Itraconazole pulse therapy for dermatophyte onychomycosis in children.

BACKGROUND Onychomycosis, or fungal infection of the nail, can occur in prepubertal children. However, its diagnosis is often missed or the condition is inappropriately treated with topical medication. Griseofulvin has been the therapy of choice, but even long-term treatment is associated with a poor cure rate and high rate of relapse. Trials with adult patients have shown that itraconazole pulse therapy for onychomycosis requires a shorter duration of total therapy than griseofulvin treatment and is rarely associated with adverse reactions, suggesting that it may be the treatment of choice for pediatric patients with onychomycosis. DESIGN We retrospectively reviewed the courses of prepubertal patients with dermatophyte onychomycosis who initiated treatment with itraconazole pulse therapy between January 1995 and June 1998. SETTING Urban and suburban pediatric dermatology clinics of a children's hospital. PATIENTS Seventeen prepubertal patients met the enrollment and follow-up criteria. These included fungal infection of the nail(s), documented by fungal culture and/or positive potassium hydroxide mounts of nail scrapings; at least 1 follow-up visit; and contact by telephone or clinic visit within 2 months prior to compilation of data. In 59% of patients, a relative living at the home had onychomycosis at the time of diagnosis. INTERVENTION Patients were treated with daily to twice-daily pulses of itraconazole, administered for 1 week of each of 3 to 5 months. MAIN OUTCOME MEASURES Clinical cure after itraconazole therapy in patients with documented onychomycosis and clinical and mycologic relapse after initial cure. Fungal cultures were not repeated if clinical cure was noted. RESULTS All but 1 patient responded fully to therapy, showing improvement within a few months and subsequently clearance (94% clinical cure rate). No patients experienced any clinical adverse reactions. No relapses occurred after clinical cure during a follow-up period of 1 to 4.25 years after initiation of therapy. CONCLUSIONS Itraconazole pulse therapy is effective and safe for the treatment of onychomycosis in children. The relapse rate in pediatric patients is lower than in adults, although the high frequency of onychomycosis in non-pediatric family members suggests that the recurrence risk is increased if other family members are not treated concomitantly.