Summertime brings many fun adventures. Unfortunately, it also brings predictable illness and injury (ex, Gastroenteritis, Handlebar Injuries, Sparkler Injuries). People also tend to wear less clothing and that can allow parents to see those areas that have been hidden all winter long. Fingers and Toes are now exposed to the world! Certainly, they are prone to be injured themselves (ex, Subungal Hematoma), but sometimes they just look “funny.” While Onychomycosis is certainly not a medical emergency, its presence may be enough to concern a parent to come to ask you for your advice. So let’s take a quick look at what advice there may be for us to care for the child with Onychomycosis:
Onychomycosis: Basics
Onychomycosis is a fungal infection of the nail plate caused by:
Dermatophytes (Trichophyton rubrum is the most common cause [Totri, 2017])
Non-dermatophyte Molds
Candida
Risk Factors:
Local nail trauma
Occlusive foot wear
Communal locker rooms
Public swimming pools
Patient or Family member with tinea pedis [Totri, 2017]
Diagnosis should be made prior to treatment. [Totri, 2017; Chu, 2014]
Avoids inappropriately treating a mimic of onychomycosis.
Avoids unnecessary exposure to prolonged treatment courses with medications that may have substantial side effects.
Diagnostic Tools:
Fungal Culture
Considered the standard since it provides information on pathogen. [Totri, 2017]
Nail clippings can be sent in formalin
Before obtaining sample, area should be cleaned with alcohol and then nail clipped back to the area of most active infection. [Chu, 2014]
(This totally does not sound like something I’m doing in my ED… maybe that is just me…)
KOH prep and direct microscopy
PCR is evolving and may prove to be more useful.
Therapies:
Oral antifungal therapy
Currently the widely chosen option. [Chernoff, 2016; Chu, 2014]
May require monitoring of CBCs and LFTs, although currently debated. [Chernoff, 2016]
Medication inserts recommend checking levels before starting the therapy. [Castelo-Soccio, 2018]
Best Options:
Oral Intraconazole
Oral Terbinafine
Griseofulvin and fluconazole are not as effective.
Topical antifungal therapy
May be more effective in children than adults. [Friedlander, 2013]
Most useful for Superficial White or mid-moderate Subungal onychomycosis.
Avoids systemic treatment, although good results found with using combination of oral and topical antifungal therapies. [Friedlander, 2013]
Options:
Topical Ciclopirox 8%
Topical Amorolfine 5%
Moral of the Morsel
It’s Toe Fungus! Or… is it? Don’t be cavalier and be in a rush to treat a condition that may be a mimic of it instead. It is ok to counsel and recommend outpatient referral for acute diagnostic testing.
Paint it on! Kids do better with topical therapy. While initiating therapy without a diagnosis is not recommended, if you had to, and it was a minor infection, try something topical.
References
Gupta AK1,2, Mays RR1, Versteeg SG1, Shear NH3, Friedlander SF4. Onychomycosis in children: Safety and efficacy of antifungal agents. Pediatr Dermatol. 2018 Jun 26. PMID: 29943838. [PubMed] [Read by QxMD]
Onychomycosis is an uncommon condition in childhood, but prevalence in children is increasing worldwide.The objective was to review the efficacy and safety of systemic and topical antifungal agents to treat onychomycosis in children. Databases (Pubmed, OVID, Scopus, clinicaltrials.gov, Cochrane Library) were searched. Seven studies were selected for inclusion. Only one was a randomized controlled trial. In total, 208 children were administered an […]
Solís-Arias MP1, García-Romero MT1. Onychomycosis in children. A review. Int J Dermatol. 2017 Feb;56(2):123-130. PMID: 27612431. [PubMed] [Read by QxMD]
Onychomycosis is considered an age-related infection with increasing prevalence in the older age groups. It is rare in the pediatric population, except in children with Down syndrome and with immunodeficiencies, who are more likely to have fungal nail infections. The number of reports about onychomycosis in children is relatively small, and the epidemiologic data vary, but a rise in prevalence has been demonstrated. In this article, we review the […]
Eichenfield LF, Friedlander SF. Pediatric Onychomycosis: The Emerging Role of Topical Therapy. J Drugs Dermatol. 2017 Feb 1;16(2):105-109. PMID: 28300851. [PubMed] [Read by QxMD]
Fungal infection of the nails is an increasingly recognized disease in infants and children. However, it can be difficult to distinguish clinically from other nail dystrophies. In addition, many mistakenly believe that onychomycosis does not occur in childhood. Under-recognition of this infectious disorder therefore occurs. Although many consider “nail fungus” a trivial cosmetic concern, it can lead to discomfort, risk of secondary infection, and […]
Chu DH1, Rubin AI2. Diagnosis and management of nail disorders in children. Pediatr Clin North Am. 2014 Apr;61(2):293-308. PMID: 24636647. [PubMed] [Read by QxMD]
The authors herein describe several nail conditions, which the general pediatrician is likely to encounter in the course of routine practice. Because pediatric nail disorders represent a limited component of a general pediatric practice, it can be challenging for practitioners to establish expertise in the diagnosis and treatment of these conditions and to recognize when reassurance is appropriate or when referral to a specialist is necessary. Th […]
Young LS1, Arbuckle HA, Morelli JG. Onychomycosis in the Denver pediatrics population, a retrospective study. Pediatr Dermatol. 2014 Jan-Feb;31(1):106-8. PMID: 22612465. [PubMed] [Read by QxMD]
Onychomycosis (OM) is a common nail disorder in adults but has been rare in children. Recent international studies have demonstrated a rise in the prevalence of OM in children and adolescents, with Trichophyton rubrum being the most common pathogen. This 5-year retrospective chart review of children (aged <18) found that 66 of 141 patients (46.8%) presenting to Children’s Hospital Colorado or Denver Health Medical Center Dermatology clinics wi […]
Friedlander SF1, Chan YC, Chan YH, Eichenfield LF. Onychomycosis does not always require systemic treatment for cure: a trial using topical therapy. Pediatr Dermatol. 2013 May-Jun;30(3):316-22. PMID: 23278851. [PubMed] [Read by QxMD]
Standard teaching dictates that systemic therapy is required for treatment of onychomycosis. It is unknown whether topical antifungal therapy is effective for pediatric nail infections. This prospective, randomized, double-blind, vehicle-controlled study was conducted in the Pediatric Dermatology Research Unit at Rady Children’s Hospital to determine whether topical antifungal therapy is efficacious for pediatric onychomycosis. Forty patients age […]
I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.
I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.
Is there a possibility of HIV Infection Manifesting as Proximal White Onychomycosis