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So it's pediatric onychomycosis. Now what?

EXPERT ANALYSIS FROM SUMMER AAD 2018

CHICAGO -- Though research shows that nail fungus occurs in just 0.3% of pediatric patients in the United States, that's not what Sheila Friedlander, MD, is seeing in her southern California practice, where it's not uncommon to see children whose nails, toe nails in particular, have fungal involvement.

"I know I started out telling you fungus isn't that common in children. ... but you do need to think about it," said Dr. Friedlander during a nail-focused session at the annual summer meeting of the American Academy of Dermatology. Dr. Friedlander, professor of dermatology and pediatrics at the University of California San Diego and Rady Children's Hospital, said that she suspects that more participation in organized sports at a young age may be contributing to the increase, with occlusive sports footwear replacing bare feet or sandals for more hours of the day, presenting more opportunities for toenail trauma in sports such as soccer.

When making the clinical call about a nail problem, bear in mind that the younger the child, the less likely a nail problem is fungal, Dr. Friedlander noted. "Little children are much less likely than older children to have nail fungus. Pediatric nails are thinner, and they are faster growing, with better blood supply to the matrix."

And if frank onychomadesis is observed, think about the time of year, and ask about recent fevers and rashes, because coxsackievirus may be the culprit. "Be not afraid, and look everywhere if the nail is confusing to you," she said. In all ages, the diagnosis is primarily clinical, "but I culture them, I 'PAS' [periodic acid-Schiff stain] them, too. If you do both, you'll increase your yield," Dr. Friedlander said, adding, "the beauty of PAS is you can use it to give your families an answer very soon."

Once you've established that fungus is to blame for a nail problem, there's a conundrum: There are no Food and Drug Administration-approved therapies, either topical or systemic, for pediatric onychomycosis, Dr. Friedlander said. She, along with coauthors and first author Aditya Gupta, MD, of Mediprobe Research, London, Ont., recently published an article reviewing the safety and efficacy of antifungal agents in this age group (Pediatr Dermatol. 2018Jun 26. doi: 10.1111/' pde.13561).

Reviewing information available in the United States and Canada, Dr. Friedlander and her coauthors came up with three topical and four oral options for children, along with recommendations for dosage and duration.

In response to an audience question about the use of topical antifungal treatment for nail involvement, Dr. Friedlander responded, "I think topicals would be great for kids, but it's for kids where there is no nail matrix involvement. Also, cost is a problem. Nobody will cover it. But some families are willing to do this to avoid systemic therapy," and if the family budget can accommodate a topical choice, it's a logical option, she said, noting that partial reimbursement via a coupon system is available from some pharmaceutical companies.

Where appropriate, ciclopirox 8%, efinaconazole 10%, and tavaborole 5% can each be considered. Dr. Friedlander cited one study she coauthored, which reported that 70% of pediatric participants with nonmatrix onychomycosis saw effective treatment, with a 71% mycological cure rate (P = .03), after 32 weeks of treatment with ciclopirox lacquer versus vehicle (Pediatr Dermatol. 2013 May-Jun;30[3]:316-22).

Systemic therapies--which, when studied, have been given at tinea capitis doses--could include griseofulvin, terbinafine, itraconazole, and fluconazole.

In terms of oral options, Dr. Friedlander said, griseofulvin has some practical limitations. While prolonged treatment is required in any case, terbinafine may produce results in about 3 months, whereas griseofulvin may require up to 9 months of therapy. "I always try to use terbinafine ... griseofulvin takes a year and a day," she said.

She also shared some tips to improve pediatric adherence with oral antifungals: "You can tell parents to crush terbinafine tablets and mix in peanut butter or applesauce to improve adherence. Griseofulvin can be flavored by the pharmacy, but volumes are big with griseofulvin, so it's a challenge to get kids to take it all," she said.

Dr. Friedlander reported that she had no relevant financial disclosures.

COMMENTARY BY DR. SIDBURY

PEDIATRIC DYSTROPHIC NAILS

There is a large disconnect between what children with dystrophic nails are referred for and their ultimate diagnosis. Onychomycosis, a common adult malady, is not a common cause of pediatric onychodystrophy, so providers should cast a broader diagnostic net, according to Dr. Sheila Friedlander.

Dr. Friedlander emphasizes the importance of history because congenital onychodystrophy raises unique considerations. Hair, teeth, skin, and bones should be scrutinized to help identify the appropriate diagnosis. She highlights this point by describing a patient with nail-patella syndrome: The distinctive triangular lunula and abnormal elbows and knees instantly raise the specter of a diagnosis that can have significant medical morbidity.

Dr. Friedlander also makes clear that, while uncommon, pediatric onychomycosis can occur and may raise unique issues. She notes that younger age is inversely correlated with onychomycosis, whereas sports participation increases likelihood. Barriers to treatment can include the lack of Food and Drug Administration approval, cost, and adherence - particularly with systemic agents. While topical agents such as ciclopirox 8%, efinaconazole 10%, and tavaborole 5% are very appealing from both a safety and convenience perspective, she advises against their use if any nail matrix involvement is noted.

Dr. Friedlander highlights four potential systemic agents: griseofulvin, terbinafine, itraconazole, and fluconazole. While pediatricians and pediatric dermatologists have ample familiarity and comfort using griseofulvin, prolonged courses and significant recurrence risk lessen its role in onychomycosis therapy.

BY KARI OAKES

koakes@mdedge.com

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Author:Oakes, Kari
Publication:Dermatology News
Date:Jun 1, 2019
Words:941
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