de Berker, David

Johnson, EM

Trickey, Adam

Wlodek, Christina

Christina Wlodek

Adam Trickey

David de Berker

Elizabeth Johnson

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Pediatric Dermatology

Trends in Pediatric Laboratory-Diagnosed Onychomycosis Between 2006 and 2014 in the Southwest of England

This is the largest study of laboratory-diagnosed onychomycosis in England for children younger than 17 years. The most common (91.5%) cultured organism in this population was Trichophyton rubrum. Candida species were isolated only from fingernails, and the majority were from children younger than 5 years. Continued analysis of fungal pathogens is vital to identify changing trends

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                          Wlodek, C., Trickey, A., de Berker, D., & Johnson, EM. (2016). Trends inPediatric Laboratory-Diagnosed Onychomycosis Between 2006 and 2014 inthe Southwest of England. Pediatric Dermatology, 33(6), e358–e359.https://doi.org/10.1111/pde.12989Peer reviewed versionLicense (if available):CC BY-NCLink to published version (if available):10.1111/pde.12989Link to publication record in Explore Bristol ResearchPDF-documentThis is the author accepted manuscript (AAM). The final published version (version of record) is available onlinevia Wiley at http://onlinelibrary.wiley.com/doi/10.1111/pde.12989/abstract. Please refer to any applicable termsof use of the publisher.University of Bristol - Explore Bristol ResearchGeneral rightsThis document is made available in accordance with publisher policies. Please cite only the publishedversion using the reference above. Full terms of use are available:http://www.bristol.ac.uk/pure/about/ebr-terms Title page  Title: Trends in paediatric laboratory-diagnosed onychomycosis between 2006 - 2014 in the South West of England.   C Wlodek1, A Trickey2, D de Berker,1 EM Johnson3   1 Bristol Royal Infirmary, Bristol, UK 2School of Social and Community Medicine, University of Bristol, 3Public Health England Mycology Reference Laboratory, Bristol, UK   Each author has contributed to this work.  Christina Wlodek, BSc(Hons) MBBS MRCP Adam Trickey, MSc David de Berker, MRCP Elizabeth Johnson, PhD  Corresponding author: Christina Wlodek, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW.  Tel: +44(117) 923 000, Email: christina.wlodek@gmail.com  Key words: onychomycosis  Running short title: Trends in paediatric laboratory-diagnosed onychomycosis  Word count: 500   All authors consent to publishing this paper.  Funding: None  Conflict of interest: The authors have not conflicts of interest to disclose.             Abstract This is the largest study of laboratory-diagnosed onychomycosis in England for those aged ≤16 years. The commonest (91.5%) cultured organism in this population was Trichophyton rubrum. Candida species were only isolated from finger nails and the majority were from children under the age of 5 years.   Continued analysis of fungal pathogens is vital to identify changing trends.    Background There are few reports studying onychomycosis in children, with a reported prevalence of 0.2% - 2.6%(1).  Aim The aim was to analyse epidemiological trends of laboratory-diagnosed onychomycosis from the paediatric population in the South West of England between March 2006 – October 2014.   Methods Data was collected from computerised records at the Public Health England Mycology Reference Laboratory and included nail specimens received from the Bristol and Bath catchment area, from patients aged 16 years of age or younger.  We recorded the patients’ age, gender, microscopy and culture results and site of specimen.  Statistical analysis was carried out in STATA 13®.    Results A total of 1,434 specimens were received. The mean age of patients was 9.6 years (95% CI 9.3, 9.8), Table 1.   There were significant differences in the proportion of positive results from different age groups: in 0-5 year olds, positive microscopy was seen in 34% and positive culture in 24%, whilst in 6-10 year olds the results were 64% and 47% respectively and in 11-16 year olds 50% and 35% respectively (p<0.001).  There were statistically more culture-positive results from males than females (38% vs 33%, p=0.038).  There was some evidence of this for the microscopy-positive results (males 56% vs females 44%, p=0.054). Thirty-five percent (501/1434) of samples were both microscopy and culture positive.  Eighty nine percent (948/1070) of specimens were from toe nails. There were significantly more finger nail specimens received from children under 5 years of age compared to the older age groups (16% vs 9.5%, p=0.027).    Eight different organisms were cultured.  The commonest was Trichophyton rubrum (91.5%), Table 2.  The percentage of Candida species grown from children aged 0-5 years (13%) was significantly higher than the older age groups (3%) (p<0.001); 9/15 were from unspecified sites and the remaining 6/15 from fingernails.  Fusarium was only cultured in those over the age of 11 years.   Discussion This is the largest study to date looking at trends in paediatric laboratory-diagnosed onychomycosis in England.   Smaller European studies and one from Korea found T.rubrum to be the most prevalent organism in their paediatric population (1-4). Although Candida was the most commonly isolated organism from finger nail specimens in our population, one cannot determine if it represents true nail plate infection or colonisation of onycholysis. Candida was nevertheless exclusively isolated from fingernails and the majority was from children under the age of 5 years. This finding has been reported in Poland (5). We postulate thumb sucking to be a contributory factor.  Onychomycosis is more common with increasing age due to slower nail growth, larger contact surface increasing the risk of trauma and fungal colonisation, more frequent exposure to fungi in public spaces and a higher prevalence of tinea pedis (1). It is therefore surprising that onychomycosis was most prevalent in the 6-10 years of age group and is different to that found in other studies (1,2).    Although this is the first UK study of its type, it is limited by its retrospective nature and lack of clinical case information. Performing such studies is important for the continued analysis of fungal pathogens. The British Association of Dermatologists’ guidelines (6) recognise that the dominant aetiological agents are T. rubrum, T, mentagrophytes and Candida, and as such recommend the use of terbinafine, itraconazole and fluconazole. Griseofulvin is still the only licensed systemic antifungal drug for children, however it is no longer first line treatment due to the long treatment duration and low efficacy.  The azoles are advocated in onychomycosis caused by Candida species. This study therefore reinforces the recommendations set out in the UK guidelines.    References 1. Rodriguez-Pazos L, Pereiro-Ferreiros MM, Pereiro M, Jr., et al. Onychomycosis observed in children over a 20-year period. Mycoses. 2011;54(5):450-3. 2. Sigurgeirsson B, Kristinsson KG, Jonasson PS. Onychomycosis in Icelandic children. J Eur Acad Dermatol Venereol. 2006;20(7):796-9. 3. Lateur N, Mortaki A, Andre J. Two hundred ninety-six cases of onychomycosis in children and teenagers: a 10-year laboratory survey. Pediatr Dermatol. 2003;20(5):385-8. 4. Kim DM, Suh MK, Ha GY. Onychomycosis in children: an experience of 59 cases. Ann Dermatol. 2013;25(3):327-34. 5. Lange M, Roszkiewicz J, Szczerkowska-Dobosz A, et al. Onychomycosis is no longer a rare finding in children. Mycoses. 2006;49(1):55-9. 6.          Ameen M, Lear JT, Madan V, et al. British Association of Dermatogists’ guidelines for the management of onychmycosis 2014. Br J Dermatol. 2014;171(5):937-958            TABLE 1. Patient characteristics.                                   Variable Number of patients (%) Gender   Male 768 (54%) Female 664 (46%) Unknown 2 (0.1%)  Age (years), Median (IQR) 10.4 (5.9, 13.7)  Season  Winter 739 (52%) Summer 695 (48%)   Site  Finger 122 (9%) Toe 948 (66%) Unspecified 364 (25%)   Microscopy  No Fungus seen 721 (50%) Fungal elements seen 711 (50%) Yeast seen 2 (0.1%)   Culture  No fungus isolated 919 (64%) Culture positive 515 (36%)     TABLE 2. Species cultured according to site of nail infection.  These results exclude the specimens from unspecified sites. (% out of the total, 377)   Site of specimen Organism Finger Toe Total Dermatophyte mould        Trichophyton rubrum Trichophyton interdigitale 5 (1.33%) 1 (0.27%) 343 (90.98%) 14 (3.71%) 348 (92.31%) 15 (3.98%) Trichophyton violaceum 1 (0.27%) 0 (0.00%) 1 (0.27%) Non-dermatophyte mould    Fusarium sp. 1 (0.27%) 5 (1.33%) 6 (1.59%) Scopulariopsis brevicaulis 0 (0.00%) 1 (0.27%) 1 (0.27%) Yeasts    Candida sp. 6 (1.59%) 0 (0.00%) 6 (1.59%) Total 14 (3.71%) 363 (96.29%) 377 (100%)           

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Trends in Pediatric Laboratory-Diagnosed Onychomycosis Between 2006 and 2014 in the Southwest of England

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