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Superficial Infection

ONYCHOMYCOSIS IN A 3-YEAR-OLD TODDLER


Muhammad Sjahrir, Irma D. Roesyanto-Mahadi, Meidina K. Wardani
Dermatovenereology Department
Medical Faculty of North Sumatera University/ H. Adam Malik General Hospital Medan
Email: muhammadsjahrir@gmail.com
Abstract
Introduction: Onychomycosis is a relatively uncommon condition in children. Studies report
an overall prevalence of approximately 0.3% in children, compared with 2% to 13% in adults.
The incidence of onychomycosis increases with age. In contrast to the adult onychomycosis,
onychomycosis in children show no sign of inflammation of the surrounding skin. Distal and
lateral subungual onychomycosis is the most common type of onychomycosis in children.
Trichophyton rubrum is the cause of most cases of onychomycosis in this population.
Case: A 3 years old female toddler, weight 15 Kg, came with her parents with complaints
groove and brittle nails on the entire of her left fingernails since a month ago. Initially groove
and brittle nails occur only slightly at the proximal of the nail, but along with the growth of
nails, this groove and brittle nail continues until the edge of the nail. This patient has a fingersucking habit. These complaints also occur in her right and left toenails. Patient had no
history of chronic disease and not in a long term medication. Dermatological examination
found onychodistrophy on the entire digiti manus sinistra, digiti I, IV and V pedis sinistra and
digiti I pedis dekstra. There is onycholysis on digiti I manus sinistra.

First Examination: Onychodistrophy on the entire digiti manus sinistra, digiti I, IV and V pedis
sinistra. Onycholysis on digiti I manus sinistra.

Examination after three-cycle pulse doses of Itrakonazol (5mg/Kg/d): Normal growth of the
nail plate on the entire digiti manus dextra et sinistra, digiti IV and V pedis sinistra and there
is new healthy nail growth on digiti I pedis dextra et sinistra.

Diagnosis and treatment: Based on history and physical examination, the diagnosis of this
patient is onychomycosis. Nail samples taken for 30% KOH examination and culture to
confirm the diagnosis. KOH examination found hyphae and spores while in culture found

Trichophyton rubrum. The parents was educated to prevent the finger-sucking habit on their
daughter. Patient was given three-cycle pulse doses of Itraconazole (5mg/kg/d) and showed
significant clinical improvement.
Discussion: Dermatophyte nail infection is uncommon in children. Suggested factors for
less prevalence may be the faster nail growth, the smaller surface area and the less
likelihood of traumatic nail injury compared with adults. This patient has finger sucking habit
which can cause trauma to the nail barrier, making it easier for fungal infection.
Onychomycosis with involvement of the nail matrix requires systemic treatment. Research
shows the use of Itraconazole in children with onychomycosis proved to be effective and
safe.

References
1. Mayser P, Graser Y. Superficial fungal infection. In: Irvine A, Hoeger P, Yan A, editor.
Harpers textbook of pediatric dermatology. Edisi ke-3. UK: Blackwell; 2011.
2. Feldstein S, Totri C, Friedlander SF. Antifungal therapy for onychomycosis in children.
Clin Dermatol. 2014; 33:333-9.
3. Gupta AK, Paquet M. Systemic Antifungals to Treat Onychomycosis in Children: A
Systematic Review. Pediatr Dermatol. 2013; 30:294-302.