From the Guidelines
For a 4-year-old with fungal toenail infection (onychomycosis), the recommended treatment is pulse itraconazole therapy (5 mg kg-1 per day for 1 week every month) for 3 months, as it has shown a high clinical cure rate of 94% with no relapse for 1–4 years after therapy initiation 1.
Treatment Approach
When considering treatment for a 4-year-old with onychomycosis, it's essential to weigh the potential benefits and risks of different approaches.
- Topical antifungal medications like ciclopirox 8% nail lacquer (Penlac) or amorolfine 5% nail lacquer may be considered, but they typically have lower cure rates compared to systemic treatments 1.
- Oral antifungal medications such as terbinafine or fluconazole are generally effective, but their use in young children requires careful consideration due to potential side effects and limited safety data in this age group.
Systemic Treatment
The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 recommend the following systemic treatments for pediatric onychomycosis:
- Pulse itraconazole therapy (5 mg kg-1 per day for 1 week every month) for 3 months for toenail infection 1.
- Daily terbinafine for 12 weeks for toenail infection at a dose determined by body weight (e.g., 625 mg per day if weight is < 20 kg, 125 mg per day for 20–40 kg weight, and 250 mg per day if weight exceeds 40 kg) 1.
Additional Measures
In addition to medication, it's crucial to practice good foot hygiene to prevent worsening or recurrence of the infection:
- Keep the child's feet clean and dry.
- Trim nails straight across.
- Wear breathable shoes and cotton socks.
- Avoid walking barefoot in public areas. Regular nail trimming to reduce the infected portion can also help improve treatment outcomes. Treatment in children this young requires patience, as fungal nail infections can be persistent, and complete resolution may take many months as the healthy nail grows in.
From the Research
Treatment Options for Fungal Toenail Infection in Children
- The treatment of onychomycosis in children is challenging, and recurrence appears to be more common in children than in adults 2.
- Prolonged systemic antifungal therapy is commonly required, but pediatric practitioners and parents alike hesitate when asked to treat young children with a systemic drug that requires laboratory monitoring and can have systemic toxicities 2.
- Topical antifungal therapy may be a viable option for children due to their thinner, faster-growing nails, which can respond better to topical monotherapy than adults 2.
Recommended Treatments
- Oral antifungal agents such as terbinafine, itraconazole, and fluconazole are effective in treating onychomycosis, but their use in children is not approved 3.
- Terbinafine has been shown to be more effective than placebo in achieving clinical and mycological cure, with a risk ratio of 6.00 and 4.53, respectively 4.
- Azoles have also been shown to be effective in treating onychomycosis, with a risk ratio of 22.18 and 5.86 for clinical and mycological cure, respectively 4.
Considerations for Treatment
- The choice of treatment should be based on the severity of the infection, the age and health status of the child, and the potential risks and benefits of each treatment option 5.
- Topical antifungal agents such as ciclopirox and efinaconazole may be considered as an alternative to systemic therapy, especially for mild to moderate infections 6.
- Preventive measures, such as avoiding or promptly treating tinea pedis infections, can help reduce the risk of recurrence 6.