What is the best treatment approach for refractory onychomycosis (fungal infection of the nail) in a 3-year-old child?

From the Guidelines

For refractory onychomycosis in a 3-year-old child, the best treatment approach is typically a combination of topical antifungals and gentle mechanical debridement, with oral antifungals considered only in severe cases under close monitoring. The treatment should prioritize minimizing morbidity, mortality, and improving quality of life. According to the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1, topical treatments such as ciclopirox 8% nail lacquer applied daily or amorolfine 5% nail lacquer used weekly are recommended. These treatments should be applied after gentle filing of the nail to improve penetration.

The duration of treatment is crucial, with recommendations for at least 6-9 months for fingernails and 9-12 months for toenails, due to the slow growth of nails 1. Regular gentle trimming and filing of the affected nail, keeping the nails short, clean, and dry, and ensuring proper foot hygiene are also important aspects of the treatment regimen. For cases that significantly impact the child's quality of life, consultation with a pediatric dermatologist may be necessary to consider short courses of oral terbinafine or fluconazole, with careful monitoring of liver function 1.

Key considerations in the treatment approach include:

• The use of topical antifungals as the first line of treatment
• Gentle mechanical debridement to aid in the removal of infected nail portions
• The importance of proper foot hygiene and nail care
• The potential need for oral antifungals in severe or refractory cases, under close supervision
• The role of pediatric dermatologist consultation for complex cases

Given the available evidence, the most effective and safest initial approach for refractory onychomycosis in a 3-year-old child involves the use of topical antifungal treatments, such as ciclopirox or amorolfine, combined with good nail hygiene practices 1. This approach aims to minimize the risk of side effects associated with oral antifungals while effectively managing the infection and improving the child's quality of life.

From the Research

Treatment Approaches for Refractory Onychomycosis in a 3-Year-Old Child

• The treatment of refractory onychomycosis in children, including those as young as 3 years old, can be challenging due to the limited number of approved antifungal agents for this age group 2, 3.
• Topical antifungal agents such as efinaconazole, tavaborole, and ciclopirox have been found to be safe and effective in children, with some studies suggesting that children respond better to topical therapy than adults due to their thinner and faster-growing nails 2, 4.
• Efinaconazole 10% solution and tavaborole 5% solution are FDA-approved for the treatment of onychomycosis in children aged 6 years and older, while ciclopirox 8% nail lacquer is approved for children aged 12 years and older 2, 3.
• For children under the age of 6, such as the 3-year-old in question, there is limited data on the efficacy and safety of antifungal agents, and treatment may need to be approached on a case-by-case basis, potentially involving off-label use of approved agents or alternative therapies 2, 3.
• A study using ciclopirox lacquer in children as young as 2 years old found it to be an effective option for nonmatrix onychomycosis, suggesting that topical antifungal therapy may be a viable treatment approach for young children with onychomycosis 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 the treatment 2, 3.
• Topical antifungal agents may be a preferred treatment option for young children due to their relatively low risk of side effects and potential for high efficacy 4, 5.
• Close monitoring and follow-up are essential to ensure the effectiveness of the treatment and to minimize the risk of adverse effects 2, 3.

Available Treatment Options

• Efinaconazole 10% solution: FDA-approved for children aged 6 years and older, with studies suggesting high efficacy and safety in pediatric patients 3, 5.
• Tavaborole 5% solution: FDA-approved for children aged 6 years and older, with limited data on its use in younger children 2, 3.
• Ciclopirox 8% nail lacquer: FDA-approved for children aged 12 years and older, with studies suggesting efficacy and safety in younger children 2, 4, 6.