PEDIATRIC ANTIFUNGAL THERAPY - 09/09/11
Résumé |
Fungal infections are a significant component of any pediatric or dermatologic practice. The incidence of tinea capitis appears to be increasing in urban areas, and the sometimes subtle nature of these scalp infections has led to difficulty in diagnosis and eradication of such infections.24 As a recent review from Kenya illustrates, dermatophyte infections are also a significant problem in rural areas. In a clinical survey of approximately 6000 children in western Kenya, a 10% prevalence rate of dermatophyte infections was found. Of note, over three-quarters of these children suffered from tinea capitis.31
In the United States, the recommended dosage of griseofulvin for the treatment of fungal scalp infections has steadily increased over the last decade, as the offending pathogens in scalp infections appear to have become tolerant to lower dosages that were previously effective. Prepubertal tinea pedis26 and tinea unguium29 have also recently attracted more attention, and many specialists feel such fungal infections in young children may be more common than previously suspected. Such trends have highlighted the need for safe, inexpensive, and effective antifungal therapy in the pediatric age group. This review will focus on the topical and systemic agents now available for use in childhood dermatophyte infections.
Superficial fungal infections in children are usually caused by yeasts (Candida, Pityrosporum) or dermatophytes (Trichophyton, Microsporum, or Epidermophyton genera). Dermatophyte infections are usually referred to as “tinea”, a term surviving Roman antiquity and translating as “moth-eaten”, aptly describing the appearance of many scalp infections caused by dermatophytes.18 Superficial fungal infections of the skin generally respond to topical therapy, whereas those of the nail or hair require systemic treatment.
Therapy for fungal infections depends on the offending pathogen. Although many agents are effective against both yeasts and dermatophytes, some agents do not possess such broad efficacy and the practitioner must be aware of the limitations of each drug. Although nystatin (Mycostatin) is an excellent treatment for superficial Candida infections, it will have no effect on a dermatophyte infection such as tinea corporis. In contrast, although tolnaftate and griseofulvin are effective against dermatophytes, they are not efficacious in Candida infections. Table 1 lists some of the more common topical antifungal agents and their applications. Several new topical antifungals are now on the market; however, in most uncomplicated cases of superficial infections, cost and comparable efficacy make the more traditional drugs still the best choice for first-line therapy.
The mainstay of therapy for refractory skin infections as well as nail and hair infections has been griseofulvin. The benefits of griseofulvin include its excellent safety profile, as well as extensive experience with the drug for over 40 years in both children and adults. However, this drug does have significant shortcomings, which include possible gastrointestinal and hepatic toxicity, the need for prolonged duration of therapy, and low cure rates for nail infections. Ketoconazole was transiently felt to be a preferable drug for dermatophyte infections; however, it is now known that the drug is less effective than griseofulvin for tinea capitis and possesses higher risks of hepatotoxicity, particularly when used for prolonged periods.35
Several new antifungal agents appear to be efficacious and safe in pediatric fungal infections. The systemic triazoles fluconazole and itraconazole appear to be extremely effective in nail and hair infections. They require shorter treatment courses than griseofulvin and therefore promote compliance and minimize the risk of adverse side effects.23, 33 These drugs may be more effective because of their distinctive pharmacokinetics, leading to compartmentalization of the drug in infected tissues and extremely long half lives at these sites.
Terbinafine, an allylamine, is fungicidal in vitro. It also appears to persist for prolonged periods after treatment in skin, nail, and hair, leading to therapeutic effects after even very short dosing periods.6, 36 Although none of these drugs is currently FDA approved for treatment of pediatric nail and hair infections, they are available for use in the United States, and open-label and controlled studies in Europe have demonstrated efficacy and tolerability in the pediatric population.19, 23 The following discussion will highlight the relevant aspects of each drug in its use for superficial fungal infections in the pediatric age group.
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| Address reprint requests to Sheila Fallon Friedlander, MD, Department of Pediatric and, Adolescent Dermatology, Children's Hospital and, Health Center, San Diego, 3030 Children's Way, Suite 408, San Diego, CA 92123 |
Vol 16 - N° 3
P. 527-537 - juillet 1998 Retour au numéro
Article précédent
- ANTIBIOTICS IN THE MANAGEMENT OF PEDIATRIC SKIN DISEASE
- Gary L. Darmstadt
- ANTIVIRAL TREATMENT OF DISEASES IN PEDIATRIC DERMATOLOGY
- Zoltán Trizna, Stephen K. Tyring
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