ONYCHOMYCOSIS IN CHILDREN - PREVALENCE AND TREATMENT STRATEGIES

Background: Onychomycosis is observed less frequently in children than adults. Until recently management of onychomycosis in children includ ed topical formulations, oral griseofulvin, and in some cases deferral of treatment. Objective: We attempted to determine the prevalence of onychomycosis in North American children 18 years old or younger atten ding our dermatology offices (three Canadian, two U.S.) and to report the group's experience using fluconazole, itraconazole, and terbinafin e for onychomycosis. Methods: We undertook a prospective, multicenter survey in which all children, regardless of presenting complaint, were examined for onychomycosis by a dermatologist. In instances of clinic al suspicion appropriate nail samples were obtained for light microsco py and culture. Results: A total of 2500 children under age 18 were ex amined in the five-center survey (1117 males and 1383 females, mean +/ - S.E. age: 11.2 +/- 0.1 years). There was one child with fingernail a nd ten with mycologically confirmed toenail dermatophyte onychomycosis . The overall prevalence of onychomycosis was 0.44%. Considering those children whose primary or referring diagnosis was not onychomycosis o r tinea pedis, the prevalence of onychomycosis was 0.16%. Outside the survey we have seen six other children with dermatophyte onychomycosis ; these 17 cases form the basis for the remainder of the report. Of th e 17 children, eight (47%) had concomitant tinea pedis infection, and in 11 (65%) a sibling, parent, or grandparent had onychomycosis or tin ea pedis. Management included topical terbinafine (two patients: one c ured, one failed therapy), topical ketoconazole (one patient: clinical improvement), oral fluconazole (two patients. one cured, one had Down 's syndrome and was noncompliant), oral itraconazole (four patients: t hree cured with subsequent recurrence at follow-up in one patient, one lost to follow-up), oral terbinafine (five patients: four cured with subsequent recurrence at follow-up in one patient, one failed therapy) . One child received no therapy following discussion with the parents, one was lost to follow-up and one was found to have asymptomatic hepa tic dysfunction with hepatitis C at pretherapy bloodwork. Conclusion: The prevalence of onychomycosis in our sample of North American childr en 18 years old or younger was 0.44% (n = 2500). In the subset of chil dren whose primary or referring diagnosis was not onychomycosis, the p revalence of onychomycosis was 0.16%. Children with onychomycosis shou ld be carefully examined for concomitant tinea pedis, and their parent s and siblings checked for onychomycosis and tinea pedis. The newer or al anti fungal agents fluconazole, itraconazole, and terbinafine may b e effective and well-tolerated in the treatment of onychomycosis in th is age group. These drugs should be carefully evaluated in a larger co hort of children with onychomycosis.