Onychomycosis is less common in children than adults. Children’s better blood flow, less nail trauma, and faster-growing nails lower their risk, though those with immunodeficiency or Down’s syndrome are more susceptible. Distal and lateral subungual onychomycosis (DLSO) is the most common form, mainly affecting toenails. Trichophyton rubrum is the primary cause, though in very young children, fingernail infections caused by yeasts are more common.
Key considerations and tips for management of onychomycosis in children
1. Inspection and Family Treatment
- Inspect affected children for tinea pedis.
- Examine parents and siblings for onychomycosis and tinea pedis.
- Treat infected family members to prevent recurrence.
2. Education
- Inform high-risk families about potential fungal infections.
3. Preventive Strategies
- Avoid occlusive footwear.
- Avoid areas with high dermatophyte concentrations (e.g., gyms, communal showers, pools).
- Maintain clean, trimmed nails.
- Opt for breathable shoes.
- Use moisture-wicking socks (cotton or wool).
- Don’t share footwear.
4. Sanitization
- Consider ozone gas for footwear sanitization.
- Use commercial UV-C devices to reduce dermatophyte contamination in shoes.
5. Laundry Practices
- Wash clothes at 60°C to eliminate T. rubrum.
- Separate infected clothes from regular laundry.
6. Prophylaxis
- Consider regular use of topical antifungals to prevent relapse or reinfection.
- Proposed: Apply topically twice weekly for 2–3 years to minimize recurrence.
7. Treating Coexisting Conditions
- Address concurrent tinea pedis when treating onychomycosis with topicals.
8. Choice of Treatment
- Prefer FDA-approved topical antifungals for children (efinaconazole, tavaborole, ciclopirox) due to established safety profiles.
- Reserve systemic antifungals (terbinafine, itraconazole) for severe cases, with careful monitoring.
9. Monitoring
- For systemic treatments, follow recommended lab guidelines, especially for liver functions.
10. Follow-up
- Schedule regular check-ups to assess treatment efficacy and monitor for side effects.
11. Long-term Management
- Note that recurrence is common (10–53% in adults).
- Consider ongoing preventive measures for high-risk individuals.
Medical treatment options for onychomycosis in children
1. Oral Antifungal Agents (Off-label Use)
Terbinafine
- For children under 20 kg: 62.5 mg/day
- For children 20-40 kg: 125 mg/day
- For children over 40 kg: 250 mg/day
- Treatment duration: 6 weeks for fingernails, 12 weeks for toenails
Itraconazole
- Continuous therapy: 3-5 mg/kg/day.
- 10-20 kg: 50 mg/day.
- 20-30 kg: 100 mg/day.
- 30-40 kg: 150 mg/day.
- 40-49 kg: 200 mg/day
- Pulse therapy: 5 mg/kg/day for 1 week per month
- Treatment duration: 2 pulses for fingernails, 3 pulses for toenails
Fluconazole
- Dosage: 6 mg/kg once weekly
- Treatment duration: 12-16 weeks for fingernails, 18-26 weeks for toenails
2. FDA-Approved Topical Antifungal Agents for Pediatric Use
Efinaconazole 10% Solution
- Application: Once daily for 48 weeks
- Approved for ages 6 years and older
Tavaborole 5% Solution
- Application: Once daily for 48 weeks
- Approved for ages 6 years and older
Ciclopirox 8% Nail Lacquer
- Application: Once daily for 48 weeks
- Approved for ages 12 years and older