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Hi guys,

Please see attached photos.

Any thoughts and help for the diagnosis of this one would be grateful.

Young boy (11yro) with over 5 years history of nail texture changes. Not sure how it started. Never had treatment. No other know skin conditions, no allergies, medically well. Don't go to communal shared area often (e.g. swimming pool etc). No family history of nail disease.

I've seen few cases in kids especially with nails like this, very difficult to treat. In fact, I haven't found anything that work on these nails.

Was wondering is this more fungal infection or yeast infection.

Anyone dealt and had success with these nails before?

Thanks a million!


Mike

 

Looks fungal to me. The 4/5 web space also looks sus.

What are the finger nails and plantarpalmer surfaces like?

I`d take nail and subungual tissue samples from the most proximal part of the discolouration (where the fungus is active) and send for microscopy and culture to identify whether it is dermatophyte or candida species.

Dependant upon the result, I would recommend either an oral course of terbinafine/griseofulvin if dermatophyte or itraconazole if candida.

Cheers,
Bel

 

Agreed but the distribution also suggests a mechanical element to me as the affected toes are the "sticky out" ones. Also check all the footwear, I suspect he may have been wearing shoes too small to cause the dystrophy and render the nails vulnerable.

 

Yep, what he says. Generally, fungus is not common in children. However, it is an opportunistic pathogen and will take full advantage of a damaged nail. Right, Dennis? ;)

 

Thanks guys.

Will try and get some lab test done when I see them next.

Have also addressed the skin infection as well.

It's just I've treated nails like this before with all sorts of fungal treatment (oral + topical + laser) but found this particular type hard to treat.

Any other treatment after we've tried all the "conventional" stuff?


cheers.


Mike

 

Hi Mike,

`Tis true that it often takes many months for treatment of OM to be effective as the infection has to `grow out` with the nail (the average growth rate for a Great toenail in a healthy young adult is 1.62 mm per month) even then incidence of reinfection is high. However, risk of reinfection can be reduced if the pt is encouraged to regularly apply a fungicde (I advise pts prone to tinea to apply Lamisil Once every 3 months to keep those pesky dermatophytes under control) and, obviously, keep his feet dry.

I`m not too sure what you mean by `conventional` stuff? If you are referring to folklore/alternative remedies, I would urge you to use extreme caution in recommending anything which has not been tested for efficacy and safety. I`ve seen some pretty undesirable side effects of so-called `natural` remedies.

Cheers,
Bel

 

I dont want to start a flame war - but I wouldn't put an 11yo on terbinafine for that type of infection. The nail path has a high false negative chance so good luck even getting a positive result that isnt normal skin flora. Address the reason for the mycotic infection and then treat the nails themselves. 1064nm laser is an option if you or anyone you know has one. Otherwise your options based on evidenced based practice may be limited.

 

No flaming from here; hence the suggestion of pathogen specific meds based on further lab testing. I agree, find out what is pathogenic as opposed to normal skin flora which ain't always the problem. The high incidence of false negative is often due to inappropriate sample taken, ie nail clippings instead of harvesting active subungual tissue at its most proximal point.

So Paul, you say; "address the reason for mycotic infection and then treat the nails themselves". What would you say is the reason for infection, if not tinea pedis and trauma induced dystrophy, as Mr Isaacs and I suggested? Do you think that onychomicosis should be treated in isolation of tinea Pedis?

I'm not in favour of any one anti-fungal tx over another (to quote another; I go where the evidence takes me), and I am pleased to see that laser tx has been shown to be effective, where available. However, oral meds for long standing OM are the recommended tx in the UK....at the moment. Lets hope that changes soon.

Cheers,
Bel

 

I agree your suggestion is probably correct - trauma induced onycolysis/dystrophy is the most likely cause. That being most likely due to incorrectly fitting footwear.

I think the treatments for OM and TP would be different in my clinic. Topicals for the skin infection and 1064 laser for the nails. Monitor over 12 weeks and repeat if necessary. The main argument being the foot is obviously in an environment where fungal infections are prevelent - this obvious thing requires addressing otherwise continued problems associated with this will occur.

I am assuming psoriasis isnt an issue of course.

But still you would have to push me to put that patient on oral terbinafine even with a positive nail sample.

 

Hi, am I right in assuming there are no family members with the same symptoms?

I have seen families of 3 generations with the same appearance??

Laser treats the nails which is a secondary infection to the skin??

How do you treat the primary infection Paul?

Thanks

Heather

 

Hi Heather exactly what is the "primary" infection? Is the OM the same pathogenic fungus as the skin infection? Do all patients who have OM also have tinea pedis? Do all patients who have tinea pedis have OM? You are making the assumption that the OM has the same pathogenic cause as the tinea pedis. Regardless - I think as clinicians we can all agree the "easy" thing to fix is the superficial fungal infection of the skin.