Pediatric Dermatology Consult

Pediatric Dermatology Consult - September 2016

Publish date: September 9, 2016

A 5-year-old boy presents to his physician for evaluation of "toenail issues" for at least 1 year. The family has noticed changes of the his right great toenail, which they thought might be due to "tight shoes," stating that the boy has been growing out of his shoes quickly. In the last 6 months, his mother has noted a "crumbly" nail with yellow discoloration. There has been no prior treatment, although his parents now are replacing his sneakers more regularly to allow him "room to grow." He has no history of toe swelling or pain. He is otherwise healthy, and he has no history of psoriasis or eczema. He has had no significant viral infections, although some children in his school did have hand, foot, and mouth disease several months ago. His mother states that her husband has athlete's foot, which has been treated with "creams and sprays." Physical exam The toenail of the right foot great toe has thickening of the distal part of the nail, with onycholysis (separation of the nail plate from the nail bed), yellow discoloration, and subungual debris. The right toe shows some chronic dystrophy. Other toenails appear normal, and the skin of the feet is otherwise unremarkable.

Topical antifungal agents can be used in pediatric nail infections that do not involve the nail matrix (lunula). Pediatric nails grow faster than adult nails and children have a thinner nail plate, which may allow better penetration of the drug, making children more likely to respond better to topical treatment.¹⁰ Topical therapy options for onychomycosis include ciclopirox and amorolfine nail lacquers, and bifonazole-urea; these require application for prolonged periods of time. Friedlander et al. showed that children with onychomycosis without nail matrix treated with ciclopirox 8% over 32 weeks had a 90% mycologic cure rate.11 Recently, new topical treatments (efinaconazole and tavaborole) became available for treatment of onychomycosis in adults and appear to be more effective.^12,13 The data for these treatments in pediatric onychomycosis are being gathered, and the results will provide insight into the efficacy of these new formulations in the pediatric population.

Behavioral measures that may reduce risk of onychomycosis include: keeping feet cool and dry, wearing shoes in public areas, and avoidance of shared, unsterilized nail manicure equipment.⁵

References

J Eur Acad Dermatol Venereol. 2014 Nov;28(11):1480-91.
J Eur Acad Dermatol Venereol. 2015 Jun;29(6):1039-44.
J Eur Acad Dermatol Venereol. 2011 Feb;25(2):235-7.
Pediatric Dermatology 2001 Mar;18:107-9.
J Drugs Dermatol. 2015 Oct;14(10 Suppl):s32-4.
J Am Acad Dermatol. 1997 Mar;36(3 Pt 1):395-402.
Dermatology. 2004;209(4):301-7.
Pediatr Dermatol. 2013 May-Jun;30(3):294-302.
Tinea Pedis and Tinea Unguium, in "Red Book: 2015 Report of the Committee on Infectious Diseases, 30th Edition (Elk Grove Village, IL: American Academy of Pediatrics, 2015; 784-6).
Am J Clin Dermatol. 2014 Dec;15(6):489-502.
Pediatr Dermatol. 2013 May-Jun;30(3):316-22.
J Am Acad Dermatol. 2015 Jul;73(1):62-9.
J Am Acad Dermatol. 2013 Apr;68(4):600-8.

Dr. Matiz is assistant professor of dermatology at Rady Children’s Hospital San Diego–University of California, San Diego, and Mr. Ginsberg is a research associate at the hospital. Dr. Matiz and Mr. Ginsberg said they have no relevant financial disclosures.

	A. Traumatic onychodystrophy
	B. Nail psoriasis
	C. Lichen planus
	D. Onychomycosis
	E. Seborrheic dermatitisE. Onychomadesis

Pediatric Dermatology Consult - September 2016

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