What is the recommended treatment for a pediatric patient with a generalized fungal skin infection?

Treatment for Generalized Fungal Skin Infection in Pediatric Patients

For a pediatric patient with a generalized superficial fungal skin infection (such as widespread tinea corporis), topical antifungal therapy with clotrimazole 1% cream applied 2-3 times daily for 7-14 days is the recommended first-line treatment. 1

Distinguishing Superficial from Invasive Disease

The term "generalized fungal skin infection" requires careful clinical assessment to determine whether this represents:

• Superficial dermatophyte infection (tinea corporis): Confined to skin surface, typically responds to topical therapy 2
• Invasive or systemic fungal infection: Requires systemic antifungal agents and represents a medical emergency 3

Critical distinction: If the patient has fever, immunocompromise, neutropenia, or signs of systemic illness, this is NOT a simple superficial infection and requires immediate systemic antifungal therapy as outlined below. 3

Treatment Algorithm for Superficial Generalized Fungal Skin Infections

First-Line Topical Therapy

• Apply clotrimazole 1% cream or paste formulation 2-3 times daily for 7-14 days to all affected areas 1
• Alternative topical agents include other azoles (miconazole, ketoconazole) or allylamines (terbinafine) for similar duration 2
• Avoid systemic ketoconazole due to hepatotoxicity, adrenal suppression, and drug interactions 1

When Systemic Therapy is Required for Extensive Superficial Infections

If topical therapy fails or the infection is too extensive for practical topical application:

• Terbinafine or griseofulvin are FDA-approved systemic options for dermatophyte infections in children 2
• These are specifically indicated for tinea capitis but can be considered for extensive tinea corporis 2

Treatment for Invasive/Systemic Fungal Infections

If the patient has invasive candidiasis, aspergillosis, or other systemic fungal infection, topical therapy is completely inadequate and systemic antifungal therapy must be initiated immediately. 1

For Invasive Candidiasis

Echinocandins are first-line agents for invasive candidiasis in children: 3

• Caspofungin: 70 mg/m² loading dose, followed by 50 mg/m²/day IV (A-I recommendation) 3
• Micafungin: 2-4 mg/kg/day IV (A-I recommendation) 3
• Anidulafungin: 3 mg/kg loading dose, followed by 1.5 mg/kg/day IV (B-II recommendation) 3

Alternative first-line option:

• Liposomal amphotericin B: 3 mg/kg/day IV (A-I recommendation, with lower toxicity in children compared to adults) 3

Fluconazole (8-12 mg/kg once daily) is appropriate for invasive or mucosal candidiasis but is NOT mold-active 1, 4

For Invasive Aspergillosis

Voriconazole is the first-line agent for invasive aspergillosis in children ≥2 years: 3, 5

• Dosing: 9 mg/kg twice daily orally (maximum 350 mg twice daily) 3, 6
• Therapeutic drug monitoring (TDM) is mandatory: Target trough concentrations 1-5.5 mg/L for treatment 3
• Check levels on day 3 and repeat regularly during therapy 3

Alternative agents for invasive aspergillosis: 3

• Liposomal amphotericin B in amphotericin B-naive patients (B-IIt recommendation) 3
• Caspofungin (B-IIt recommendation) 3
• Posaconazole for patients ≥13 years with TDM (target trough >1 mg/L for treatment) (B-IIt recommendation) 3

High-Risk Immunocompromised Patients

For pediatric patients with acute myeloid leukemia, allogeneic hematopoietic stem-cell transplantation, or graft-versus-host disease requiring systemic immunosuppression, mold-active prophylaxis is strongly recommended: 3

• Echinocandin, voriconazole, or itraconazole for children <13 years 3
• Posaconazole may also be used in those ≥13 years 3
• Do NOT use amphotericin routinely for prophylaxis (strong recommendation against) 3

Critical Monitoring and Drug Interactions

All azole antifungals (voriconazole, posaconazole, itraconazole) require therapeutic drug monitoring and have significant interactions with immunosuppressants (cyclosporine, tacrolimus, sirolimus) 3, 6, 4

Voriconazole shows high inter- and intraindividual pharmacokinetic variability and is both a substrate and inhibitor of CYP450, carrying high potential for drug-drug interactions 3

Duration of Therapy

• Superficial infections: 7-14 days of topical therapy 1
• Invasive candidiasis: 14 days after blood cultures are sterile, provided no unresolved deep infection 3
• Invasive aspergillosis: Continue until clinical improvement and resolution of immunosuppression 3

Common Pitfalls to Avoid

• Never attempt topical treatment for invasive, systemic, or mucosal fungal infections - these require systemic therapy 1
• Never use systemic ketoconazole in pediatric patients 1
• Do not forget ophthalmological examination in all cases of candidemia to assess for endophthalmitis 3
• Consider removing or replacing intravenous catheters in candidemia cases 3
• Do not use fluconazole for mold infections (Aspergillus, Fusarium, Scedosporium) - it lacks mold activity 3, 1