Onychomycosis in Children

Onychomycosis in children is rare, with an estimated prevalence of 0.2 percent. Most often, it develops in children with immunosuppression, a strong familial history of onychomycosis or extensive cutaneous mycosis. Although griseofulvin remains the mainstay of onychomycosis treatment in children, the efficacy of this drug is variable, and relapse is common.

Newly available medications may improve the traditionally mediocre treatment outcomes in this age group. The FDA has not yet labeled terbinafine for use in children. However, some studies have shown terbinafine to be safe and quite effective in the treatment of tinea capitis, and it is licensed for this purpose in several countries.

In more limited trials, itraconazole has also been shown to be safe and efficacious in the treatment of tinea capitis. If the safety and effectiveness of terbinafine and itraconazole are established over the longer courses needed to treat nail infections, they may become potent first-line therapies for onychomycosis in children.

Rates of treatment failure can be extracted from published trials, but data on relapse are less readily available. Post-treatment follow-up is long, drop-out rates in many studies are significant or unreported, and most studies have not allowed crossover of treatment regimens. Furthermore, especially in outcomes of clinical improvement, evaluation criteria have not been standardized and often include subjective assessments that are difficult to quantify.

Despite these difficulties, several measures may be helpful in managing unsuccessful treatment or relapse. The first step is to confirm mycology. If the initial diagnosis was based on a KOH preparation alone, culture of properly collected specimens is mandatory. Culture reports often identify multiple organisms, including possibly nonpathogenic molds, and treatment should be directed at the organisms most likely to be causative.

A microbiology or infectious disease consultation may be valuable in interpreting the culture report. Of note, there has been some concern about evolving drug resistance among fungal pathogens, particularly with the widespread use of systemic fluconazole therapy to treat oropharyngeal and recurrent vaginal candidiasis. However, the impact of antifungal resistance on the treatment of onychomycosis is not yet clear.

Careful clinical review may identify patient or nail characteristics that are impeding treatment. These factors can be addressed with appropriate medication changes or adjuvant measures. Because of superior efficacy, continuous antifungal therapy may be considered in patients who fail or relapse after pulse therapy.

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