Itraconazole pulse therapy for dermatophyte onychomycosis in children

Background: Onychomycosis, or fungal infection of the nail, can occur in pr epubertal children. However, its diagnosis is often missed or the condition is inappropriately treated with topical medication. Griseofulvin has been the therapy of choice, but even long-term treatment is associated with a po or cure rate and high rare of relapse. Trials with adult patients have show n that itraconazole pulse therapy for onychomycosis requires a shorter dura tion of total therapy than griseofulvin treatment and is rarely associated with adverse reactions, suggesting that it may be the treatment of choice f or pediatric patients with onychomycosis. Design: We retrospectively reviewed the courses of prepubertal patients wit h dermatophyte onychomycosis who initiated treatment with itraconazole puls e therapy between January 1995 and June 1998. Setting: Urban and suburban pediatric dermatology clinics of a children's h ospital. Patients: Seventeen prepubertal patients met the enrollment and follow-up c riteria. These included fungal infection of the nail(s), documented by fung al culture and/or positive potassium hydroxide mounts of nail scrapings; at least 1 follow-up visit; and contact by telephone or clinic visit within 2 months prior to compilation of data. In 59% of patients, a relative living at the home had onychomycosis at the time of diagnosis. Intervention: Patients were treated with daily to twice-daily pulses of itr aconazole, administered for 1 week of each of 3 to 5 months. Main Outcome Measures: Clinical cure after itraconazole therapy in patients with documented onychomycosis and clinical and mycologic relapse after ini tial cure. Fungal cultures were not repeated if clinical cure was noted. Results: All but 1 patient responded fully to therapy, showing improvement within a few months and subsequently clearance (94% clinical cure rate). No patients experienced any clinical adverse reactions. No relapses occurred after clinical cure during a follow-up period of 1 to 4.25 years after init iation of therapy. Conclusions: Itraconazole pulse therapy is effective and safe for the treat ment of onychomycosis in children. The relapse rate in pediatric patients i s lower than in adults, although the high frequency of onychomycosis non-pe diatric family members suggests that the recurrence risk is increased if ot her family members are not treated concomitantly.