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I am treating a young man of age 12.He hasbilateral hallux onychomycosis.I discussed surgical removal of both nails and he(and his mother,of course) consented.I shall do the procedures next week.My questionis:I would like to start him on a short course of lamisil.What would the right dose be on someone of that age?Should I use Clark'srule? Can I even give a person of that age Lamisil?

Novartis, Rx List & Drugs.com all say:
Maybe use a topical.

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Topical Lamisil is not recommended for Paeds according to MIMS.

I have had some pretty good luck after excision of the nails (or without) for that matter using it off label. The Novartis reps say they are working on a similar preparation, and it is as follows....

Give the patient a sample pack of the pills containing 2 pills. Have the patient CRUSH both pills and add to any topical antifungal liquid with a brush. (available in most pharmacies for about $9 or so) Shake and apply daily. It does take a long time to work if used alone, but seems to work better than other topicals. As an adjunctive to oral therapy, it seems to decrease the healing time of the nails by about 20%-30% as well as to improve the appearance of the nails rather quickly. I see the patient regularly to monitor improvement as well as to grind the fungus away. It seems this decreases the "fungal load" and therefore there is less for the oral medication to destroy.

If used after excision, it prevents the nails from regrowing the mycosis as the nails grow back.

I had a 16 yo female in the E.R. with a traumatic avulsion of grossly mycotic Hallux nail ( Hallux only nail affected), I removed it and wanted to start a pulse dose of Lamisil; A rep came and gave the weight based dosages for peds and she would be on the regular dose but my question is this; being that it is offlabelfor peds; where does the line of peds end. I say its 18-20; a pediatric doctor said that 16 was old enough to be considered not pediatric, I decided to go without it and treat the nail topically as it grows back. Any suggestions.

I haveasuggestionwhich I myself will do:Give theyoung lady 3 lamisil tabs.Prescribe tincture of fungoid.Have her crush the tabs and put the powder in the topical.Then,she should apply the mixture to the nail(once the nail grows back in) daily.See if that helps.

I have been reading the threads about this. Have you considered a short course of griseofulvin? Providing the fungus was a dermatophyte this drug is indicated, safe and legal to use in children. Many would question this "out dated" therapy but when the nails are avulsed, this therapy may be an appropriate choice. Despite its poor cure rate in nail infection (around 38%), it still remains useful and effective in dermatophyte skin infection and also in cases where you need to provide antifungal cover after such a procedure.

I was wondering how many podiatrists are doing TNA's when treating fungal infections, Arn't there risks of damaging the nail matrix and causing more problems. I know Onychomycosis can be a difficult persistant problem but is it worth the trouble???

What criteria do you use when deciding to do this or do you leave it up to the client?

I know there are probably studies out there but how much better are the results when the nail has been removed compared to when they haven't?

I use some common sense.For instance,I cannot see doing this on an 85 yr old diabetic.I will try to do this on a young healthy pt(who may not want to keep coming in to debride his/her nails every 2 months).

I know Biogun has been dissed for verrucae, but has anyone tried it on onychmycosis?

I remember this thread when I got my PM News today:

RE: Oral Lamisil Use in Children (Bruce N. Block, DPM, Brian, Kashan, DPM)
From: Bryan C. Markinson, DPM, Maurice W. Aiken, DPM
The use of terbinafine is not approved in children. Gupta. et al., established in several large series that use of terbinafine in children is safe. In one study of almost 1000 children, there was a 10% adverse effect incidence, of which only 8 out of 100 such incidences actually led to cessation of the treatment.
See Gupta, et al., Onychomycosis in children: prevalence and treatment strategies. J AM Acad Dermatol. 1997;36:395-402, and Gupta AK, Cooper EA, Lunde CW. The efficacy and safety of terbinafine in children. Dermatol Clin 2003;21:511-20.
The dose is by body weight as follows: Less than 25 kg. - 62.5 mgs per day; 25 - 40 kg. - 125 mgs per day; >40 kg. - 250 mgs per day.
The parents should be informed that the drug is not FDA approved for use in children. I always inform the pediatrician.
Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org

Dr. Kashan urges utmost caution regarding use of terbinafine in children. In fact, he states clearly that he would not do it. He does not say, however, what he would do with a child who clearly is distressed at having onychomycosis. In general, I would not argue that his position is too rigid, as he is being true to his own level of tolerance and experience in this situation. However, I would argue that advancing the position that off-label use of anything in children should absolutely be avoided (which I do not think Dr. Kashan intended) may be the wrong message to take away from his post.
For example, the use of Marcaine is not approved in children, but I welcomed the ENT surgeon's injecting it into my own kids throats post-op when they had their tonsilectomies. When I eventually get my own case of prostate hypertrophy, I may welcome the off-label use of Nizoral to help shrink it. Now, one might point out that the risk severity in using terbinafine in children is much greater than my two examples, but the scientific evidence, in well done large sample size studies, states otherwise.
Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org

I have had several pediatric patients in this age range who I have used oral Lamisil successfully. Prior to its use in this population, I contacted Novartis and obtained several articles on its use in Great Britain. It is extensive and has been used in ped populations for many years.
As usual, you do your pre-treatment liver function studies and a CBC w/diff, and do a monthly repeat of those labs if you are more comfortable then the recommended 6 week repeat. As far as dosing is concerned, I have used the usual 250 mg dose each day as per the articles that I have referred to previously. Call Novartis or ask your rep to inquire about this subject. They have been very responsive in the past.
Maurice W. Aiken, DPM, Baltimore, MD, mwaiken@comcast.net

John:

If you give a 12 year old oral lamisil ....... pray that there are no lawyers reading this thread!!!!

Steve

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