Systemic antifungal therapy for cutaneous infections in children.

The skin, hair and nails are common sites for superficial dermatophyte infection in children. Systemic antifungal therapy is indicated for a variety of cutaneous disorders in the pediatric population. In this article, we review the common indications for the use of systemic antifungal therapy, including terbinafine, ketoconazole, itraconazole, fluconazole and griseofulvin, in children and young adults. Cutaneous fungal infections that generally require systemic antifungal therapy include tinea capitis and onychomycosis. Tinea capitis, which is most often caused by Trichophyton tonsurans, is among the most common fungal infections in children. Tinea capitis occurs primarily in the prepubertal age group. Immunosuppression, eg, human immunodeficiency virus infection, does not increase the frequency of dermatophyte infection; however, the severity of disease and the likelihood of recurrence are greater in this population. Although griseofulvin remains the recommended therapy, terbinafine, itraconazole and fluconazole have been reported to show efficacy in the treatment of tinea capitis in children. Onychomycosis refers to dermatophyte and nondermatophyte infections of the nail unit. The most common dermatophytes responsible for causing onychomycosis include Trichophyton rubrum and Trichophyton mentagrophytes. Children with onychomycosis should be examined for the presence of tinea capitis or pedis, and parents should also be examined for onychomycosis. Most children with onychomycosis have distal subungual onychomycosis, which requires systemic treatment. For this reason, the diagnosis of onychomycosis should always be confirmed by mycology culture. Effective treatment may require prolonged courses of therapy, and the rate of recurrence is high. Currently in North America, there is no FDA-approved treatment of onychomycosis in children. However, terbinafine, itraconazole, and fluconazole are generally well-tolerated and safe and have few side effects. Laboratory monitoring of liver function in patients treated with these agents is prudent. Griseofulvin, although considered the treatment of choice for dermatophyte infections in children, is not recommended for the treatment of onychomycosis given the long duration of treatment and high recurrence rate. Griseofulvin is available in an oral suspension; however, terbinafine is available only in tablet form. Although itraconazole is also available in an oral solution, this is not approved for onychomycosis and contains cyclodextrin, which may cause diarrhea and has induced pancreatic adenocarcinoma in rats. Fluconazole is also available as an oral suspension, but is not FDA-approved for dermatophyte infections.