Pediatric Dermatology: Nail Diseases

Ilona Frieden, MD
Sheila Friedlander, MD

In this section, Drs Frieden and Friedlander reviewed  coxsackie onychomadesis, the treatment of onychomycosis in children and a how to best obtain nail specimens in kids.

Healthcare providers should be aware that onychomadesis is a sequela of HFMD and fairly commonly seen after  coxsackie A-6 infection. With onychomadesis, you typically see shedding of the fingernails and toenails within one to two months after HFMD. Onychomadesis can appear in the form of exaggerated Beau’s lines. It is not surprising that this happens with infection, but why can it occur with mild disease? Osterback R et al obtained shed nails from two siblings with onychomadesis who had HFMD eight weeks before the nail shedding. The nail clippings were enterovirus positive by RT-PCR and one case was identified as CVA6. Dr Frieden believes that this may, in fact, be an infection of the nail matrix and not merely a physiological response of stopping nail growth.


Fungal nail infections are more common in adults; however, they DO affect children (0.16%). The incidence of fungal nail infections in children may be increasing due to occlusive foot lifestyle. While families want their children to be “perfect”, they are reluctant to put their children on prolonged systemic therapy, and do they want their children to undergo lab studies. It is important to keep in mind that children have thinner nails and; therefore, grow faster.

How do we best approach fungal nail infections in children? A study by Lawry MA, et al. showed that the best approach to diagnosing fungal nail infections is through PAS and culture and the second best approach is PAS.

Clinical Pearl: Dr Frieden comments that one of the best ways to get a diagnosis of onychomycosis in a small child is by using a disposable curette. Kids are not as afraid of this versus a scalpel because this instrument is blunt and looks more like a spoon. This is a great technique for a KOH or culture specimen.

How do we treat children?
  • Benign neglect (this is certainly still a reasonable approach)
  • Ciclopirox, amorolfine lacquer, bifonazole-urea
  • Griseofulvin 20/kg for at least 6 months; don’t exceed 1 gram (compliance can be difficult as well as side effects)
  • Terbinafine 5mg/kg/d  don’t exceed 250mg; FN 6 wks; TN 12 wks (Families can get a month supply for $3-$6)
  • Fluconazole 6mg/kg/week once a week; FN 12 weeks; TN 26 wks
  • Itraconazole caps 5mg/kg/d  pulse therapy; FN 2 pulses; TN 3 pulses

Dermatologists should know that onychomycosis does not always require systemic treatment for a cure. Dr Friedlander and her colleagues conducted a prospective trial of forty children with non-matrix nail disease. 30 patients  (25 male and 15 female with a median age of 9.8) were placed on active topical ciclopirox lacquer and 10 patients on vehicle. The lacquer was applied daily and nails were trimmed weekly for 32 weeks. If the patients had a poor response, they were rolled over to active treatment at week 12. The only known AE was a transient discoloration of the nail.



The graph above shows that 77 percent of these patients had mycologic cure, 71 percent had effective treatment and 34 percent had a complete cure. These numbers are much higher than what we see in adults. These patients were followed over one year and the vast majority of them did not relapse.  When asked about quality of life and whether or not the patients would undergo this treatment again, over 90 percent responded “definitely yes” or “probably yes.” (Friedlander SF et al. Ped Dermatology. 2012;Dec28)

This trial was just a a small pilot study, and thus  needs to be repeated.  Non-lunula nail disease can remit without medication (n =2); and topical therapy appears to work better in young nails than in adult nails.  This data suggests that topical therapy may be a reasonable option as first-line therapy for some children with fungal nail disease.

There are new products currently being studied for the treatment of nail disease. Nuvail, for example, is an innovative approach in that it is a poly-urethane vapor permeable substance. It is currently marketed for dystrophic/brittle nails. A small prospective study of Nuvail in 62 patients demonstrated 60 percent improvement in six months and a 62 percent mycologic cure in six months. Stay tuned for more information….