Nail Issues - Paediatric CPC

For clinical advice, please telephone the relevant specialty service.

Northern Adelaide Local Health Network 

• Lyell McEwin Hospital (08) 8182 9000 
  

Southern Adelaide Local Health Network

• Flinders Medical Centre (08) 8204 5511, after hours on-call service for patients of all ages until 11:00 pm

Women’s and Children’s Hospital Network

• Women’s and Children’s Hospital (08) 8161 7000

Inclusions

• onychomycosis
• melanonychia
• paronychia
• congenital nail disorders

Exclusions

• ingrown toenail, refer to Plastics and Reconstructive Surgery

Triage categories

Category 1 (appointment clinically indicated within 30 days)

• new onset melanonychia, especially longitudinal

Category 2 (appointment clinically indicated within 90 days)

• nil

Category 3 (appointment clinically indicated within 365 days)

• onychomycosis
• paronychia
• congenital nail disorders
• deformed nail plate
• lifted nail plate
• discoloured nail plate

Additional information to assist triage categorisation

• associated findings, especially if congenital nail disorders
• prior treatments, especially if nail infection

Clinical management advice

Onychomycosis

• if suspected, take a nail clipping and request fungal microscopy, culture and sensitivity (MCS), note 30% false negative rate
• the most common causative organism is Trichophyton rubrum
• once diagnosis is confirmed, options are topical or oral, although topical options require treatment for almost 12 months to be effective
• topical options, avoid sucking on nail
  • Miconazole 20% bd (i.e. Daktarin tincture)
  • Ciclopirox 8% daily (Rejuvenail)
  • Amorolfine 5% weekly (Loceryl)
• oral options
  • Terbinafine (liver function test (LFT) monitoring required monthly): six weeks for fingernails and 12 weeks for toenails, 62.5 mg/day less than 20 kg, 125 mg/day between 20 to 40 kg, and 250 mg/day greater than 40 kg
  • Itraconazole, blood monitoring required if used longer than 1 month. Complete blood examination, electrolytes/urea/creatinine and liver function tests.
• pulse therapy: 5mg/kg/day for one week every month for two months for fingernail infections; three months for toenail infections
• continuous therapy: six weeks for fingernail infections and 12 weeks for toenails, 5mg/kg/day
• less than 50 kg, 200 mg/day > 50 kg
• strategies to reduce re-infection: washing shoes in warm water for at least 45 minutes, ultraviolet sanitization of sports equipment, post-treatment prophylaxis with topical antifungals, treatment of affected family members

Paronychia

Acute often occurs at the cuticle or at the site of a hangnail or other injury. The area around the nail becomes painful, red and swollen.

Chronic caused by damage to the waterproof seal between the proximal nail fold and the nail plate (e.g. from pushing back the cuticles or removing the cuticles with keratolytics). Once the seal is damaged, water and debris can enter under the proximal (posterior) nail fold and cause inflammation.

Management measures

General management measures

• avoid pushing back cuticles or manicuring nails
• avoid picking at cuticles
• avoid inserting objects beneath cuticles to remove debris
• keep hands out of water, and wear cotton-lined rubber gloves when washing dishes or doing other wet work
• dry hands and nails well after any water or moisture exposure
• wear gloves when gardening or exposed to the cold
• use a mild soap-free wash
• manage any underlying chronic dermatoses (e.g. dermatitis, psoriasis).

Acute infection

That does not respond to local drainage, prescribe 1) Flucloxacillin 12.5mg/kg up to 500mg) orally, 6-hourly for five days or Cephalexin or Clindamycin if allergies exist

Chronic paronychia

Recommend regular thick greasy emollient (i.e. Dermeze ointment/Epaderm ointment) and Elocon ointment to inflamed nail folds

Clinical resources

• Current Opinion in Pediatrics – Pediatric nail disorders: a review

Consumer resources

• Raising Children Network – Baby nails: how to cut them and treat nail problems
• Raising Children Network – Nail Infections: fingernails and toenails

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.