Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.
- Presentation
Pediatric Onychomycosis: Diagnosis, Risk Factors, and Treatment Options
Description
The talk reviews pediatric onychomycosis, emphasizing that it is uncommon in children and that accurate diagnosis is crucial because many nail disorders are mistaken for fungus and do not respond to antifungals. Typical pediatric toenail disease is distal lateral subungual onychomycosis, most often caused by Trichophyton rubrum, while Fusarium is the most common non-dermatophyte mold seen in children. Risk factors discussed include Down syndrome and immunosuppression, and the speaker also highlights neonatal acquired candidiasis and Candida onychomycosis in infants, which may present with associated diaper involvement, oral thrush, or paronychia and often improve with topical azoles and nail trimming. Treatment options are reviewed in detail: topical therapies work better in children because their nails are thinner and grow faster; ciclopirox, tavaborole, and efinaconazole were compared, with efinaconazole noted as the strongest topical option and used for long courses. For more severe disease or matrix involvement, systemic therapy is needed, though all systemic agents are off-label in pediatrics and dosing is weight-based. The speaker also distinguishes mycologic from clinical cure and notes that terbinafine hepatotoxicity is very rare, so baseline liver tests may be considered but routine concerns should be balanced against low risk, cost, and unnecessary patient anxiety.
View moreConclusions
- Pediatric onychomycosis is uncommon, with culture-positive dermatophyte nail infection in children averaging only about 0.33%.
- When pediatric onychomycosis does occur, it most often presents as distal lateral subungual disease and is usually caused by Trichophyton rubrum, while Fusarium is the most common non-dermatophyte mold in children.
- Accurate diagnosis is critical because many children with nail dystrophy actually have other conditions, such as trachyonychia or congenital malalignment of the great toenail, that will not respond to antifungal therapy.
- Down syndrome and immunosuppression are important risk factors that should raise suspicion for true fungal nail disease in children.
- Neonatal acquired candidiasis is a distinct entity from congenital cutaneous candidiasis and often resolves with minimal or no treatment because infant nails grow out quickly.
- Candida onychomycosis in young children is often linked to chronic paronychia and hand-to-mouth behavior, with fingernails affected more often than toenails.
- Topical treatments work better in children than in adults because pediatric nails are thinner and grow faster, making drug delivery and clearance more favorable.
- Among topical options, efinaconazole appears to have the best evidence and can achieve meaningful mycologic cure, though treatment must be continued for many months.
- Systemic antifungal therapy remains off-label in children but is favored for nail matrix involvement or more severe disease because it offers higher cure rates.
- Terbinafine appears to have a very low risk of hepatotoxicity in children, so baseline liver enzymes may be reasonable while routine repeated lab monitoring may not be necessary for most patients.
- Gupta AK, Taylor D. Pediatric dermatophyte onychomycosis: a review. Int J Dermatol. 2025 Mar;64(3):465-472.#10.1111/ijd.17495
- Gupta AK et al. Onychomycosis in the US pediatric population – an emphasis on Fusarium onychomycosis. Pediatr Dermatol. 2025;42:47-53.
- Buttars B et al. Congenital malalignment of the great toenail and onychomadesis of monozygotic twins. JAAD Case Reports. 2021 Aug;14(1-3).#10.1016/j.jdcr.2021.05.027
- Baran and Hay. Onychomycosis in children. Chapter cited in slide on neonatal acquired candidiasis.
- Eichenfield LF et al. Efinaconazole 10% topical solution for the treatment of onychomycosis in pediatric patients: open-label phase 4 study. J Am Acad Dermatol. 2021 Apr;84(4):1140-1142.#10.1016/j.jaad.2020.06.1004
- Gupta AK et al. Systemic therapies / pediatric onychomycosis dosing table. Journal of Dermatologic Treatment. 2022.
- Gupta AK, Taylor D. Review of pediatric onychomycosis treatment outcomes. Int J Dermatol. 2025.
- Dentinger et al.; Patel et al.; Wang et al. Citations listed on the reference slide for pediatric onychomycosis and antifungal therapies.