MAUI, HAWAII – Conventional wisdom holds that systemic therapy is necessary for effective treatment of onychomycosis. Not so in children, according to Dr. Sheila F. Friedlander.
"You can have different treatment plans depending on the severity of disease. If you have a child with minimal involvement – not involving the nail matrix – I would consider topical therapy rather than systemic," Dr. Friedlander said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Dr. Sheila F. Friedlander
Dr. Friedlander and her coinvestigators conducted a prospective trial of 40 children and teens aged 2-16 years with nonmatrix onychomycosis. The patients were randomized 3 to 1 to receive topical ciclopirox nail lacquer or a vehicle control. The lacquer was applied daily, with weekly removal and nail trimming, for the duration of the 32-week trial.
At 32 weeks, the mycologic cure and effective treatment rates were 77% and 71%, respectively, in the ciclopirox group compared with 22% for both mycologic cure and effective treatment rates in controls.
"Those treatment success rates in excess of 70% were exciting to us. Those are data you never see in adults," said Dr. Friedlander, professor of clinical medicine and pediatrics at the University of California, San Diego, and president of the Society for Pediatric Dermatology. "If you were to do this study of ciclopirox in adults, the numbers would be in the teens or twenties," she said.
Ninety-two percent of patients with mycologic cure at 32 weeks remained clear after 1 year, and the only adverse effect noted was transient discoloration of the nails.
Topical therapy is so much more effective in children and teens because they have thinner, faster-growing nails than adults, Dr. Friedlander explained.
The families of the patients loved this treatment, she added. More than 90% said they would definitely or probably undergo the treatment again.
Eighty-two percent of study participants had one or more family members with onychomycosis, which raises the question of whether the participants’ fungal diseases were caused by environmental exposure or genetic susceptibility, Dr. Friedlander said.
Systemic antifungal therapy is clearly more effective than is topical therapy, Dr. Friedlander noted. But her preferred oral therapy, terbinafine, requires 3 months of daily use to cure a pediatric toenail infection. Also, the Food and Drug Administration recommends that patients get liver function tests when using this drug, which makes terbinafine a tough sell to parents.
"Families are loath to put their children on prolonged systemic therapy. And they do not want their children poked for lab studies," she observed.
Dr. Friedlander reported having no financial conflicts. SDEF and this news organization are owned by the same parent company.