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Onychomycosis in 8yr old

Discussion in 'General Issues and Discussion Forum' started by Mike Plank, Mar 18, 2013.

  1. Mike Plank

    Mike Plank Active Member

    Members do not see these Ads. Sign Up.
    I would like to get opinions and guidance with treatment of a case of onychomycosis in an 8 year old girl with an interesting medical history.

    Born prematurely at 26 weeks she developed Necrotising Enterocolitis (NEC) at approximately 4 weeks old which perforated her intestines and led to Peritonitis. She had to undergo radical excision of the dead portion of her bowel leaving her with approximately 50% small intestine remaining. She is a healthy 8 year old, taking no medication, however is smaller and more slightly built than average for her age.

    She presented in July 2010 with mycosis of her right toenails 2-5 and her left toenails 3-5. She has had treatment continuously using topical treatments, Curanail, Tea Tree oil and latterly Trosyl. Her left nails 3 and 4 have cleared using these treatments but the other nails have shown little improvement.

    A Dermatologist has prescribed Griseofulvin (in suspension) however her parents are reluctant to give this to her due to the possibility of gastrointestinal side effects. I am also reluctant to recommend this and am also aware that Lamisil can have the same effects.

    My questions are should her parents try the Griseofulvin? How effective is it? Are there alternatives that could be suggested? Laser treatment?

    Her words “when I get nice nails back I will be over the moon!”
    I would appreciate any suggestions.
    Apologies for the poor focus on the photo taken on a phone camera. Can take better photos if helps.

    Attached Files:

  2. Admin2

    Admin2 Administrator Staff Member

  3. Nina

    Nina Active Member

    Given the huge cost of laser treatment and the potential adverse side effects of oral medication I think the high possibility of recurrence needs to be discussed.

    I can quite understand a little girl wanting to have pretty nails so she can wear sandals in the summer, perhaps you need to go on a LCN (light cure nails) course, or find someone in your area who does. DLT have been running courses they may be able to put you in touch with someone.

  4. blinda

    blinda MVP

    Hi Mike,

    Quick question; Which pathogen was isolated on culture? Was is a dermatophyte or candida?

    Candida onychomycosis has been observed in school-age children with a suspected incomplete development of the immune system, sometimes associated in prems.

    Short on time today, but I`ll post more this evening.

  5. Mike Plank

    Mike Plank Active Member

    [Quick question; Which pathogen was isolated on culture? Was is a dermatophyte or candida?]

    Blinda, I am not sure but will find out asap if it has a bearing on treatment choice.

  6. blinda

    blinda MVP

    It does....and if you can obtain better pics, it would be muchly appreciated.
  7. frintonpod

    frintonpod Member

    As Nina said, as a 'quick fix' to sort out the cosmetic appearance the LCN system would seem to suit her needs.

    We use the LCN system here and have a school-age patient who used to hide her toes from her mum, to the point of wearing socks to bed and never wearing any sort of open-toed footwear.

    We used the system to help her with the cosmetic side of things (as well as treating the underlying issue) and she has now stopped wearing socks to bed and last year was the first time she's worn anything remotely resembling an open-toed sandal.

    If there is someone nearby to you that uses this system, I'd suggest getting in touch with them. Failing that, it's *only* a 2 hour drive to get to us (assuming the patient lives nearby to your clinic).
  8. Mike Plank

    Mike Plank Active Member

    Thank you for your suggestions. I will inform her parents of the LCN treatment and know of colleagues who provide this locally. This may be good for a summer holiday.

    This however is only temporary and I am sure she wants the infection cleared. Her nail clippings have been analysed once with the result being no fungal pathogens isolated on culture but fungal hyphae seen on microscopy. I believe Hyphae can be seen with both Dermatophyte and Candida. Her family report a history of Tinea and nail mycosis. Would you recommend another sample is analysed?
  9. blinda

    blinda MVP

    Difficult to say as I cannot see from the pics provided the extent of infection. In particular; Is there matrix involvement?

    I would certainly recommend pathogen specific meds. The usual suspect in the majority of OM is your tri-rubrum dermatophyte, with candida yeasts being a likely secondary infection. Terbinafine and clotrimazole (fungicides) are the most effective oral meds respectively. Griseofulvin (a broad spectrum fungistatic med) is the least expensive, but requires a more lengthy treatment course with poor cure rates (because it is fungistatic, not fungicidal). So, yes. I would say an up-to-date good quality culture is warrented here, due to the gastrointestinal side effects of most oral anti-fungals. Once the primary pathogen has been isolated, the appropriate oral tx should only be administered with careful liver function tests before and during an initial short course. This is easily monitored by simple blood tests.

    In view of this little gals`medical hx, I would also consider other treatment modalities such as; regular mechanical reduction of the nail plate prior to twice weekly application of amorolfine, nail avulsion or laser tx.

    That said, ALL anti-fungals have a high relapse rate. A large number of the population are prone to recurrence of OM regardless of how effective initial treatment was. Prevention and/or maintenance of this pathology should be the treatment strategy.

    Hope that helps!

  10. Mike Plank

    Mike Plank Active Member

    Great advice, Thanks. I have uploaded a clearer picture. It is difficult to determine whether the nail matrix is involved in all toes. As over 2 years of topical treatment has had limited success I will have to have a discussion with her parents to see if they are willing to try systemic treatment. However I will certainly take another sample for testing. Are there any recommendations to taking a good sample apart from trying to obtain nail from the deepest part of the nail and does ceasing the topical treatments have any bearing on the quality of the sample?
  11. Mike Plank

    Mike Plank Active Member

    Here is the picture omited from last post :eek:

    Attached Files:

  12. blinda

    blinda MVP

    Thanks, Mike.

    Looks like matrix involvement to me, so topical treatment will have a limited effect. I would recommend regular heavy mechanical reduction (they appear to be rather thickened) with a tungsten bur in addition to amorolfine 5% applied twice weekly. If reduction is uncomfortable, I would suggest nail avulsion.

    With regard to taking tissue samples; the main reason for negative results for pathogenic dermatophytes after culture is inappropriate tissue samples taken by the practitioner. The most proximal part of infected nail and associated subungual tissue, where the tinea is active and plenty of it, has to be harvested for an accurate path lab diagnosis, not nail clippings. You can scoop out subungual tissue with a currette type intrument (kinda like a miniature melon-baller) after drilling through the nail plate with a very fine bur.

    The sample should be taken prior to commencement of anti-fungal tx, as this would skew the culture.

    One last word of advice.....use tea tree oil with caution ;);

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=19758&highlight=tea tree oil

  13. Pacifico

    Pacifico Member

    I think the goal is to treat the nail fungus (not to cover it).
    She is infektious and the degree of naildestruction will worsen.
    I think she is the ideal patient for an Forma IPL Treatment (this is the only one device that shows great results . 85-90% healing rate) but you should do a culture or better a PCR test in order to be sure it is an dermatophyte. A systemic antimycotic treatment can have serious side effects and has a limited healing rate (about 50% in my experience).
    The Forma IPL Treatment is painless ;-)
    We are not very shure if the treatment is effective on candida infection.
  14. blinda

    blinda MVP

    Hi Pacifico,

    I agree that covering the nail dystrophy is not ideal, as this could promote conditions in which dermatophytes thrive.

    However, I would not be so quick to claim that this little girl is `infectious`. Not least because this perceived stigma would increase her already distressful situation. Whilst it is true that tinea can be pathological, they are only opportunistic pathogens when conditions allow them to proliferate in areas where they should not be; ie compromised nail plates and/or skin, when keratin layers become too dry and split or too wet and macerate, thereby allowing entry to deeper layers of the epidermis.

    IMO, the name of the game is to maintain control of these opportunistic organisms. You`ll never eradicate them fully as dermatophytes, yeasts and moulds form part of our skin flora and actually play a part in maintaining skin equilibrium. Anecdotally, a podiatric dermatologist friend of mine tried to deliberately infect his nail with harvested dermatophytes, unsuccessfully. Which questions their asserted contagious nature.

    If a pt is immunocompromised (such as prem babies), their anti-microbial peptides just can`t cope with proliferation of these otherwise harmless fungi.

    That said, I`m genuinely interested to hear more about this Forma IPL Treatment.

  15. Pacifico

    Pacifico Member

    Skin fungi or nail fungus is infectious.
    You get it from somewhere: sauna, swimmingpools, ... The spores are there and if your nail is damaged the spores manage to infect your nail.
    The nail is dead tissue so the immune system does not have a very big influence (in my opinion); much more importance seems to have the nail growth speed wich is decreased in older and ill people...
    About the deliberate test of your friend : it is difficult to get living fungal material from the nail. He was lucky... I so a guy (teacher) with a very bad tinea manuum and one thumb nail was also infected. So I was asking him what is he doing that could explain his infection. He told me that he use to clip the toe nais of his 90 yer old mother ...
    So imho we need to kill the fungus but this is not so easy to achieve. The fungus is growing in a vegetative state and multiplying by spores. The spores are very hard to destroy. So we need to treat as long as infected nail is still in place.
    Well, the fungi are not harmles ! Skin and nail fungal infections prepare the way for bacteria and cause great problems in patients with diabetes ...
    I do not know where you are located but I think you will find it if you ask mr. google after forma-tk
  16. blinda

    blinda MVP

    Hi Adi,

    I think maybe you misunderstood what I was trying to convey; of course treatment is indicated here and I agree that chronic and acute manifestation of both TP (tinea pedis) and OM (onychomicosis) should be treated as, you rightly say, proliferation of tinea has been associated with secondary bacterial infection and cellulitis.

    You are absolutely correct. I did not say tinea is not infectious. Fungal spores are everywhere in our environment. We come into contact with them on a daily basis as humans continuously shed their skin cells, which often contain fungal hyphae and are protected in these small pieces of keratin. Hence; the rate of re-infection is high, even after apparent resolution. However, you are just as likely to pick up a tinea infection from the environment as from someone with OM, so to state that this little girl is contagious or infectious would unnecessarily cause her distress, IMO.

    Whilst nail plates are in effect `dead tissue` as an appendage of the skin, they are made of keratin as is the nail bed, where dermatophytes also happily digest the keratin with the added protection of the nail plate which eventually becomes dystrophic as these microorganisms destroy the nail plate. This destruction is minimised when the relevant anti-microbial peptides in the subungual skin (which form an important part of our immune system) target the fungi and destroy it. See here;

    Antimicrobial peptides: an essential component of the skin defensive barrier.

    So the evidence clearly shows that that our immune system does `have a big influence` on OM. Immunosuppression is well documented as a contributing factor to treatment failure and increased risk of developing chronic polymicrobial tinea infection. Below is one the abstract from another peer reviewed paper on the Pathogenesis of dermatophytosis and tinea versicolor.

    As you can see, immunologic status does predispose severity of dermatophyte infection. Also, some types of tinea (such as versicolor) is `normal biota` which, with certain contributing factors, can become pathogenic.

    As I said, the case was anecdotal and not evidence that you cannot infect yourself. However, as the above article hightlighted, “Several steps are required for infection to take place: contact, adherence, and invasion of keratin layers.” Our skin is an active protective barrier to pathogens and only when that barrier is compromised, by too wet/dry skin, or indeed a damaged nail plate, do many bacterium, viruses and fungi become pathogenic. These microorganisms can sit quite harmlessly on our skin without presenting any immediate danger in a healthy individual, as they are effectively eliminated/controlled by these anti-microbial peptides.

    Agreed 100%. That is why I encourage pts with chronic or acute OM and TP to regularly use a fungicide instead of a fungistatic to prevent recurrence, as fungal spores can survive for many weeks after desquamation.

    I was rather hoping you would back up the 85-90% success rate that you claimed, with evidence. But, no worries, I will certainly look into this device. Thank you for bringing it to my attention.

  17. Pauline burrell-saward

    Pauline burrell-saward Active Member

    If reduction is uncomfortable, I would suggest nail avulsion.[/COLOR

    Surly not. we are talking about a 8 yr old little girl!!!

    If she cant cope with nail thinning I doubt she will cope with nail avulsion.

    L/A for such a young child, she will be traumatised for life, I would try topical or systemic treatments ( as already advised) if not how about a professional pedicure with gel, on a regular basis till she is old enough for more radical treatment.

    I have a 14yr old who has a thickened yellow 5th nail, she had all types of treatment via a dermatologist many years ago with no resolution, so for the last 5years I see her every 3 months and reduce it and she paints her nails with varnish in between.

    not a cure, but a painless way of coping with it, mum no longer comes with her to see me, she simply calls in for a £5 "drill" when she needs it.
  18. blinda

    blinda MVP

    Given this girls` medical history, I would only recommend oral meds with extreme caution. Griseofulvin, in particular, is noted for its gastrointestinal side effects. As there also appears to be matrix involvement, topical tx alone will have a limited effect.

    Please evidence your statement that nail avulsion will have life-long detrimental effects. Many 8 year olds have undergone this procedure without being "traumatised" neither temporarily, nor "for life".

    Applying gels, nail varnish etc may be useful for special occasions, but will only serve to promote conditions for tinea to thrive.
  19. Pauline burrell-saward

    Pauline burrell-saward Active Member

    Sorry no evidence.
    Just a mum, who has had a 8 yr old

    It's called life
  20. blinda

    blinda MVP

    Let's not get personal, eh Pauline?

    Bel (mother of 4)
  21. Mike Plank

    Mike Plank Active Member

    Every time we treat a child using a painful procedure we should take into account their age, maturity and anxiety level. All 8yr olds are not the same (which can also be said of any patient of any age).
    That said, I was also a little surprised at the suggestion of nail avulsion. I have never avulsed a nail to treat mycosis before. This is mainly because I was taught
    1. That avulsion of the nail(s) could damage the nail matrix with the resulting 'new' nail permanently growing thicker.
    2. Re-occurrence rate of mycosis is high.
    3. Applying topical nail treatment is not possible until the nail bed had healed.
    4. Obviously avulsion would be without phenolisation as the idea would be to let the nail regrow. I always assumed that without nail ablation the nail bed is more painful following avulsion.

    In this case 5 nails would have to be avulsed which could not be done in one go.
    How long after avulsion can topical treatment be started? What topical treatment would you suggest?

    These are only educated assumptions and I would be interested in others views.
  22. blinda

    blinda MVP

    Hi Mike,

    Agreed. Each patient should be assessed as an individual, taking into account medical history, maturity, etc in addition to explicitly explaining all treatment options, including no treatment. Nail avulsion, with topical antifungals post healing, was just one suggestion of a variety of recognised treatment modalities, not my first choice of treatment by any means. I would definatley explore the option of laser therapy, does anyone in your geographical area offer this?

    As I said previously;

    Let the patient and her parents make an informed choice.

  23. Jo BB

    Jo BB Active Member

    An alternative for the nail varnish which will provide lustre [and camouflage to some extent the appearance of the nail] and not dehydrate the plate like the varnish is to use almond oil [if nil nut allergy]. I still recommend no double dipping into the oil to contaminate the oil.
  24. blinda

    blinda MVP

    Interesting concept. Could you please explain how a varnish dehydrates a nail plate?
  25. Jo BB

    Jo BB Active Member

    I am no chemist but nail varnishes also contain smaller concentrations of the solvents used in nail varnish removers [to mix the varnish components].The alcohols,toulenes, ethyl acetates and butyl acetates cause dehydration of the nail plate [and brittleness if used excessively] and surrounding skin and may also cause irritation/contact dermatitis.
    ps I started using the almond oil after a month of dry northerly winds here on the Gold Coast and couldn't cut a nail straight.They were ricocheting about the room! Seems to help.
  26. blinda

    blinda MVP

    Of course, it is well documented that varnishes contain ingredients which are known sensitizers for contact dermatitis. So is almond oil. Aside from common tree nut allergy, almond oil contains significant amounts of amygdalin, which, when oxidised, breaks down into the peroxides hydrogen cyanide and benzaldehyde. Both of which are potent allergens.

    But, that wasn`t really what I was asking.

    Personally, I think the term `dehydration` when referring to brittleness of the nail plate is not appropriate nomenclature. As an appendage of the skin, nails are incapable of registering a physiological response, which is what dehydration is.

    I would also question whether application of oil to tinea infection is appropriate, as dermatophytes thrive in damp and dark conditions.
  27. Jo BB

    Jo BB Active Member

    Lucky us live in sandals [and thongs if I am honest] most of the year- hence we cannot hide away nails in dark damp shoe wear ! If you would prefer the wording "dryness" with "brittleness" I am sweet with that ! If you have some alternatives to nail varnish apart from the almond oil I would be grateful. I suspect I have had a few patients who have had issues with onychomycosis from salon varnishes.
  28. blinda

    blinda MVP

    Lucky indeed:drinks

    I don`t recommend nail varnish for OM for the reason you highlighted; ACD is more likely to occur in compromised/breached skin, ie paronychia, often manifest in OM. Also, the varnish occludes the tinea, creating perfect conditions for it to thrive.

    Combination therapy, that is, regular mechanical reduction, topical anit-fungals and, if appropriate, oral anti-fungals is my recommended treatment regime, at the moment. I am, however, following the trials on laser tx closely.

  29. Jo BB

    Jo BB Active Member

    Sorry I must be tired or language/generational/education gap! ACD ?
    My apologies for being obtuse. I have always been keen on aggressive nail reduction. If that is all that can be done it is number 1. Paints including tea tree oil [the melaleuca plantations grow down the road] and even weak solutions of bicarb of soda are popular here as well. I am now showing my age here when Daktarin was a prescription medicament and OMG we discovered organisms growing in the solution from the brush contamination! So I still cannot abide paints with brushes attached to lids.Has this changed? I am also keen to see how the laser therapy pans out.
  30. blinda

    blinda MVP

    No need to apologise. I'm aware that I sometimes come across as terse, that's the downside of forum speak.

    ACD - Allergic Contact Dermatitis. Something frequently associated with oxidated tea tree oil and other essential oils which contain terpenoids....

    Agreed on brushes, the topical antifungal I currently recommend is amorolfine 3%, which comes with individual, single use plastic applicators. No double-dipping here;)

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