Treatment Of Onychomycosis In Children Research Articles

Pediatric dermatophyte onychomycosis: a review.

Recent studies have reported an increase in pediatric onychomycosis prevalence worldwide, suggesting that this population may be increasingly affected by the infection. A summary of the epidemiological impact, antifungal treatment options, special considerations for at-risk subpopulations, and methods to prevent infection and recurrence are discussed. A systematic review of available epidemiological studies found the worldwide prevalence of culture-confirmed pediatric toenail onychomycosis to be 0.33%, with no significant increases in prevalence over time. A systematic review of studies investigating the efficacy of various antifungals in treating pediatric onychomycosis found high cure rates and low frequency of adverse events with systemic itraconazole and terbinafine; however, the studies are few, dated, and lack impact because of small sample sizes. Comparatively, clinical trials implementing FDA-approved topical antifungal treatments report slightly reduced cure rates with larger sample sizes. Patients with immunity-altering conditions, such as Down's syndrome, or those immunosuppressed because of chemotherapy or HIV/AIDS are at a greater risk of onychomycosis infection and require special consideration with treatment. Proper sanitization and hygiene practices are necessary to reduce the risk of acquiring infection. Early diagnosis and treatment of onychomycosis in children, as well as any affected close contacts, are crucial in reducing the impact of the disease.

Labeled use of efinaconazole topical solution 10% in treating onychomycosis in children and a review of the management of pediatric onychomycosis

Onychomycosis is a difficult to treat condition whose prevalence is increasing. Until recently, there was no FDA approved antifungal agent for the treatment of onychomycosis in children. Although systemic antifungal agents are effective, their use is restricted by the potential adverse events and drug-drug interactions. There is evidence regarding the safety and efficacy of topical antifungal agents for pediatric onychomycosis. We have summarized the results of a recently published study using efinaconazole topical solution 10% to treat onychomycosis in children and discuss management of pediatric onychomycosis. In a multicenter, open-label phase 4 study, efinaconazole 10% solution was applied topically once daily in children aged 6 to 16 years with mild to severe, culture positive, distal and lateral subungual onychomycosis. Treatment was for 48 weeks with a follow-up at week 52. Pharmacokinetics was performed in a subset of patients. There were 62 patients enrolled in the study. At week 52, the efficacy was mycological cure rate 65% and complete cure rate 40%. All treatment-emergent adverse events (TEAE) were mild to moderate in severity with none resulting in study discontinuation. The only treatment-related TEAE was ingrown toenail. Efinaconazole was detected at low levels in plasma. Efinaconazole topical solution 10% is effective and safe in treating onychomycosis in children age 6 to 16 years and was recently FDA-approved for this indication. The on-label use of other topical agents, tavaborole solution 5% and ciclopirox nail lacquer solution 8% is reviewed. We also briefly discuss the use of oral agents, terbinafine, itraconazole, and fluconazole in pediatric onychomycosis.

Onychomycosis in children: Safety and efficacy of antifungal agents.

Onychomycosis is an uncommon condition in childhood, but prevalence in children is increasing worldwide.The objective was to review the efficacy and safety of systemic and topical antifungal agents to treat onychomycosis in children. Databases (Pubmed, OVID, Scopus, clinicaltrials.gov, Cochrane Library) were searched. Seven studies were selected for inclusion. Only one was a randomized controlled trial. In total, 208 children were administered antifungal agents for the treatment of onychomycosis. Four reports of mild adverse events were documented (1.9% of treated children), one of which discontinued treatment (0.5%). Limitations of this review are the lack of randomized controlled trials available in pediatric onychomycosis. These findings suggest that antifungal therapies used to treat onychomycosis in children are associated with a low incidence of adverse events. Current dosing regimens for antifungal drugs are effective and appear safe to use in children, notwithstanding that the Food and Drug Administration has not approved any of these agents for the treatment of onychomycosis in children. To our knowledge, this review is the most up-to-date, comprehensive summary of pediatric onychomycosis treatment.

Onychomycosis in children. A review.

Onychomycosis is considered an age-related infection with increasing prevalence in the older age groups. It is rare in the pediatric population, except in children with Down syndrome and with immunodeficiencies, who are more likely to have fungal nail infections. The number of reports about onychomycosis in children is relatively small, and the epidemiologic data vary, but a rise in prevalence has been demonstrated. In this article, we review the most up-to-date literature and summarize the epidemiology, etiology, clinical presentation, diagnosis, and treatment of onychomycosis in children, as well as the differences with the disease presenting in adults. Dermatologists must consider onychomycosis in the differential diagnosis of nail alterations in children and always perform a mycological study to confirm the diagnosis.

Mycology - an update Part 3: Dermatomycoses: topical and systemic therapy.

Treatment of dermatophyte infections is based on the clinical picture and mycological detection of the causative pathogen. Based on the appropriate indication, onychomycosis can be treated topically using an antimycotic nail lacquer. Atraumatic nail abrasion with 40 % urea ointment has a beneficial effect on healing. Continuous treatment of onychomycosis with terbinafine represents the most effective systemic therapy. Terbinafine or itraconazole are the safest and most effective antimycotic agents for the treatment of onychomycosis in children. For laser therapy of onychomycosis, only a few studies on clinical efficacy are available. Regarding tinea capitis, targeted species-specific therapy of dermatophytosis of the scalp is currently recommended. Terbinafine, yet also itraconazole and fluconazole, are effective in tinea capitis caused by Trichophyton species. Microsporum infections of the scalp are preferably treated with griseofulvin, alternatively with itraconazole or fluconazole. Terbinafine is less effective. Candidal intertrigo are topically treated with nystatin, but azoles or ciclopirox olamine are also suitable candidates. Systemically, fluconazole or itraconazole are used. Topical and systemic antimycotics are equivalent forms of therapy in acute vulvovaginal mycosis. Fluconazole is the drug of choice in chronic recurrent vulvovaginal mycosis caused by Candida albicans. Ketoconazole shows very good efficacy in tinea versicolor. With respect to systemic treatment of severe and widespread tinea versicolor, itraconazole is the drug of choice.

Systemic Antifungals to Treat Onychomycosis in Children: A Systematic Review

Because of the low prevalence of onychomycosis in children, little is known about the efficacy and safety of systemic antifungals in this population. PubMed and Embase databases and the references of related publications were searched in March 2012 for clinical trials (CTs), retrospective analyses (RAs), and case reports (CRs) on the use of systemic antifungals for onychomycosis in children (<18years). Twenty-six studies (5 CTs, 3 RAs, and 18 CRs) were published between 1976 and 2011. Most of these studies reported the use of systemic terbinafine and itraconazole for the treatment of onychomycosis in children. Therapy with systemic antifungals alone in children ages 1 to 17years resulted in a complete cure rate of 70.8% (n=151), whereas combined systemic and topical antifungal therapy in one infant and 19 children age 8 and older resulted in a complete cure rate of 80.0% (n=20). The efficacy and safety profiles of terbinafine, itraconazole, griseofulvin, and fluconazole in children were similar to those previously reported for adults. In conclusion, based on the little information available on onychomycosis in children, systemic antifungal therapies in children are safe and cure rates are similar to the rates achieved in adults.

PHARMACOLOGY AND THERAPEUTICS: Onychomycosis in Children: Prevalence and Management

: Onychomycosis in children is often accompanied by tinea pedis and a family history of onychomycosis. The prevalence of onychomycosis in children is substantially lower than that of adults; therefore it is important to confirm the clinical diagnosis. The most common presentation of onychomycosis is the distal and lateral subungual type. The organism most commonly isolated in North America is Trichophyton rubrum. Oral antifungal therapy is required, especially when the onychomycosis is of moderate to severe intensity, with nail matrix involvement. The new oral antifungal agents itraconazole, terbinafine, and fluconazole are being increasingly used for the treatment of onychomycosis. Review of the literature suggests that these agents are effective and safe in managing onychomycosis in children. The short duration of therapy required with these drugs should help improve compliance. The data suggest that the new oral antifungal agents have a role in the treatment of onychomycosis in children. Further experience will help us better position these drugs when evaluating the management of onychomycosis in children.

Systemic Antifungal Therapy for Cutaneous Infections in Children

The skin, hair and nails are common sites for superficial dermatophyte infection in children. Systemic antifungal therapy is indicated for a variety of cutaneous disorders in the pediatric population. In this article, we review the common indications for the use of systemic antifungal therapy, including terbinafine, ketoconazole, itraconazole, fluconazole and griseofulvin, in children and young adults. Cutaneous fungal infections that generally require systemic antifungal therapy include tinea capitis and onychomycosis. Tinea capitis, which is most often caused by Trichophyton tonsurans, is among the most common fungal infections in children. Tinea capitis occurs primarily in the prepubertal age group. Immunosuppression, eg, human immunodeficiency virus infection, does not increase the frequency of dermatophyte infection; however, the severity of disease and the likelihood of recurrence are greater in this population. Although griseofulvin remains the recommended therapy, terbinafine, itraconazole and fluconazole have been reported to show efficacy in the treatment of tinea capitis in children. Onychomycosis refers to dermatophyte and nondermatophyte infections of the nail unit. The most common dermatophytes responsible for causing onychomycosis include Trichophyton rubrum and Trichophyton mentagrophytes. Children with onychomycosis should be examined for the presence of tinea capitis or pedis, and parents should also be examined for onychomycosis. Most children with onychomycosis have distal subungual onychomycosis, which requires systemic treatment. For this reason, the diagnosis of onychomycosis should always be confirmed by mycology culture. Effective treatment may require prolonged courses of therapy, and the rate of recurrence is high. Currently in North America, there is no FDA-approved treatment of onychomycosis in children. However, terbinafine, itraconazole, and fluconazole are generally well-tolerated and safe and have few side effects. Laboratory monitoring of liver function in patients treated with these agents is prudent. Griseofulvin, although considered the treatment of choice for dermatophyte infections in children, is not recommended for the treatment of onychomycosis given the long duration of treatment and high recurrence rate. Griseofulvin is available in an oral suspension; however, terbinafine is available only in tablet form. Although itraconazole is also available in an oral solution, this is not approved for onychomycosis and contains cyclodextrin, which may cause diarrhea and has induced pancreatic adenocarcinoma in rats. Fluconazole is also available as an oral suspension, but is not FDA-approved for dermatophyte infections.

Ciclopirox nail lacquer in the treatment of onychomycosis

Ciclopirox nail lacquer solution 8% is the first and only topical lacquer approved in the US for the treatment of mild to moderate onychomycosis, without lunula involvement, due to Trichophyton rubrum. This antifungal agent is broad-spectrum with activity against dermatophytes, Candida species and some non-dermatophyte molds. In vitro data suggests that a synergy exists between ciclopirox and terbinafine; hence, the combination of these two agents may be more effective than terbinafine alone when treating severe onychomycosis (e.g., nail matrix involvement). Ciclopirox nail lacquer may also be a consideration in children where the nail plate is thinner and the rate of nail outgrowth is faster compared to adults. It should be noted that neither ciclopirox nor the newer antifungal agents, terbinafine and itraconazole, are approved in the US for the treatment of onychomycosis in children. The topical nail lacquer may be preferred to an oral antifungal agent when treating the elderly, diabetics, and those who are immunocompromised since these patients may have limited renal or hepatic reserve, or be taking several drugs, some of which may interact or be contraindicated with one or more of the oral antifungal agents. Ciclopirox nail lacquer may also be of value in prophylactic therapy, helping to prevent relapse of successfully treated onychomycosis especially among diabetics, immunocompromised individuals, and patients with a family history of onychomycosis or chronic fungal infections (e.g., tinea pedis) since these patients are more likely to redevelop onychomycosis following mycological cure.

Onychomycosis in Children: A Brief Overview with Treatment Strategies

Onychomycosis in children is uncommon. In those children that are affected, a family history of onychomycosis is not uncommon, giving importance to the examination of the entire family for fungal nail infections. In the United States, the newer oral antifungal agents itraconazole, fluconazole, and terbinafine, and the topical nail lacquers ciclopirox and amorolfine are not approved for this indication. More data are needed on the use of these antifungal agents for the treatment of onychomycosis in children.

Onychomycosis in children: prevalence and management.

Onychomycosis in children is often accompanied by tinea pedis and a family history of onychomycosis. The prevalence of onychomycosis in children is substantially lower than that of adults; therefore it is important to confirm the clinical diagnosis. The most common presentation of onychomycosis is the distal and lateral subungual type. The organism most commonly isolated in North America is Trichophyton rubrum. Oral antifungal therapy is required, especially when the onychomycosis is of moderate to severe intensity, with nail matrix involvement. The new oral antifungal agents itraconazole, terbinafine, and fluconazole are being increasingly used for the treatment of onychomycosis. Review of the literature suggests that these agents are effective and safe in managing onychomycosis in children. The short duration of therapy required with these drugs should help improve compliance. The data suggest that the new oral antifungal agents have a role in the treatment of onychomycosis in children. Further experience will help us better position these drugs when evaluating the management of onychomycosis in children.