See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/262795242

Onychomycosis in children

Article  in  Expert Review of Dermatology · January 2014

DOI: 10.1586/edm.12.58

CITATIONS READS

11 4,823

3 authors, including:

Bianca Maria Piraccini Michela Starace

University of Bologna University of Bologna
361 PUBLICATIONS   5,391 CITATIONS    68 PUBLICATIONS   631 CITATIONS   

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Michela Starace on 09 January 2015.

The user has requested enhancement of the downloaded file.

 CME Review

Onychomycosis in children
Expert Rev. Dermatol. 7(6), 569–578 (2012)

Bianca Maria Onychomycosis in children is rare, with an approximate worldwide prevalence in children
Piraccini*, Michela below the age of 18 years of lower than 0.5%. Dermatophytes are responsible for the majority
Starace and Francesca of the cases, with distal subungual onychomycosis of one toenail the most frequent clinical
variety. Candida sp. may invade the nails only in predisposed children, usually producing a
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14

Bruni
total onychomycosis. Care should be taken when diagnosing onychomycosis in children, as
Department of Specialized the sole clinical appearance is not enough to establish a diagnosis and mycology is always
experimental and diagnostic medicine,
University of Bologna, Via Massarenti, mandatory.
140138 Bologna, Italy
*Author for correspondence: Keywords: Candida sp. • children • dermatophytes • differential diagnosis • fungi • nail • onychomycosis
Tel.: +39 051 636 3677
Fax: +39 051 636 4867
biancamaria.piraccini@unibo.it
Medscape: Continuing Medical Education Online

This activity has been planned and implemented in

accordance with the Essential Areas and policies of the
Accreditation Council for Continuing Medical Education through the joint sponsorship of
For personal use only.

Medscape, LLC and Expert Reviews Ltd. Medscape, LLC is accredited by the ACCME to provide
continuing medical education for physicians.
Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA
Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent
of their participation in the activity.
All other clinicians completing this activity will be issued a certificate of participation. To par-
ticipate in this journal CME activity: (1) review the learning objectives and author disclosures;
(2) study the education content; (3) take the post-test with a 70% minimum passing score and
complete the evaluation at www.medscape.org/journal/expertderm; (4) view/print certificate.

Release date: 11 December 2012; Expiration date: 11 December 2013

Learning objectives
Upon completion of this activity, participants will be able to:
• Assess the epidemiology and etiology of onychomycosis among children
• Distinguish the clinical presentation of onychomycosis among children
• Analyze the differential diagnosis of nail disorders among children
• Evaluate the management of onychomycosis among children

www.expert-reviews.com 10.1586/EDM.12.58 © 2012 Expert Reviews Ltd ISSN 1746-9872 569

 Review Piraccini, Starace & Bruni CME

Financial & competing interests disclosure

Editor
Elisa Manzotti
Publisher, Future Science Group, London, UK.
Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.
CME Author
Charles P Vega, MD
Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine, CA, USA.
Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.
Authors and Credentials
Bianca Maria Piraccini, MD
Department of Specialised Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy.
Disclosure: Bianca Maria Piraccini, MD, has disclosed no relevant financial relationships.
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14

Michela Starace, MD
Department of Specialised Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy.
Disclosure: Michela Starace, MD, has disclosed no relevant financial relationships.
Francesca Bruni, MD
Department of Specialised Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy.
Disclosure: Francesca Bruni, MD, has disclosed no relevant financial relationships.

Onychomycosis is traditionally a disease of the elderly, with preva- devoted to differential ­diagnosis of onychomycosis in children, a
lence increasing above the age of 60 years [1] . However, this diag- task that ­sometimes is not adequately considered.
For personal use only.

nosis cannot be excluded in children presenting with suggestive

nail abnormalities, and mycology should be performed. After a
review in 2009 [2] , other articles have been published reporting
onychomycosis in children, sometimes as single case reports [3–5] ,
other times as case series [6–11] .
This review will cover old and new data on onychomycosis in
children with regards to ­prevalence, etiological agents, p
­ redisposing
­factors, clinical features and treatment. A s­ pecial section has been
Prevalence of onychomycosis in children: is there any
change?
Onychomycosis in children is rare. The prevalence that results
from new articles, even if difficult to assess, confirms a world-
wide prevalence of onychomycosis in children below the age
of 18 years of lower than 0.5%, with higher numbers in some
countries. A case series study from Peru reports, in fact, a
prevalence of onychomycosis in adolescents aged 12–17 years
of 3.4% [8] , figures similar to those found years ago in other
tropical countries such as Mexico and Guatemala [12,13] . This
higher prevalence of onychomycosis in children in countries
with a hot climate is not related to causative fungi, that is der-
matophytes and Trichophyton rubrum in particular, the respon-
sible pathogens in all series, but it is possibly related to the
humid feet environment that facilitates tinea pedis. Although
the prevalence of onychomycosis increases with child age, with
higher frequency above the age of 12 years, cases in infants can
indeed occur.

Etiological agents: dermatophytes

Figure 1. Tinea pedis plantaris ‘mocassin type’ in an
8-year-old girl with Trichophyton rubrum onychomycosis.
Mild erythema and scaling.
Dermatophytes are responsible for the great majority of onycho-
mycosis in children, accounting for more than 95% of cases.
Nondermatophyte molds are extremely rare. Among dermato-
phytes, the prevalence of the different species parallels that of
adults, with T. rubrum and Trichophyton interdigitale as the most
common causes.
A study on onychomycosis observed in children in a 20-year
period in the sanitary area of Santiago de Compostela, Spain,
has reported several cases of onychomycosis of the fingernails
and toenails due to Trichophyton tonsurans, not associated with

570 Expert Rev. Dermatol. 7(6), (2012)

 CME
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14
Figure 2. Distal subungual onychomycosis caused by
Trichophyton rubrum in a 7-year-old boy: lateral onycholysis
and mild subungual hyperkeratosis can be seen.
For personal use only.
tinea capitis [10] . The authors related this emerging pathogen as
a sign of migratory phenomenon and suggest to look for tinea
capitis in children with T. tonsurans fingernail onychomycosis. In
the same way, Microsporum canis can invade the nails in children
with tinea capitis due to this dermatophyte, but this occurrence is
very rare, probably due to the low capacity of Microsporum canis
for invading hard keratins.
Candida sp. may invade the nails – both ­fingernails and toe-
nails, in predisposed children – as occurs in premature newborns
and in children with iatrogenic or genetic immunodeficiencies.
Predisposing factors: tinea pedis, family history &
immunodepression
The most important predisposing factors for dermatophyte onych-
omycosis in children include tinea pedis and family members
affected by onychomycosis or tinea pedis. It is well-known that
anthropophylic dermatophytes such as T. rubrum and T. interdigi-
tale may produce chronic foot disease in several members of the
same family due to a genetic predisposition to the infection [14] .
Box 1. Differential diagnosis of onychomycosis in
children, according to clinical presentation.
• Congenital malalignment of the great toenail
• Pachyonychia congenita
• Traumatic onycholysis
• Nail psoriasis
• Parakeratosis pustolosa
• Punctate leukonychia
• Nail fragility
www.expert-reviews.com
Onychomycosis in children Review
Figure 3. White superficial onychomycosis ‘classic type’ due
to Trichophyton interdigitale in a 12-year-old boy:
superficial white nail fragility caused by fungal colonies
can be seen.
Tinea pedis in children is usually moccasin-type and very mild.
It clinically presents with bilateral slight erythema of the sole with
mild scaling (Figure 1) .
The use of occlusive shoes, feet trauma and barefoot contact
with the soil are, on the other hand, still not proven predispos-
ing factors for the development of onychomycosis in children.
Predisposing factors to Candida onychomycosis are all types of
immunodeficiencies, including incomplete development of the
immune system in premature newborns, chronic mucocutaneous
candidiasis and iatrogenic immunodeficiencies.
Clinical features: do not overestimate!
Distal and lateral subungual onychomycosis is the most com-
mon clinical presentation of onychomycosis owing to derma-
tophytes in children, as it is in adults [15] . The affected nail,
usually a single toenail in children, presents a disto-lateral area
of onycholysis and a mild-to-moderate subungual hyperkeratosis
(F igure 2) . The color of the detached area ranges from white to
­yellow to orange.
Superficial onychomycosis, both in its ‘deep’ and ‘classic’ varie-
ties, is rare and especially found in young children. In the ‘clas-
sic’ variety of superficial onychomycosis, the nail plate of one
or several toenails shows multiple small, whitish opaque friable
patches that are easily scraped away (Figure 3) . The ‘deep’ variety
571
 Review Piraccini, Starace & Bruni CME

Differential diagnosis of
onychomycosis in children
Care should be taken when diagnosing
onychomycosis in children, as the sole
clinical appearance is not enough to
establish the diagnosis and mycology is
always mandatory. Potassium hydroxide
(KOH) and cultures are still the easiest
way to confirm the clinical diagnosis
of onychomycosis, as other techniques,
including PAS stain of nail clippings
and PCR, are not always available.
Differential diagnosis may sometimes be
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14

difficult, especially in older children who

may have nail diseases that are, on the
other hand, rare before the age of 5 years
[16] . Dermatophyte onychomycosis is fre-
quently restricted to one digit, usually
the toenail, but a fingernail can also be
Figure 4. White superficial onychomycosis ‘deep’ caused by Trichophyton affected. Candida onychomycosis fre-
interdigitale in a 6-year-old boy: the nail plate is diffusely white and opaque quently occurs in all digits and is most
due to massive fungal invasion. severe in the fingernails.
Diseases that should be excluded in
of superficial onychomycosis presents with a larger and deeper ­differential diagnosis with onychomycosis
For personal use only.

nail plate involvement (Figure 4) . Proximal subungual onychomy- in children are listed in Box 1.
cosis in children is uncommon, while total onychomycosis can
occur as an evolution of any form, when fungi grow to colonize Congenital malalignment of the great toenail
the whole nail. The condition is not rare but is frequently undiagnosed. The
Onychomycosis owing to Candida may present as disto-lat- nail plate of one of both the big toenails deviates laterally from
eral subungual onychomycosis, usually affecting fingernails and the longitudinal axis of the distal phalanx. Congenital malalign-
toenails (Figure 5) , and as superficial onychomycosis. Paronychia ment is already present at birth, but the nail becomes thickened
is frequently associated with any form of Candida onychomy- and discolored with aging, clinical dystrophy being evident at
cosis and is especially severe in children affected with chronic around the age of 3 years. The affected nail has a triangular shape
­mucocutaneous candidiasis. and frequently shows dystrophic changes due to repetitive trau-
matic injuries. The nail plate may be thickened, yellow–brown
in color and presents transverse ridging due
to ­intermittent nail matrix damage [17] .
Onycholysis is frequent (Figure 6) .

Pachyonychia congenita
This is a rare condition but must be
excluded in children with thick nails. Nail
abnormalities are in fact a constant feature
and usually develop during childhood [18] .
All the nails are thickened, difficult to trim
and show an increase in the lateral curva-
ture of the nail plate (Figure 7) . Associated
findings include follicular hyperkerato-
sis and palmoplantar keratoderma. Oral
lesions are characteristic for type I, while
premature dentition and pilosebaceous
cysts are observed in type II. When pre-
Figure 5. Distal subungual onychomycosis caused by Candida in a newborn:
onycholysis and subungual hyperkeratosis with yellow discoloration of several sented with a child with thickening of all
fingernails. nails a careful family history should be
taken.

572 Expert Rev. Dermatol. 7(6), (2012)

 CME Onychomycosis in children Review

Traumatic onycholysis of the toenails

Traumatic onycholysis of the toenails is
very common in adults but can occur in
children due to trauma from ill-fitting
shoes. The nail plate is detached from
the nail bed and appears white because of
the presence of air in the subungual space
(Figure 8) . Onycholysis frequently involves
the lateral side of the nail. Although nail
dermoscopy may be useful for differential
diagnosis, showing specific patterns for
onychomycosis, mycology is m ­ andatory to
rule out fungal infection [19] .
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14

Nail psoriasis Figure 6. Congenital malalignment of the great toenails with distal onycholysis
Nail involvement is not rare in children and subungual hyperkeratosis. Differential diagnosis with distal subungual
with skin psoriasis and the nails may be onychomycosis requires mycology.
the sole localization of the disease. The
clinical manifestations of nail psoriasis
in children are quite similar to those of
adults, with fingernails more commonly
affected than toenails. The typical symp-
tom is nail pitting, characterized by deep
and irregular punctate depressions on the
For personal use only.

nail plate surface. Diffuse crumbling of the

nail plate is uncommon and must be differ-
entiated from total onychomycosis caused
by Candida in immunodepressed patients
(F igure  9) . Nail psoriasis of the nail bed
produces salmon patches, which appear
as reddish-orange patches localized in the
center of the nail or surrounding an area
of onycholysis, onycholysis and sub­ungual
hyperkeratosis. Differential diagnosis with
distal subungual onychomycosis may be
difficult when nail psoriasis involves the
nail bed of one or a few digits, producing
onycholysis and subungual hyperkerato-
sis. The presence of splinter hemorrhages
­suggests psoriasis (Figure 10) .

Parakeratosis pustulosa
Parakeratosis pustulosa is a chronic con-
dition that exclusively affects children
and usually involves a single finger, most
commonly a thumb or an index finger. It
is now considered a variant of nail pso-
riasis in c­ hildren, as most of the patients
will develop psoriasis [20] . The affected
digit shows eczematous changes of the
Figure 7. Pachyonychia congenita. Nail lesions in a 7-year-old boy. All nails show mild
hyponychium and pulp associated with thickening with distal onycholysis and subungual hyperkeratosis.
mild distal subungual hyperkeratosis and
onycholysis (Figure 11) . Nail abnormalities
are usually more marked on a corner of the nail. The nail plate Differential diagnosis with distal subungual onychomycosis
may occasionally show superficial abnormalities and pitting. requires mycology, also taking into account that in children

www.expert-reviews.com 573
 Review Piraccini, Starace & Bruni
Figure 8. Traumatic onycholysis of the left toenail in a
12-year-old girl: the subungual space is white and there is
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14
no hyperkeratosis.
For personal use only.
Figure 9. Nail psoriasis of the fourth left fingernail in a
5-year-old girl. Diffuse crumbling of the nail plate.
Figure 11. Parakeratosis pustulosa. A single fingernail showing mild subungual
hyperkeratosis and onycholysis, associated with periungual scaling. Note traumatic
punctate leukonychia of the fifth fingernail.
574
CME
Figure 10. Nail psoriasis of the third right toenail.
Onycholysis with erythematous border and splinter hemorrhages.
distolateral subungual onychomycosis is often confined to a ­single
fingernail.
Subungual exostosis
Subungual exostosis is a benign bone tumor of the distal pha-
lanx occurring beneath or adjacent to the nail. It is commonly
precipitated by trauma and is usually seen on the great toe of
young patients. Clinically, subungual exostosis appears as a firm,
­tender subungual nodule that elevates the nail plate (Figure 12) . The
nodule may ulcerate or become ­hyperkeratotic. The diagnosis is
­confirmed by x-ray examination.
Subungual warts
HPV-induced warts are frequent in children, the most common
localizations being the proximal nail fold and the pulp. Warts
may localize in the hyponychium, producing a keratotic mass
under the nail (Figure 13) .
Punctate leukonychia
Punctate leukonychia should be consid-
ered in differential diagnosis with white
superficial onychomycosis. The nail plate
shows small, opaque, white spots that
move distally with nail growth and some-
times disappear before reaching the dis-
tal nail (Figure 14) . It is caused by trauma
and is most commonly observed in the
fingernails.
Nail fragility
Children’s nails are very thin, as thickening
gradually occurs with aging, and are very
prone to breakage. The distal nail plate
often has an irregular, sharp margin due to
breakage of small nail fragments and shows
lamellar splitting. Diffuse nail plate fragil-
ity can be see on the toenails and may be
misdiagnosed as superficial ­onychomycosis
(Figure 15) .
Expert Rev. Dermatol. 7(6), (2012)
 CME Onychomycosis in children Review

Besides these nail diseases that can be dif-

ferentiated from onychomycosis through a
careful clinical examination and mycology,
other nail abnormalities are commonly
wrongly called onychomycosis as yeast
can be isolated from them. These mainly
include irritant paronychia (nail sucking).
Thumb sucking occurs in approximately
80% of babies and infants, and generally
stops by the age of 5 years. The continu-
ous maceration of the periungual tissues
by saliva, which also has irritant properties
as it is more alkaline, induces inflamma-
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14

tion of the periungual tissues and nail plate

changes (chronic paronychia). The proxi-
mal nail fold shows mild erythema, edema
and absence of the cuticle, and the nail
plate shows surface abnormalities (Figure 16) .
Bacteria and yeast easily colonize the mois-
Figure 12. Subungual exostosis of the fourth right toenail in a 13-year-old boy
tened new space under the proximal nail who played soccer: the subungual mass uplifts the nail plate.
fold and are often isolated when micro-
biology tests are carried out. Isolation of is not effective against Candida. A possible alternative for chil-
Candida from the fingers with paronychia due to sucking, however, dren suffering from onychomycosis is itraconazole, also effective
only indicates secondary colonization and not primary invasion. against Candida, prescribed in pulse therapy as for adults, at a
For personal use only.

In the same way, isolation of fungi from the nails or a positive dose of 5 mg/kg/day for 1 week per month for 2 months for
KOH nail examination do not allow diagnosis of onychomycosis fingernails and 3 months for toenails. Fluconazole can be used
if the clinical features are not consistent with fungal nail inva-
sion. A paper published in 2012 reports a 9-month-old child
with recurrent onychomadesis of the fingernails associated with
erythematous papules and plaques on the dorsum of the hand
and wrist [5] . Skin scrapings from the hand cultured T. tonsurans
and KOH examination of the nail showed septate hyphae. The
authors concluded that onychomadesis was a clinical presentation
of fungal nail infection, while it is more likely that periodic nail
shedding resulted from nail matrix damage due to inflammation
of the skin on the hand induced by the fungus.

Treatment
There are no new data on the treatment of onychomycosis in
children, and the drugs available remain the same. Since the
condition is very rare, there are no published series, thus a com-
parison between efficacy and tolerability of the different agents
is not possible. The indications for treatment come from the
authors’ personal experience, discussion with other nail experts
and from cases published in the literature.
Distal subungual onychomycosis caused by dermatophytes
involving several digits, particularly in children with tinea pedis
and strong familial predisposition, which are therefore prone
to recurrences, is an indication for systemic treatment. Possible
options include terbinafine tablets, which can be chopped into
small pieces and put into meals at a dosage of a quarter of a
tablet in children weighing <20 kg and half of one tablet in Figure 13. Subungual wart of the fifth right fingernail in a
children weighing 20–40 kg. Above that weight, the dosage 7-year-old girl: subungual scales uplift and detach the
distal nail plate and resemble distal subungual
is 1 tablet, as for adults. Duration of treatment is 6 weeks for onychomycosis.
fingernail and 3 months for toenail onychomycosis. Terbinafine

www.expert-reviews.com 575
 Review Piraccini, Starace & Bruni CME

Expert commentary
From our experience and from the data
obtained in the literature, few comments are
new since our 2009 review. The most com-
mon form of onychomycosis we can encoun-
ter in our practice is distal sub­ungual onycho-
mycosis due to dermatophyte involving the
first toenail or a fingernail, as onychomycosis
caused by Candida is more commonly seen by
pediatricians or by ­pediatric dermatologists.
When facing a child with a whitish nail,
or a nail detached and uplifted from the
nail bed, we should perform a thorough
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14

clinical examination, looking at the nail

dystrophy with attention, perhaps with
the aid of a dermatoscope. The soles and
interdigital spaces should be checked for
signs of tinea pedis, and a family ­history of
nail diseases should be obtained.
In our experience, onychomycosis is not
a common cause of nail disease in children,
thus other possible causes should be ruled
Figure 14. Punctate leukonychia in the fingernails of an 8-year-old boy: small out in differential diagnosis. Mycology will
white spots within the nail plate that has a normal surface. solve any doubt. The choice of treatment
For personal use only.

should be based on mycology results and

both in dermatophyte and Candida onychomycosis at a dose of disease severity. Follow-up is mandatory as onychomycosis tends
3–6 mg/kg once a week. Duration of therapy is 12–16 weeks to relapse, more often in children than in adults.
for fingernails and 18–26 weeks for toenails.
Duration of treatment with itraconazole and fluconazole may Five-year view
be longer in children with immunodepression and with chronic Diagnostic methods could be improved over the next 5 years,
mucocutaneous candidiasis. Topical therapy, whether associated with quick and inexpensive techniques made available to every
or not with mechanical or ­chemical avulsion of the affected nail, dermatological center. Most topical drugs on the market are not
is suggested in mild distal subungual onychomycosis of one digit approved for child use, and the possibility of overcoming this
and in superficial onychomycosis. However, none of the available problem is the best hope for the future.
topical drugs for ­onychomycosis are indicated for use in children.
Recurrences of dermatophyte onychomycosis seem to be more
common in children than in adults, ­perhaps due to their strong
predisposing factors.

Figure 16. Paronychia due to finger sucking of two fingers

in a 1-year-old boy: swelling and mild erythema of the
proximal nail folds, absent cuticles and an irregular nail
Figure 15. Nail fragility in an 8-month-old child: the distal plate surface can be seen. Isolation of Candida indicates
nail plate is broken with sharp margins. secondary colonization and not primary invasion.

576 Expert Rev. Dermatol. 7(6), (2012)

 CME
Key issues
• Onychomycoses in children are rare, and worldwide data confirm a prevalence below 0.5%, except for some countries with a higher
incidence, as such as Mexico and Guatemala (>5%).
• Dermatophytes are the most common cause in children with familial predisposition to fungal disease.
• The most difficult task is diagnosis: do not underestimate, but to not overestimate onychomycosis in children!
• Treatment options are the same as for adults, but topical drugs are not approved for use in children.
References
Papers of special note have been highlighted as:
• of interest
•• of considerable interest
1 Raran R. The nail in the elderly. Clin.
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14
Dermatol. 29, 54–60 (2011).
• In-depth review of all nail changes
observed in the elderly.
2 Piraccini BM, Patrizi A, Sisti A, Neri I,
Tosti A. Onychomycosis in children. Exp.
Rev. Dermatol. 4, 177–184 (2009).
•• Broad review of onychomycosis in
children, divided into clinical types and
etiological agents.
3 Zac RI, Café ME, Neves DR,
E Oliveira PJ, Barbosa VG. Onychomycosis
For personal use only.
in a very young child. Pediatr. Dermatol.
26(6), 761–762 (2009).
4 Khurana VK, Gupta RK, Pant L, Jain S,
Chandra K, Sharma Y. Trichophyton
rubrum onychomycosis in an 8-week-old
infant. Indian J. Dermatol. Venereol. Leprol.
77(5), 625 (2011).
5 Khanna D, Khanna PP, Fitzgerald JD et al.
2012 American College of Rheumatology
guidelines for management of gout. Part 2:
therapy and antiinflammatory prophylaxis
of acute gouty arthritis. Arthritis Care Res.
(Hoboken) 64(10), 1447–1461 (2012).
6 Vásquez-del Mercado E, Arenas R.
[Onychomycosis among children. A
retrospective study of 233 Mexican cases].
Gac. Med. Mex. 144(1), 7–10 (2008).
7 Pérez-González M, Torres-Rodríguez JM,
Martínez-Roig A et al. Prevalence of tinea
pedis, tinea unguium of toenails and tinea
capitis in school children from Barcelona.
www.expert-reviews.com
Onychomycosis in children
Rev. Iberoam. Micol. 26(4), 228–232
(2009).
8 Medina Flores J, Bejar Castillo V,
Cortez Franco F, Betanzos Huata A. Super-
ficial fungal infections: clinical and
epidemiological study in adolescents from
marginal districts of Lima and Callao,
Peru. J. Infect. Dev. Ctries 3, 313–317
(2009).
9 Leibovici V, Evron R, Dunchin M,
Westerman M, Ingber A. A population-
based study of toenail onychomycosis in
Israeli children. Pediatr. Dermatol. 26(1),
95–97 (2009).
10 Rodríguez-Pazos L, Pereiro-Ferreirós MM,
Pereiro M Jr, Toribio J. Onychomycosis
observed in children over a 20-year period.
Mycoses 54(5), 450–453 (2011).
11 Young LS, Arbuckle HA, Morelli JG.
Onychomycosis in the Denver pediatrics
population: a retrospective study. Pediatr.
Dermatol. (2012)
doi:10.1111/j.1525-1470.2012.01769.x.
(Epub ahead of print).
12 Ruiz-Esmenjaud J, Arenas R,
­Rodríguez-Alvarez M, Monroy E,
Felipe Fernández R. [Tinea pedis and
­onychomycosis in children of the Mazahua
Indian Community in Mexico]. Gac. Med.
Mex. 139(3), 215–220 (2003).
13 Chang P, Logemann H. Onychomycosis in
children. Int. J. Dermatol. 33(8), 550–551
(1994).
14 Rebell G, Zaias N. Tinea pedis: the child
and the family. Pediatr. Dermatol. 16(2),
157 (1999).
15 Hay RJ, Baran R. Onychomycosis: a
proposed revision of the clinical
Review
c­ lassification. J. Am. Acad. Dermatol.
65(6), 1219–1227 (2011).
•• Classification of onychomycosis that
includes all possible varieties and
etiological agents. Helpful for correct
management of the disease.
16 Richert B, André J. Nail disorders in
children: diagnosis and management. Am.
J. Clin. Dermatol. 12(2), 101–112 (2011).
17 Perlis CS, Telang GH. Congenital
malalignment of the great toenails
mimicking onychomycosis. J. Pediatr.
146(4), 575 (2005).
18 Iorizzo M, Vincenzi C, Smith FJ,
Wilson NJ, Tosti A. Pachyonychia
congenita type I presenting with subtle nail
changes. Pediatr. Dermatol. 26(4),
492–493 (2009).
19 Piraccini BM, Balestri R, Starace M,
Rech G. Nail digital dermoscopy
(onychoscopy) in the diagnosis of
onychomycosis. J. Eur. Acad. Dermatol.
Venereol. (2011) doi:
10.1111/j.1468-3083.2011.04323.x. (Epub
ahead of print).
• Study that compared clinical and
dermoscopic features with mycology
results and suggested dermoscopic
features typical of traumatic
onycholycolisis and distal onychomycosis.
20 Tosti A, Peluso AM, Zucchelli V. Clinical
features and long-term follow-up of 20
cases of parakeratosis pustulosa. Pediatr.
Dermatol. 15(4), 259–263 (1998).
• First and largest series of children
published with the disease, describing
clinical features, causes and evolution.
577
 Review Piraccini, Starace & Bruni CME

Onychomycosis in children

To obtain credit, you should first read the journal article. After
reading the article, you should be able to answer the following,
related, multiple-choice questions. To complete the questions
(with a minimum 70% passing score) and earn continuing medi-
cal education (CME) credit, please go to www.medscape.org/
journal/expertderm. Credit cannot be obtained for tests com-
pleted on paper, although you may use the worksheet below to
keep a record of your answers. You must be a registered user on
Expert Review of Dermatology Downloaded from informahealthcare.com by 116.226.77.86 on 05/20/14
that physicians not licensed in the US who participate in this
CME activity are eligible for AMA PRA Category 1 Credits™.
Through agreements that the AMA has made with agencies in
some countries, AMA PRA credit may be acceptable as evidence
of participation in CME activities. If you are not licensed in the
US, please complete the questions online, print the AMA PRA
CME credit certificate and present it to your national medical
association for review.

Medscape.org. If you are not registered on Medscape.org, please

click on the New Users: Free Registration link on the left hand
side of the website to register. Only one answer is correct for each
question. Once you successfully answer all post-test questions
you will be able to view and/or print your certificate. For ques-
tions regarding the content of this activity, contact the accredited
provider, CME@medscape.net. For technical assistance, contact
CME@webmd.net. American Medical Association’s Physician’s
Recognition Award (AMA PRA) credits are accepted in the
US as evidence of participation in CME activities. For further
information on this award, please refer to http://www.ama-assn.
For personal use only.
Activity Evaluation
Where 1 is strongly disagree and 5 is strongly agree
1 2 3 4 5
1. The activity supported the learning objectives.
2. The material was organized clearly for
learning to occur.
3. The content learned from this activity will
impact my practice.
4. The activity was presented objectively and

org/ama/pub/category/2922.html. The AMA has determined free of commercial bias.

1. You are seeing a 5-year-old boy with a chief complaint of nail abnormalities. As you begin to evaluate this child,
what should you consider regarding the epidemiology and etiology of onychomycosis among children?
£ A The prevalence of onychomycosis among children is less than 0.5%
£ B The causative organisms of onychomycosis differ in tropical vs temperate countries
£ C Trichophyton tonsurans is the most important cause of onychomycosis among children
£ D Microsporum canis is the mostimportant cause of onychomycosis among children

2. What should you consider regarding the clinical features of onychomycosis and fungal infections among children
as you examine this patient?
£ A Tinea pedis is usually limited to the interdigital space and is severe among children
£ B Most cases involve the entire nail
£ C Most cases involve only a single toenail
£ D The color of the nail in onychomycosis is invariably white

3. What should you consider regarding other conditions that might mimic onychomycosis in this case?
£ A Congenital malalignment of the great toenail is usually evident by age 3 months
£ B Pachyonychia congenita involves all the nails
£ C Traumatic onycholysis is characterized by a lack of changes to the color of the nail plate
£ D Toenails are more commonly affected than fingernails in cases of psoriasis

4. You diagnose onychomycosis in this child. What should you consider regarding treatment of this condition?
£ A Onychomycosis limited to the distal subungual area does not merit treatment
£ B Onychomycosis in several digits is an indication for systemic treatment
£ C Terbinafine should be avoided among children
£ D Several topical drugs are indicated for the treatment of superficial onychomycosis among children

578 Expert Rev. Dermatol. 7(6), (2012)

View publication stats