What is the diagnosis and treatment for a 9-year-old male with thickened, yellow great toenails and bilateral peeling, crusting feet, suspected to have Tinea pedis (fungal infection of the foot), without signs of infection or systemic symptoms?

Clinical Note Assessment: Pediatric Tinea Pedis with Onychomycosis

Overall Note Quality

Your clinical note demonstrates appropriate recognition of tinea pedis with onychomycosis in a pediatric patient, appropriate procedural intervention for symptomatic nail removal, and correct referral to podiatry. The documentation is thorough and includes key elements of history, physical examination, procedure details, and patient education 1, 2.

Diagnosis Confirmation

The clinical presentation strongly supports tinea pedis with onychomycosis, but you must obtain mycological confirmation before initiating systemic antifungal therapy. 3, 4

• The combination of thickened, yellow toenails, bilateral peeling/crusting feet, and callus formation is highly suggestive of dermatophyte infection, most commonly caused by T. rubrum or T. mentagrophytes 1, 5
• However, 50% of dystrophic nails in children are non-fungal despite similar clinical appearance 3, 4
• You should perform KOH preparation of skin scrapings from the active border of foot lesions and nail debris as point-of-care testing 5, 6
• Consider fungal culture on Sabouraud's glucose agar if KOH is negative but clinical suspicion remains high 3

Critical Missing Elements in Your Note

You must examine this child for concomitant tinea capitis, as dermatophyte infections commonly occur at multiple body sites simultaneously in pediatric patients. 3, 4

• Concomitant dermatophytosis at other body locations occurs in 25% of pediatric onychomycosis cases 1, 2
• Screen parents and siblings for onychomycosis and tinea pedis, as household transmission is the most common route of infection 4, 5

Treatment Plan Refinement

Topical Therapy for Tinea Pedis

Your prescription of topical antifungals is appropriate first-line therapy, but specify the agent and duration. 2, 5

• Terbinafine 1% cream applied twice daily for 1 week is the most effective topical treatment for interdigital tinea pedis 2
• Alternative: Ciclopirox olamine 0.77% cream/gel twice daily achieves approximately 60% clinical cure at end of treatment and 85% two weeks after treatment 2, 7
• Clotrimazole 1% cream is less effective but widely available over-the-counter 2

Systemic Therapy Considerations for Onychomycosis

Given the bilateral onychomycosis with nail plate involvement, this child will likely require systemic antifungal therapy after mycological confirmation. 1, 4

• Terbinafine is the preferred first-line systemic treatment for dermatophyte onychomycosis in children 3, 4

• Weight-based dosing: 62.5 mg daily if <20 kg, 125 mg daily for 20-40 kg, 250 mg daily if >40 kg 1, 3, 4

• Treatment duration: 12 weeks for toenails 4

• Obtain baseline liver function tests and complete blood count before starting terbinafine, as it is unlicensed for pediatric use 4

• Alternative: Itraconazole pulse therapy (5 mg/kg/day for 1 week per month) for 3 pulses (3 months total) achieves 94-100% clinical cure rates 1, 3, 4

• Azoles (itraconazole or fluconazole) are preferred when Candida species are suspected 1, 4

When to Consider Oral Therapy

Oral antifungal therapy should be reserved for severe disease, failed topical therapy, concomitant onychomycosis, or immunocompromised patients. 2, 5

• This patient meets criteria for systemic therapy due to bilateral onychomycosis with nail plate involvement 5, 6
• Topical therapy alone is insufficient for onychomycosis, though some guidelines suggest it may work in children due to thinner, faster-growing nail plates 1

Prevention Strategies to Include in Patient Education

Your patient education should include specific environmental control measures to prevent reinfection. 1, 2

• Apply antifungal powder (miconazole, clotrimazole, or tolnaftate) inside shoes daily 1, 2
• Change socks daily and wear cotton, absorbent socks 1, 2
• Thoroughly dry between toes after showering 2
• Discard old, moldy footwear when possible, or place naphthalene mothballs in shoes sealed in plastic bag for minimum 3 days 1, 2
• Alternatively, spray terbinafine solution into shoes periodically 1, 2
• Wear protective footwear in public bathing facilities, gyms, and locker rooms 1, 2
• Cover active foot lesions with socks before wearing underwear to prevent spread to groin area 2
• Avoid sharing toenail clippers with family members 1
• Keep nails as short as possible 1

Common Pitfalls to Avoid

Do not assume fungal infection without laboratory confirmation, as this leads to inappropriate treatment in 50% of cases. 3, 4

• Inflammatory tinea pedis can masquerade as bacterial cellulitis in children—KOH examination prevents misdiagnosis 8
• Failing to treat all infected family members simultaneously results in reinfection 1, 2
• Neglecting to address contaminated footwear as a source of reinfection leads to recurrence 1, 2
• Not examining for concomitant infections at other body sites misses 25% of cases with multiple-site involvement 1, 2

Procedural Documentation Strengths

Your procedure note for partial nail removal is well-documented with appropriate elements:

• Clear indication (symptomatic partially detached nail) 6
• Patient consent obtained 6
• Procedure details (cleaning, removal technique, patient tolerance) 6
• Post-procedure care (coband wrapping to prevent snagging) 6

Follow-Up Recommendations

Monitor this patient for at least 48 weeks from treatment start to identify potential relapse, as children achieve higher cure rates but require extended monitoring. 4

• Reassess clinical response at 4-6 weeks after initiating topical therapy 5
• If systemic therapy is initiated after mycological confirmation, monitor liver function tests for patients on terbinafine or itraconazole receiving continuous therapy >1 month 3
• Podiatry follow-up is appropriate for ongoing nail management 6