Received: 21 February 2022 Accepted: 15 July 2022

DOI: 10.1111/pde.15100

Pediatric
REVIEW ARTICLE Dermatology

Systematic review of the prevalence of onychomycosis

in children

Sif Vestergaard-Jensen1 | Abdullah Mansouri MD2 | Lise Heilmann Jensen MD2 |

1,3 1,3
Gregor B. E. Jemec MD, DrMedSci | Ditte Marie L. Saunte MD, PhD

1
Department of Dermatology, Zealand
University Hospital, Roskilde, Denmark
2
Department of Pediatrics, Zealand University
Hospital, Roskilde, Denmark
3
Department of Clinical Medicine, Faculty of
Health Science, University of Copenhagen,
Copenhagen, Denmark
Correspondence
Ditte Marie L. Saunte, Department of
Dermatology, Zealand University Hospital,
Roskilde, Sygehusvej 10, DK-4000 Roskilde,
Denmark.
Email: disa@regionsjaelland.dk
Abstract
Onychomycosis is one of the most common nail diseases in adults but is described as
infrequent in children. Data are, however, scattered and diverse. Studies have never-
theless suggested that the prevalence of onychomycosis is increasing in children
lately and the aim of this review was therefore to examine this problem. Two authors
individually searched PubMed, Embase, and Cochrane Library for articles on epidemi-
ology and prevalence of onychomycosis in children. The literature search was con-
ducted in accordance per PRISMA guidelines. In total 1042 articles were identified of
which 23 were eligible for inclusion. One of the articles presented two studies and a
total of 24 studies were therefore included. Seventeen studies presented data of the
prevalence of onychomycosis in children in the general population and seven studies
among children visiting a dermatological and pediatric department or clinic. The prev-
alence ranged from 0% to 7.66% with an overall discrete increase of 0.66% during
the period 1972 to 2014 in population studies (not statistically significant). This
review supports a trend towards an increased prevalence of onychomycosis in chil-
dren, albeit based on a paucity of studies. The data suggests an increasing prevalence
of onychomycosis with age, and co-infection with tinea pedis (reported in 25% of the
studies). The most common pathogen reported was Trichophyton rubrum and onycho-
mycosis was more prevalent in toenails compared to fingernails. The general charac-
teristics of onychomycosis in children are thus similar to those described in adults.

KEYWORDS
child, onychomycosis, prevalence, systematic review, tinea

1 | I N T RO DU CT I O N onychomycosis in children may have increased over the last three

Fungal infection of the nails accounts for 15%–40% of all nail disease
and is one of the most common nail diseases in adults. The prevalence
of onychomycosis increases with age and is reported to be infrequent
in children.1 It has nevertheless been suggested that the incidence of
decades.2–4 However, most studies are retrospective and based on
information from medical records or laboratory data.2–4
Pediatric onychomycosis is important to diagnose and treat for
several reasons. Early detection and treatment of onychomycosis is
crucial to prevent disease progression.1 In addition, early treatment

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Pediatric Dermatology. 2022;39:855–865. wileyonlinelibrary.com/journal/pde 855

856 Pediatric VESTERGAARD-JENSEN ET AL.
Dermatology

F I G U R E 1 PRISMA Flow Diagram 2020. 6 Reason 1: Cohort of patients with a superficial mycosis or suspected onychomycosis
(n = 64), Reason 2: Not enough data on children (n = 21), Reason 3: Wrong publication type (n = 9), Reason 4: Wrong population (n = 3),
Reason 5: <100 children included (n = 2), Reason 6: Diagnosis method not available or specified (n = 2), Reason 7: Included in another
study (n = 1)

of onychomycosis can result in higher cure rates. Mild onychomy- 2 | M A T E R I A L S A N D M ET H O D S

cosis can be treated topically with good clearance in children. Few
antifungal therapies are licensed to onychomycosis treatment in
children. Topical therapy is used as monotherapy for milder cases
and is approved by the United States Food and Drug Administra-
tion (FDA) from the age of ≥12 years (ciclopirox), and ≥6 years (efi-
naconazole, tavaborole). Treatment with topical therapy is reported to
be more effective in children than in adults,5 with low risk of side
effects and low systemic exposure. Systemic treatment is added when
the disease is more severe but has a larger risk of drug interaction and
adverse events. No systemic antifungal therapy is licensed for treat-
ment of onychomycosis in children.5
The aim of this systematic review is to explore the worldwide
prevalence of onychomycosis in children.
This systematic review focus on the prevalence of onychomycosis in
children (0–18 years) and it is reported in accordance with the
PRISMA guidelines.6 The systematic review was registered at PROS-
PERO April 11, 2021 with the registration number
CRD42021241810. Details of the protocol can be accessed at www.
crd.york.ac.uk/prospero/display_record.php?ID=CRD42021241810.
The databases PubMed, Embase, and Cochrane Library were
searched for articles on March 11, 2021. Two authors (SVJ & AM)
conducted the search independently using the literature search tool
Rayyan.7 In case of disagreement the senior author (DMS) was
consulted.
The final search string is available in Appendix A.
TABLE 1 Studies on the prevalence of onychomycosis in children in the background population

Prevalence
Country, Male % of total Age range Diagnostic (number of cases/
[Ref.] publication year(ref) Study cohort Children/total children (years) method total) Etiological agents (n, %)
17
17 India, 1972 School 440/440 69.1% 5–16 CL + M + C 0.22% NA
(1/440)
23 Mexico, 200323 School 133/133 79.0% 7–18 CL + M + C 0.75% T. mentagrophytes (1, 100%)
VESTERGAARD-JENSEN ET AL.

(1/133)
28 Solomon Islands, 198528 Populationa 5160/10,224 NA 0–14 CL 7.66% NA
(395/5160)
18 UK, 198918 Primary schools 494/494 NA 5–10 CL + M + C 0.20% T. rubrum (1, 100%)
(1/494)
19 Finland, 199519 Schools 100/800 48% 6–10 CL + M + C 0% NA
(0/100)
24 Turkey, 200224 Primary schools 785/785 56.1% 6–14 CL + Mc 0.25% NA
Mean: 9.25 (2/785)
± 1.55
11 Turkey, 200411 Residents of the rural 109/227 NA 0–14 CL + M + C 0% NA
region of Duzce (0/109)
26 Turkey, 200526 Boarding school 166/682 100% 14–16 CL + M 0% NA
(0/166)
9 Turkey, 20069 Schools 7158/7158 52.6% 6–14 CL + M + C 0.15%b C. albicans (5, 45.5%)
(11/7158) C. glabrata (5, 45.5%)
C. tropicalis (1, 9.0%)
10 Turkey, 200610 Primary schools 23,235/23,235 54.5%b 7–14 CL + M + C 0.10% Trichosporon spp. (11, 45.8%)
Mean: 9.72 (24/23,235) T. rubrum (6, 25%)
± 1.06 C. albicans (5, 20.8%)
C. glabrata (2, 8.3%)
13 Israel, 200913 Primary schools 1148/1148 52.1% 5–14 CL + M + C 0.87% T. rubrum (7, 70%)
(10/1148) T. mentagrophytes (2, 20%)
C. albicans (1, 10%)
14 Peru, 200914 Schools 1361/1361 NA 12–17 CL + M + C 3.37% NA
(46/1361)
Pediatric

12 Spain, 200912 Schools 1305/1305 50.1% 3–15 CL + M + C 0.15% T. rubrum and T. tonsurans
Dermatology

(2/1305) (2, 100%)

27 Ethiopia, 201027 Primary schools 382/1104 NA 7–12 CL 7.59% NA
(29/382)
8 Turkey, 20138 Primary schools 8122/8122 49.6% 5–16 CL + M + C 0.33% T. rubrum (12, 44.4%)
Mean: 10.61 (27/8122) T. mentagrophytes (1, 3.7%)
± 2.41 T. tonsurans (1, 3.7%)
T. spp. (3, 11.1%)
C. glabrata (4, 14.8%)
857

(Continues)
 858 Pediatric VESTERGAARD-JENSEN ET AL.
Dermatology

2.1 | Inclusion criteria

Rhodotorula spp. (3, 11.1%)

Trichosporon spp. (2, 7.4%)
Studies reporting prevalence of onychomycosis in children published
Etiological agents (n, %)
C. parapsilosis (1, 3.7%)

E. floccosum (5, 71.4%)

in a peer reviewed journal in English or Danish language. Only studies

T. rubrum (2, 28.6%)

with 100 or more children (<18 years) were included.

Abbreviations: C., Candida; C, culture; CL, clinical; E., Epidermophyton; M, microscopy; NA, not available; OM, onychomycosis; SFI, superficial fungal infection; T., Trichophyton; spp., species.
2.2 | Exclusion criteria
NA

Studies with special patient groups (e.g., diabetes and immunodefi-

(number of cases/

ciency) and studies where the whole study population had or was sus-
pected of having onychomycosis or a superficial mycosis before
Prevalence

(2/6162)

entering the study were excluded. Studies focusing on a specific etio-

(7/800)
0.88%b
0.03%
total)

logical agent or laboratory surveys of specimens from patients with

suspected onychomycosis were also excluded.
Details of the literature search and screening of the articles are
CL + M + C

available in Figure 1.
Diagnostic
method

CL

2.3 | Data collection and statistic

Data on the prevalence of onychomycosis, publication year, country,

Mean: 9.42
Age range

± 2.00

the type and size of the study population, diagnostic method, preva-
(years)

6–12

5–16

lence of onychomycosis in fingernails compared with toenails, risk fac-

tors, etiological agents, concomitant mycosis, or skin disease were
extracted by one researcher (SVJ) to a predesigned Excel sheet. The
data were reported as a narrative synthesis. Meta-analysis could not
Male % of total

be made because of heterogeneity of the study designs. Linear regres-

children

sion was fitted to the data for prevalence of onychomycosis in chil-

44.8%

51%

dren in percent (%) as a function of time, using the program RStudio

Version 1.2.1335 (RStudio ©, Boston) to ascertain if the variable time
could explain the change in prevalence.
Children/total

6162/6162

800/800

3 | RE SU LT S

3.1 | Literature search

Screening in combination with a treatment campaign for Yaws.
Primary schools

A total of 1042 articles were identified by searching Embase,

Study cohort

PubMed, and Cochrane library of which 237 articles were dupli-

Calculation based on data extracted from the article.
Schools

cates and 805 were screened. Of these, 680 were out of scope, and
125 articles were read. In total 23 articles were included in the
review (Figure 1). The 23 articles with 24 studies were conducted
over a period of 44 years. A total of 17 studies explored the preva-
C was performed but contaminated.

lence of onychomycosis in the general population (Table 1),

publication year(ref)

whereas seven studies investigated the prevalence of onychomyco-

Nigeria, 201415
(Continued)

Egypt, 201429

sis among children which were attending a pediatric or dermatolog-

ical clinic or department (Table 2). In population-based studies, the
Country,

prevalence of onychomycosis in children ranged from 0% to 3.37%

and in studies from pediatric or dermatological clinics or depart-
TABLE 1

ments the prevalence varied from 0% to 0.53% (prevalence from

[Ref.]

studies that used clinical observation, microscopy, and culture as

29

15

diagnostic method).
b
a

c
TABLE 2 Studies on the prevalence of onychomycosis in children in hospitals and clinics

Country, publication Male % of total Number referred Prevalence (number Etiological agents
VESTERGAARD-JENSEN ET AL.

[Ref.] year(ref) Study cohort Children/total children Age range (years) with SFI or OM Diagnostic method of cases/total) (n, %)
18 UK, 198918 Pediatric out-patient 200/200 NA 3–12 OM: 0 CL + M + C 0% NA
clinic SFI: 0 (0/200)
20 North America Dermatology centers 2500/2500 44.7% 0–18 Mean: 1.2 SFI:NA CL + M + C 0.44% T. rubrum (8, 72.7%)
(Canada & USA), and GP ± 0.1 years OM: 7 (11/2500) T. rubrum and E.
199720 floccosum (1,
9.1%)
M positive only: (2,
18.2%)
21 USA, 199721 Dermatology 189/1038 NA 0–18 OM: 0 CL + M + C 0.53% NA
department SFI: All cases of tinea (1/189)
pedis excluded.
Other SFI: NA
25 Canada, 199725 Dermatology offices 126/2001 54.8% 0–10 OM: 0 CL+ Mb 0% NA
SFI: 17 with Tinea (0/126)
pedis
22 Belgium, the Czech Dermatology centers 1613/13,486 NA <18 OM and SFI: NA CL + M or CL+ C 0.19% (3/1613) NA
Republic, Germany, Patients, who (either or both
Great Britain, presented with any positive)
Greece, Hungary dermatological
and Luxembourg, disorder included
199922
30 Brazil, 201330 Dermatology office 718/7687 NA 0–17 OM: NA CL 5.01%a NA
SFI: NA (36/718)
16 Canada, 201616 Dermatology centers 2783/32,193 49.4% 0–9 OM: 0 CL + Cc 0.29% NA
and GP SFI: NA (8/2783)
Pediatric

Abbreviations: C., Candida; C, culture; CL, clinical; E., Epidermophyton; GP, general practitioner office; M, microscopy; NA, not available; OM, onychomycosis; SFI, superficial fungal infection; T., Trichophyton.
Dermatology

a
Calculation based on data extracted from the article.
b
M positive was used as the definition of onychomycosis. C was also performed, but patients with negative C and positive M were also defined as having onychomycosis.
c
C positive was used as the definition of onychomycosis. M was also performed, but either M positive or negative with C positive was included.
859
860 Pediatric
Dermatology
The number of children included in the studies ranged from
100 to 32,235 children, and the majority of the included children
were in the age range from 5 to 16 years in population-based
studies and 0 to 18 years in dermatological clinics or departments,
respectively.
3.2 | Demographic data
Two studies showed an association between an increase in prevalence
of onychomycosis and increasing age in children.8,9 Unfortunately,
separate details on age and onychomycosis were not available to
allow further analysis.
For the studies that provided sex data, the frequency of males
ranged from 44.7% to 100%, and the mean prevalence of males in the
included studies was 51.9% (28,507 male children/65,189 children). It
was not possible to extract the exact male frequency of onychomyco-
sis, but one study found that boys were more likely to have onycho-
mycosis than girls (p = 0.001, male frequency: 54.5%).10
3.3 | Diagnostic work-up
All studies reported on clinical diagnosis (nail changes) and most stud-
ied confirmed the clinical suspicion of onychomycosis with micros-
8–23
copy in combination with culture (17/24). The prevalence of
onychomycosis in studies using a combination of clinical diagnosis,
microscopy and culture ranged from 0 to 3.37%.8–23
Three studies relied on clinical diagnosis and microscopy only
24–26
with prevalence rates ranging from 0 to 0.25%.
27–29
Three studies relied on clinical diagnose only. One study
reported that only half of the cases had a mycological confirmation of ony-
chomycosis, all cases were therefore reported as diagnosed clinically.30
Prevalence rates in studies relying primarily on clinical diagnosis ranged
from 0.03% to 7.66%27–30 and of those, three reported the highest preva-
28
lence rates in the current review (7.66% from 1985 Solomon Islands,
7.59% 2010 Ethiopia, and 5.01% from 2013 Brazil30 respectively).
VESTERGAARD-JENSEN ET AL.
F I G U R E 2 Prevalence of
onychomycosis in children in
population studies (blue) and studies
from pediatric or dermatological clinics
or departments (orange diagnosed by
clinical observation, microscopy, and
culture). Notice an outlier data point
(prevalence of 3.37%14)
3.4 | Distribution over time
Figure 2A illustrates the prevalence of onychomycosis over time in
12 population-based studies and five studies from dermatology clinics
and departments diagnosed clinically and with culture and micros-
copy. The studies were published during the years 1972–2016 and
the prevalence increased from 0.22% in 197217 to between 0.29%
and 0.88% in 2014–16.15,16
When focusing on the prevalence of childhood onychomycosis in
Turkey only, this review identified six studies published during the
years 2002–2013.8–11,24,26 The prevalence of onychomycosis among
Turkish children ranged from 0% to 0.33% and showed a small
increase in prevalence from 2004 to 2013.8,11
3.5 | Geographical distribution
The geographical distribution is presented in Figure 3. The included
studies from dermatology clinics, departments and hospitals originate
from South America (Brazil), North America (Canada and USA), Europe
(UK and a co-operative study [the Achilles project] performed in
Belgium, the Czech Republic, Germany, Great Britain, Greece, Hungary,
and Luxembourg). The population studies were executed in Western
Asia (Turkey, Egypt, Israel), Oceania (the Solomon Islands), East Africa
(Ethiopia), South America (Peru), Europe (Spain, UK, Finland), West
Africa (Nigeria), South Asia (India), and North America (Mexico).
The highest prevalence of onychomycosis in children diagnosed
mycologically was 3.37% in a study from 2009 from Peru.14 This preva-
lence was much higher than what similar studies using the same diagnos-
tic methods from other countries reported 0%–0.88%.8–13,15–21,23
Besides the prevalence from Peru, the highest prevalences, diagnosed
clinically and with microscopy and culture, were from Mexico 0.75%,23
Israel 0.87%13 and Nigeria 0.88%.15 In studies with clinical diagnosis only
(without mycological confirmation) the prevalence is generally higher
and up to 7.59% in Ethiopia27 and 7.66% from 1985 Solomon Islands.28
The prevalence of mycologically confirmed onychomycosis in
Europe ranged from 0% to 0.20%,12,18,19,31 in North America from 0%
VESTERGAARD-JENSEN ET AL. Pediatric 861
Dermatology

F I G U R E 3 The worldwide
prevalence of onychomycoses.
Prevalence for each study shown
in %. M: microscopy; C: culture;
Cl: clinical. In a joined study of
Belgium, The Czech Republic,
Germany, Great Britain, Greece,
Hungary and Luxembourg the
prevalence was 0.19%22

TABLE 3 Studies with data on the distribution of onychomycosis in toenails and fingernails

Country, publication Male % of Prevalence (number Cases with toenails

[Ref.] year(ref) Study cohort Children/total total children Age range (years) of cases/total) affected (n, %)
20 North America Dermatology 2500/2500 44.7% 0–18 Mean: 1.2 0.44% (10, 91%)
(Canada + USA), centers and ± 0.1 years (11/2500)
199720 GP
9 Turkey, 20069 Schools 7158/7158 52.6% 6–14 0.15%a (7, 64%)
(11/7158)
10 Turkey, 200610 Primary 23,235/23,235 54.5%a 7–14 0.10% (24, 100%)
schools Mean: 9.72 ± 1.06 (24/23,235)
14 Peru, 200914 Schools 1361/1361 NA 12–17 3.37% (40, 87%)
(46/1361)
8 Turkey, 20138 Primary 8122/8122 49.6% 5–16 0.33% (27, 100%)
schools Mean: 10.61 ± 2.41 (27/8122)
15 Nigeria, 201415 Schools 800/800 51% 5–16 0.88%a (1, 14%)
Mean: 9.42 ± 2.00 (7/800)

Note: All studies used clinical observation, microscopy and culture as diagnostic methods.
a
Calculation based on data extracted from the article.

to 0.75%,16,20,21,23,25 and in West Asia from 0% to 0.87%.8–11,13,24,26 T. mentagrophytes (4/55) including a co-infection with T. tonsurans
See Tables 2 and 3 for details of the five studies from other geograph- and E. floccosum (3/55). The most common yeasts isolated were
17,27–30
ical regions. C. albicans (11/40) and C. glabrata (11/40). The only study that speci-
fied the isolates from fingernails reported C. albicans (1/4), C. glabrata
(2/4) and C. tropicalis (1/4) in four patients.9 Trichosporon spp.
3.6 | Onychomycosis with concomitant skin (n = 13/40) were isolated in two studies from Turkey.8,10
infections

A total of seven studies reported on co-infection on other body sites
(tinea pedis [6/105]8,9,12,14,20,23 or tinea capitis [1/105]).15 In two
studies no concomitant mycosis was found,18,24 and in one study no
concomitant tinea pedis was found.10
3.7 | Fungal pathogens
Dermatophytes (55/95) were more common than yeast (40/95) and
the most prevalent dermatophyte species were T. rubrum (39/55),
3.8 | Prevalence of onychomycosis in fingernails
compared to toenails
The distribution of onychomycosis infecting fingernails compared to
toenails was examined in six studies.8–10,14,15,20 The prevalence of ony-
chomycosis in toenails ranged from 0.10% to 2.94%, and in fingernails
from 0% to 0.75%. In five studies8–10,14,20 onychomycosis was more
prevalent in the toenails than the fingernails, and in one study it was
more prevalent in fingernails.15 In six studies only toenails were exam-
ined.12,13,16,22–24 The details of the studies can be seen in Table 3.
862 Pediatric
Dermatology
4 | DISCUSSION
This systematic review supports the hypothesis of a generally increas-
ing prevalence of onychomycosis in children especially during the
years 2000–2015 (Figure 2).
Estimated prevalence rates are based on diagnosing onychomyco-
sis in a given sample. Diagnostic accuracy in the pediatric population
is of the outmost importance as only about 15.5% of nail dystrophies
in children are caused by onychomycosis.32 The majority of the
studies8–26 (83% [20/24] see Table 1) confirmed the clinical suspicion
of onychomycosis by mycological examination.
The data appear independent of the sampling method in spite of
great variation in the number or sex of the participants, cultural differ-
ences such as type of footwear, sport activities etc. which may all
impact the prevalence.
We expected to find a higher prevalence rate of onychomycosis in
dermatology centers and clinics than in the background population,33
represented by the studies carried out at schools and in the general pop-
ulation, but this hypothesis remains un-supported (Table 1 compared to
Table 2). This lack of difference in prevalence rates might be influenced
by the difference in age groups examined, where most of the studies
from hospitals and clinics included younger children aged 0–4 years
16,20–22,25,30
(6/7), while most of the studies from the background popula-
tion (14/17) included older school children.8–10,13–15,17–19,23,24,26,27,29
Furthermore, geography may play a role, as a higher prevalence
occurs in warmer countries, see Figure 3. The analysis does however not
allow us to adjust the data for possible confounders such as footwear,
access to health care and similar factors that may all influence the result.
Topographically, onychomycosis is generally more prevalent in toe-
nails than fingernails in children and adults alike.1 Transfer apparently
occurs when tinea pedis spread to the toenails, which has also been
described in adult studies.34 This could correlate with the six studies where
concomitant tinea pedis and onychomycosis were found.8,9,12,14,20,23
The dermatophyte, T. rubrum was the most prevalent pathogen
identified (39/153), 36% of the total cases confirmed with culture,
which is in good agreement with previous studies in adults.1,33 Yeasts
accounted for 26% (40/153) of the infections, represented by the
Trichosporon spp. (13/40), C. albicans (11/40), C. glabrata (11/40),
Rhodotorula spp. (3/40), C. parapsilosis (1/40), C. tropicalis (1/40)
primarily isolated in Turkish studies.8–10
Onychomycosis caused by yeasts is more prevalent in the finger-
nails than toenails and is also more prevalent in the immunosup-
1,35
pressed and in neonates. It is therefore interesting that most cases
of onychomycosis caused by yeasts were found in toenails (35/39) of
supposedly healthy school children in the Turkish studies.8–10 An
exploration of associated factors as, for example, moist shoe environ-
ment, genetic predisposition, odiabetes would be of interest.
In 38% of the cases, the species of fungus were not determined
in children. Additional limitations to our results are the population size
limit of minimum 100 children, a difference in age groups between
children seen at dermatology centers and clinics (younger) compared
with children from background populations (mainly older school chil-
dren) and lack of testing for yeast and non-dermatophyte molds but
VESTERGAARD-JENSEN ET AL.
also the prevalence of familial disease as an indicator of both higher
exposure as well as genetic predisposition. All studies with a preva-
lence of 0% (5/5) had study populations of 100–200 chil-
dren.11,18,19,25,26 This indicates that the limit of at least 100 children
in the study population should have been set above 200 instead. Only
three studies examined children in the age range from 0–18 years
old20–22 while the other studies had a more narrow age range. In stud-
ies from hospitals and clinics most (6/7) of the included children aged
0–4 years old up to 18 years.16,20–22,25,30 (Table 2) However most of
the background population studies (14/17) only included school chil-
dren (Table 1).8–10,13–15,17–19,23,24,26,27,29
Nine of the studies only investigated for dermatophytes (and
C. albicans),12,13,15,17–21 and the prevalence of onychomycosis from
other pathogens such as non-albicans yeasts and non-dermatophyte
molds were not included.
5 | CONC LU SION
In conclusion, the systematic review suggests a trend of an increasing
prevalence of onychomycosis in children however this trend is not
statistically significant based on available data. Childhood onychomy-
cosis has many similarities with adult onychomycosis; it should be
considered when the child presents with tinea pedis. The most preva-
lent pathogen is T. rubrum and toenail infection is more prevalent as
compared to fingernails.
ACKNOWLEDG MENTS
The authors would like to thank and express our appreciation to Per-
nille Lindsø Andersen for the statistical analysis.
FUNDING INF ORMATI ON
This research did not receive any grant from funding agencies in the
public, commercial, or not-for-profit sectors.
CONFLIC T OF INT ER E ST
DM Saunte received honoraria as a consultant for advisory board
meetings by AbbVie, Janssen, Sanofi, LeoPharma, Novartis and as a
speaker and/or received grants from the following companies: Abbvie,
Janssen, Novartis, Sanofi and Leo Pharma during the last 3 years. She
is a primary investigator for Leopharma. GBE Jemec has received hon-
oraria from AbbVie, Chemocentryx, Coloplast, Incyte, Inflarx, Novartis,
Pierre Fabre and UCB for participation on advisory boards, and grants
from Abbvie, Astra-Zeneca, Inflarx, Janssen-Cilag, Leo Pharma, Novar-
tis, Regeneron and Sanofi, for participation as an investigator, and
received speaker honoraria from AbbVie, Boehringer-Ingelheim, Gal-
derma and MSD. He has also received unrestricted departmental
grants from Abbvie, Leo Pharma and Novartis. S. Vestergaard-Jensen,
A. Mansouri, L.H. Jensen declare no conflicts of interest.
DATA AVAILABILITY STAT EMEN T
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
VESTERGAARD-JENSEN ET AL. Pediatric 863
Dermatology

ORCID 19. Heikkilä H, Stubb S. The prevalence of onychomycosis in Finland.

Sif Vestergaard-Jensen https://orcid.org/0000-0003-4049-938X Br J Dermatol. 1995;133(5):699-703. doi:10.1111/j.1365-2133.
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864 Pediatric VESTERGAARD-JENSEN ET AL.
Dermatology

APPENDIX A

Database Search Search string Number of results

PubMed #1 (((((((“Onychomycosis”[Mesh]) OR (onychomycos*)) OR ((“nail*”[All Fields] AND 575
Date: “fung*”[All Fields]) OR “nail* fung*”[All Fields])) OR (((“Tinea”[MeSH Terms]
11 March OR “Tinea”[All Fields]) AND “unguium”[All Fields]) OR “tinea unguium”[All
2021 Fields])) OR ((“candidiasis”[MeSH Terms] OR “candidias*”[All Fields]) AND
“unguium”[All Fields])) OR ((“nail*”[All Fields] AND “mycos*”[All Fields]) OR
“nail* mycos*”[All Fields])) AND ((((((((((((((“Child”[Mesh]) OR (Child*)) OR (kid))
OR ((“paediatrics”[All Fields] OR “pediatrics”[MeSH Terms] OR “pediatrics”[All
Fields] OR “paediatric”[All Fields] OR “pediatric”[All Fields]) AND
“patient*”[All Fields])) OR (“infant, newborn”[MeSH Terms] OR (“infant”[All
Fields] AND “newborn”[All Fields]) OR “newborn infant”[All Fields] OR
“baby”[All Fields])) OR (infant*)) OR (“Infant”[Mesh])) OR (toddler*)) OR
(“Adolescent”[Mesh])) OR (adolescent*)) OR (teenager*)) OR (youth*)) OR
(“babies”[All Fields])) OR (“kids” [All Fields]))) AND ((((((((((((“Cohort
Studies”[Mesh]) OR ((“cohort*”[All Fields] AND “study”[All Fields]) OR
(“cohort*”[All Fields] AND “studies”[All Fields]) OR “cohort study”[All Fields]
OR “cohort studies”[All Fields])) OR ((“cohort*”[All Fields] AND “analys*”[All
Fields]) OR “cohort* analys*”[All Fields])) OR (“Cross-Sectional
Studies”[Mesh])) OR ((“cross-sectional*”[All Fields] AND “study”[All Fields])
OR (“cross-sectional*”[All Fields] AND “studies”[All Fields]) OR “cross-
sectional study”[All Fields] OR “cross-sectional studies”[All Fields])) OR
((“cross-sectional*”[All Fields] AND “analys*”[All Fields]) OR “cross-sectional*
analys*”[All Fields])) OR (“Epidemiologic Studies”[Mesh])) OR
(“Epidemiology”[Mesh])) OR (“Observational Studies as Topic”[Mesh])) OR
(“epidemiolog*”[All Fields])) OR ((“epidemiolog*”[All Fields] AND “study”[All
Fields]) OR (“epidemiolog*”[All Fields] AND “studies”[All Fields]) OR
“epidemiologic study”[All Fields] OR “epidemiologic studies”[All Fields] OR
“epidemiological study”[All Fields] OR “epidemiological studies”[All Fields]))
OR ((“observational*”[All Fields] AND “study”[All Fields]) OR
(“observational*”[All Fields] AND “studies”[All Fields]) OR “observational
study”[All Fields] OR “observational studies”[All Fields]))
Embase #2 exp onychomycosis/ 6683
Date: #3 (onychomycos* or tinea unguium or candidiasis unguium).mp. [mp = title, 7333
11 March 2021 abstract, heading word, drug trade name, original title, device manufacturer,
drug manufacturer, device trade name, keyword, floating subheading word,
candidate term word]
#4 (fungal infection* adj2 nail*).mp. [mp = title, abstract, heading word, drug trade 106
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#5 (nail* adj2 fung*).mp. [mp = title, abstract, heading word, drug trade name, 471
original title, device manufacturer, drug manufacturer, device trade name,
keyword, floating subheading word, candidate term word]
#6 (nail* adj2 mycos*).mp. [mp = title, abstract, heading word, drug trade name, 75
original title, device manufacturer, drug manufacturer, device trade name,
keyword, floating subheading word, candidate term word]
#7 1 or 2 or 3 or 4 or 5 7428
#8 exp child/ 2,716,671
#9 exp pediatric patient/ 22,020
#10 exp infant/ 1,017,000
#11 exp adolescent/ 1,575,836
#12 exp juvenile/ 3,563,608
#13 (child* or kid or kids or baby or babies or infant*).mp. [mp = title, abstract, 3,184,225
heading word, drug trade name, original title, device manufacturer, drug
manufacturer, device trade name, keyword, floating subheading word,
candidate term word]
#14 (pediatric* adj2 patient*).mp. [mp = title, abstract, heading word, drug trade 120,883
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
VESTERGAARD-JENSEN ET AL. Pediatric 865
Dermatology

Database Search Search string Number of results

#15 (pediatric* adj2 patient*).mp. [mp = title, abstract, heading word, drug trade 20,220
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]

#16 (toddler* or adolescent* or teenager* or youth*).mp. [mp = title, abstract, 1,706,051

heading word, drug trade name, original title, device manufacturer, drug
manufacturer, device trade name, keyword, floating subheading word,
candidate term word]
#17 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 4,262,599
#18 Exp epidemiology/ 3,652,150
#19 Exp observational study/ 225,626
#20 Epidemiology.mp. [mp = title, abstract, heading word, drug trade name, original 1,413,597
title, device manufacturer, drug manufacturer, device trade name, keyword,
floating subheading word, candidate term word]
#21 (epidemiologic* adj2 study).mp. [mp = title, abstract, heading word, drug trade 32,991
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#22 (epidemiologic* adj2 studies).mp. [mp = title, abstract, heading word, drug trade 89,765
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#23 (observational adj2 study).mp. [mp = title, abstract, heading word, drug trade 279,405
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#24 (observational adj2 studies).mp. [mp = title, abstract, heading word, drug trade 47,527
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#25 exp cross-sectional study/ 398,929
#26 (Cohort* adj2 study).mp. [mp = title, abstract, heading word, drug trade name, 341,667
original title, device manufacturer, drug manufacturer, device trade name,
keyword, floating subheading word, candidate term word]
#27 (cohort* adj2 studies).mp. [mp = title, abstract, heading word, drug trade name, 43,758
original title, device manufacturer, drug manufacturer, device trade name,
keyword, floating subheading word, candidate term word]
#28 (cohort adj2 analys*).mp. [mp = title, abstract, heading word, drug trade name, 688,397
original title, device manufacturer, drug manufacturer, device trade name,
keyword, floating subheading word, candidate term word]
#29 (cross-sectional adj2 study).mp. [mp = title, abstract, heading word, drug trade 456,780
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#30 (cross-sectional adj2 studies).mp. [mp = title, abstract, heading word, drug trade 18,275
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#31 (cross-sectional adj2 analys*).mp. [mp = title, abstract, heading word, drug trade 18,391
name, original title, device manufacturer, drug manufacturer, device trade
name, keyword, floating subheading word, candidate term word]
#32 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 4,889,436
#33 6 and 16 and 31 467