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Onychomycosis in a Ten Year Old (Tip Sullivan, DPM)

04/13/2012      Howard J. Bonenberger, DPM


I explain to the parents that there are no oral medications that have been approved for use in this situation. I recommend a total nail avulsion (they don't like the look of a partial and the edge gets caught on their sock).

I pre-medicate the child with 5-10 mg of PO diazepam that the parent gives them an hour before the procedure visit. We always schedule the procedure for a Friday so that the child can be home that day and over the weekend.

I encourage them to eat a light breakfast two hours ahead of time so that their blood sugars don't fall and I ask them to bring an MP3 player with their favorite music. The child will typically report that the medicine "isn't doing anything" but then they have minimal if any issues with the injection, and in fact, I find that the children sometimes giggle a little bit while I am injecting.

After the avulsion, I paint the infected nail bed but not matrix with phenol to create a chemical peeling of the infected tissue. Amerigel is dispensed and they are instructed to apply this BID. No soaking, just typical cleansing with soap and water in the shower or bathtub. A light, fabric Band-Aid is to be applied loosely (that part needs to be emphasized many times to the parents) after the Amerigel is applied.

At the two week mark, the area is re-evaluated. I typically have them continue the Amerigel for another 7-10 days and then begin BID application of the topical antifungal of your own choosing. They should apply this for six months as the new nail regrows. Explain to the parents that there may be some degree of prolonged or permanent nail dystrophy if the matrix was injured or deformed by trauma or infection.

While this situation is not common, it certainly does occur and I have found this approach to work extremely well for the child and the parents will be very pleased. too.

As a footnote: I recently had a 12-year-old male who weighed 130 pounds that was going to have bilateral nail surgeries done on two separate dates. I had given his mother a prescription for two diazepam 10 mg tablets and the instructions on the prescription stated he was to take one tablet an hour before each separate procedure.

His father told the child to take both tablets prior to the first procedure. He seemed fine but I did contact a pharmacist who reassured me that 20 mg in a 130 pound 12-year-old should be no problem at all, and it wasn't.

Howard J. Bonenberger, DPM, Nashua, NH, howardbon@aol.com