your family has ringworm of the scalp or beard, talk to your doctor about whether other family members should be examined. It is quite common for one family member to spread the fungus to other family members.

Treatment Overview

Ringworm of the scalp or beard is treated with antifungal pills in combination with antifungal shampoo or lotion.

Topical antifungal medicines, such as shampoos or lotions that you apply directly to the infected area, do not work when used alone. They cannot get deep enough into the infected hair shaft to kill fungi there. But antifungal shampoo helps prevent spreading the fungus to other people, because it decreases fungal shedding from the scalp or beard area.

Doctors also recommend occasional use of antifungal shampoos for ringworm carriers, people who can spread the fungus but do not have ringworm symptoms. Often an adult becomes a carrier after exposure to an infected child.

A veterinarian can treat pets or farm animals for ringworm.

What to think about

Ringworm of the scalp or beard can come back after treatment has cleared the infection.

Ringworm of the scalp or beard can cause scarring and permanent hair loss.

Prevention

To prevent ringworm of the scalp or beard:

Keep your skin clean and dry.
Do not share hats, combs, or brushes with others. Children should use their own combs and brushes and should not share with other family members.
Shampoo once a month with a shampoo that contains selenium sulfide (such as Selsun Blue or Head and Shoulders Intensive Treatment) if you or a family member has had ringworm of the scalp recently.
Don't play with animals (including dogs and cats) that have bald or mangy spots on their coats, which may be caused by fungal infection. A veterinarian can tell what is causing a pet's skin problem and can recommend treatment.
Use hot, soapy water to clean toys, telephones, furniture, and other items that may have fungi on them.
Wash your clothes, towels, and bed sheets in hot, soapy water. Do not share towels.

Home Treatment

You usually treat ringworm of the scalp or beard with antifungal pills prescribed by a doctor. Shampoos available without a prescription are helpful if you use them along with prescription pills. But when they are used alone, they cannot completely destroy all of the fungi causing the infection.

If you have ringworm of the scalp or beard:

Be sure to complete the full course of any prescribed medicine, or follow the directions for products available without a prescription. They often require use for a period of time after symptoms go away.
Wash your hair or beard 2 or 3 times a week with shampoo that contains selenium sulfide or ketoconazole. In severe scalp fungal infections, wash your scalp daily and wear a cap. You should boil the cap after you use it.²
As soon as you start treatment, throw away your combs and brushes and buy new ones.
You will most likely see your doctor again after 3 to 4 weeks of treatment. Your doctor will also want to see you after you have finished all your medicine.
Follow the suggestions for preventing ringworm, such as keeping your skin clean and dry, and not sharing hats, combs, or brushes with others.
Ask your doctor whether your family members need to be tested. Family members can use an antifungal shampoo with selenium sulfide in it (such as Selsun Blue or Head and Shoulders Intensive Treatment) to prevent the spread of infection.

You do not need to keep your child out of school if he or she is taking pills to treat ringworm of the scalp. Although parents sometimes use a special shampoo to help prevent the spread to other children, it is not needed. And you do not need to shave your child's head.¹

Medications

Antifungal medicine (pills or liquid) and shampoo used together are most effective in curing ringworm of the scalp and beard.

Depending on the medicine, antifungal pills are taken for as few as 4 weeks or as long as 12 weeks.

Antifungal shampoo is not effective when used alone to treat ringworm of the scalp or beard, because it cannot penetrate into infected hairs and destroy the fungi present there.

Sometimes other infections occur when a person has ringworm, usually because bacteria have entered the body through the ringworm sores or rash. If needed, you can use other medicines, such as antibiotics, along with antifungals to treat these secondary bacterial infections.

Swollen areas and bumps that look like blisters and have pus (kerions) are caused by an allergic reaction to fungus. You can treat kerions with a combination of oral antifungal medicine and a corticosteroid (usually oral), such as prednisone.

To help prevent ringworm from developing after exposure to the fungus, you can use antifungal shampoo every 2 days for about a week.

Medicine choices

The most common antifungals you can use to treat ringworm of the scalp or beard include:

Griseofulvin.
Allylamines (terbinafine).
Azoles (including fluconazole, itraconazole, and ketoconazole).

Antifungal shampoos are available by prescription and as over-the-counter products. Both kinds may contain active ingredients like ketoconazole or selenium sulfide. Prescription shampoos often contain a larger amount of these medicines, or they may contain povidone.

What to think about

People who are taking antifungal pills should have a doctor monitor their blood counts and liver and kidney function during treatment to watch for any adverse side effects.

Other Places To Get Help

Organizations

American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL 60168
Phone:	1-866-503-SKIN (1-866-503-7546) toll-free (847) 240-1280
Fax:	(847) 240-1859
Email:	MRC@aad.org
Web Address:	www.aad.org

The American Academy of Dermatology (AAD) provides information about the care of skin. You can locate a dermatologist in your area by using their "Find a Dermatologist" tool. Or you can read the latest news in dermatology. "SPOT Skin Cancer" is the AAD's program to reduce deaths from melanoma. There is also a link called "Skin Conditions" that has information about many common skin problems.

American Academy of Family Physicians: FamilyDoctor.org
P.O. Box 11210
Shawnee Mission, KS 66207-1210
Phone:	1-800-274-2237
Fax:	(913) 906-6075
Web Address:	www.familydoctor.org

The website FamilyDoctor.org is sponsored by the American Academy of Family Physicians. It offers information on adult and child health conditions and healthy living. There are topics on medicines, doctor visits, physical and mental health issues, parenting, and more.

KidsHealth for Parents, Children, and Teens
Nemours Home Office
10140 Centurion Parkway
Jacksonville, FL 32256
Phone:	(904) 697-4100
Web Address:	www.kidshealth.org

This website is sponsored by the Nemours Foundation. It has a wide range of information about children's health—from allergies and diseases to normal growth and development (birth to adolescence). This website offers separate areas for kids, teens, and parents, each providing age-appropriate information that the child or parent can understand. You can sign up to get weekly emails about your area of interest.

Related Information

References

Citations

American Academy of Pediatrics (2009). Tinea capitis (ringworm of the scalp). In LK Pickering, ed., Red Book: 2009 Report of the Committee on Infectious Diseases, 28th ed., pp. 661–662. Elk Grove Village, IL: American Academy of Pediatrics.

American Public Health Association (2008). Tinea barbae and tinea capitis. In DL Heymann, ed., Control of Communicable Diseases Manual, 19th ed., pp. 172–174. Washington, DC: American Public Health Association.

Other Works Consulted

Elewski BE, et al. (2008). Terbinafine hydrochloride oral granules versus oral griseofulvin suspension in children with tinea capitis: Results of two randomized, investigator-blinded, multicenter, international, controlled trials. Journal of the American Academy of Dermatology, 59(1): 41–54.

Grossberg R (2011). Fungal diseases of the skin. In ET Bope et al., eds., Conn's Current Therapy 2011, pp. 869–871. Philadelphia: Saunders.

Habif TP, et al. (2011). Tinea of the beard (tinea barbae). In Skin Disease: Diagnosis and Treatment, 3rd ed., pp. 288–289. Edinburgh: Saunders.

Habif TP, et al. (2011). Tinea of the scalp (tinea capitis). In Skin Disease: Diagnosis and Treatment, 3rd ed., pp. 284–287. Edinburgh: Saunders.

Higgins EM (2010). Tinea capitis. In MG Lebwohl et al., eds., Treatment of Skin Disease: Comprehensive Therapeutic Strategies, 3rd ed., pp. 736–739. Edinburgh: Saunders Elsevier.

Credits

By	Healthwise Staff
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	John Pope, MD - Pediatrics
Last Revised	December 21, 2012