Hair and Nails












CHAPTER 22
HAIR AND NAILS

 


Onychomycosis







































Synonym Tinea unguium.
Inheritance n/a
Prenatal Diagnosis n/a
Incidence <18 years of age: 0.2% to 0.44%; >18 years of age: ~2% to 13% in North America; 3% to 8% internationally; may be more prevalent in patients with Down syndrome or HIV.
Age at Presentation Uncommon in children; more common in adolescents.
Pathogenesis

Caused by 3 different fungi types:



  • Dermatophytes:
  •     Trichophyton rubrum, 70%, also causes tinea pedis
  •     Trichophyton mentagrophytes, 20%
  • Non-dermatophyte molds: ~10%, Fusarium, Scopulariopsis brevicaulis, and Aspergillus
  • Yeasts: Candida albicans, rare, immunosuppressed patients.

Older siblings or parents (usually fathers) with chronic tinea pedis/onychomycosis are a common source.

Key Features

  • Nails: Toenails more common than fingernails.
  • Distal lateral subungual: Subungual hyperkeratosis and onycholysis.
  • White superficial: White patches on nail surface.
  • Proximal subungual: Proximal leukonychia, associated with immunosuppression.
  • Endonyx: Diffuse, milky white discoloration of nail, no nail bed involvement.
  • Candidal: Total nail involvement, periungual inflammation, common in immunocompetent. younger children who suck their fingers chronically; associated with immunosuppression.
Differential Diagnosis Nail manifestations of psoriasis.
Laboratory Data 20% potassium hydroxide in dimethyl sulfoxide of skin scraping on a slide and coverslip (qualitative screening test for fungus); nail culture (allows identification of specific pathogen).
Management

There is little data on efficacy and safety of most systemic antifungal agents in children; limited data does suggest systemic therapies are about as safe and efficacious as in adults.



  • Topical: If less than half of the distal nail plate or in patients unable to tolerate systemic antifungal therapy.

    • 8% ciclopirox lacquer solution (>12 years of age)
    • Bifonazole/urea
    • Vicks VapoRub: Apply nightly to involved nails. Minimum of 3 to 6 months to establish efficacy.
    • Terbinafine cream (OTC): Apply nightly to involved nails. Minimum of 3 to 6 months to establish efficacy.

  • Systemic:

    • Itraconazole (≥3 years of age), 35% to 80% cure rates, 3 to 5 mg/kg/day for 12 weeks.
    • Terbinafine (>4 years of age), 60% to 80% cure rates; 25 kg: 125 mg/day; 25 to 35 kg: 187.5 mg/day; >35 kg: 250 mg/day.
    • Fluconazole (not FDA approved), 70% to 80% cure rates; 150 to 200 mg/week for 24 weeks.
    • Posaconazole (>18 years of age), 45% to 50% cure rates; 200 mg/day for 24 weeks.
    • Griseofulvin

      • ≥1 years of age; microsize 10 to 20 mg/kg/day in single or divided doses (not >1,000 mg/day).
      • ≥2 years of age; ultramicrosize 5 to 15 mg/kg/day in single or divided doses (not >750 mg/day).

  • Surgical:

    • Nail avulsion with or without concomitant systemic antifungal agents.

  • Other:

    • Nd-YAG and diode lasers
    • Photodynamic therapy
Prognosis Cure rates are variable and even with a good response, reinfection is possible. Consider comparing the benefit of treatment with the generally low morbidity for each individual patient. With increasing experience regarding efficacy and safety with newer oral antifungals, these agents may be considered in otherwise healthy children with onychomycosis.

image PEARL/WHAT PARENTS ASK


Can we safely treat the children including prepubertal children? You can reassure parents that with appropriate monitoring and eventual preventive measures, nail infection can be treated safely and effectively with the newer systemic antifungal medications. One might also advise treating adult family members to prevent recurrence.

image

22.1. Distal onychomycosis.











Skin | Associated Findings
image

Paronychia







































Synonym n/a
Inheritance n/a
Prenatal Diagnosis n/a
Incidence Most common hand infection in the US.
Age at Presentation Any age.
Pathogenesis Inflammation of the finger or toe-nail folds (medial, lateral, and proximal nail folds) various triggers; nail biting, finger sucking, sports participation with increased sweating (toenails), overzealous nail trimming and other finger trauma, cosmetic nail procedures, exposure to irritants and hot water, immunosuppression, and antiretroviral treatment (indinavir and lamivudine); allergens and infectious organisms, Candida (chronic paronychia), and bacterial (S. aureus most common cause overall).
Key Features

  • Acute: Rapid onset of focal swelling, erythema, and pain +/– abscess formation.
  • Chronic: Symptoms >6 weeks; pain, inflammation, and swelling.
Differential Diagnosis Dyshidrotic eczema, foreign body (ie, splinter), felon, onychocryptosis, and herpetic whitlow.
Laboratory Data Bacterial, fungal, or viral culture if necessary.
Management

  • If not fluctuant: Warm compresses, +/– topical antibiotics until resolved.
  • If fluctuant: Gentle elevation of nail plate with wooden end of a cotton-tipped swab (Q-tip) to relieve pressure and allow drainage; warm compresses, I&D w/#11 blade, topical or oral antibiotics may be necessary.
Prognosis Excellent; is often self-limited.

image PEARL/WHAT PARENTS ASK


How long to heal? Is dependent upon cause, but most will resolve with little or no treatment. Can it be prevented? Avoidance of any trauma (nail biting, close trimming of nails) or irritants/allergens (nail polish, artificial nails). Will this cause permanent scarring? Generally, the infection resolves without permanent scarring. Distortion of the nail with dimpling, scaling, and separation of the nail from the nail bed may occur, but nails usually regrow normally.











Skin | Associated Findings
image

Tinea Capitis

































Synonym Ringworm.
Inheritance n/a
Prenatal Diagnosis n/a
Incidence 3% to 8% of American children affected, may be as high as 20% of black school-aged children in the US.
Age at Presentation Peak prevalence 3 to 7 years of age.
Pathogenesis

Infection with Trichophyton species (~95% of cases in US) and Microsporum species.



  • Ectothrix infection (less common in the US): Organism covers the external surface of the hair and can fluoresce under Wood’s light (320-450 nm wavelength), M. canis, M. distortum, M. ferrugineum, M. gypseum, M. nanum, and T. verrucosum Endothrix infection: Organism invades the hair shaft; will not fluoresce, T. tonsurans, T. violaceum, and T. soudanense.
Key Features

Variable clinical appearance; mild scaly patch (similar to seborrheic dermatitis on the scalp to fungal abscess (inflammatory tinea, ie, kerion, intense immune reaction to infection) to widespread yellow, cup-shaped crusts (scutula) as in favus (caused by T. schoenleinii infection). Regional lymphadenopathy is common.


More severe cases can cause associated alopecia, sometimes scarring that can be permanent.

Differential Diagnosis Seborrhea capitis, scalp psoriasis, alopecia areata, trichotillomania, bacterial folliculitis, and syphilis.
Laboratory Data

20% potassium hydroxide (qualitative screening test for fungus).

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Aug 17, 2025 | Posted by in PEDIATRICS | Comments Off on Hair and Nails

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