The Center for Podiatric Care and Sports Medicine

Does Your Child Have Toenail Fungus? Exploring Alternative Diagnoses

Posted by on Monday, July 17th, 2017


Often, parents bring their children to our office with a condition that looks like toenail fungus. But some patients have visited their primary care physicians and taken a course of oral antifungal medication before arriving at our NYC podiatry office—only to find that the reason the antifungal didn’t work was that they did not suffer from fungus at all! Here’s how to tell if your child really has toenail fungus and what other conditions may be occurring.

It can be difficult to tell the difference between different nail conditions, especially in pediatric patients.
It can be difficult to tell the difference between different nail conditions, especially in pediatric patients. Image Source: Pixabay user FeeLoona.

Can Kids Get Toenail Fungus?

Studies indicate that less than 3% of children in developed countries have toenail fungus. Experts surmise the faster nail growth and smaller surface area for invasion enhances a child’s immunity to nail fungus. Furthermore, they are less likely to spend time in locker rooms, an area where fungal nail infections often fester.

Incidence is greater in kids who have Down Syndrome or HIV. Households with moccasin type trichophyton rubrum (athlete’s foot) increase the child’s risk of getting an infection that spreads to the nail as well. Still, some children have a genetic susceptibility to foot and nail fungus, which will usually get picked up from another individual in the household before age 7.

Common Toenail Fungus Misdiagnoses Include:

  • Psoriasis: Nail psoriasis is characterized by large, irregular pits and red-orange “oil drop” spots. The nail often thickens and separates from the nail bed. Just like with onychomycosis, white and crumbly spots often form. Sometimes a nail biopsy is the only true way to tell the difference between these two conditions.
  • Subungual tumors: Benign growths in the underlying bone can push on the skin surface, causing the nail to separate from the nail bed. Signs include red-blue-purple lesions under the nail, cold sensitivity, tenderness, and pain. This condition is more common in children than adults, although the precise reason is unclear. We believe constant irritation, previous trauma, a chronic infection, or an inherited condition like multiple exostoses syndrome may have something to do with it.
  • Pachyonychia Congenita: This rare inherited condition primarily affects the skin and nails. It is believed less than 2,000 Americans have pachyonchia congenita. In addition to painful blisters along the soles of the feet, 90% of individuals with the condition have abnormal nail color and a thickened surface. A third of patients display abnormal nail shape or growth patterns as well.
  • Alopecia areata: About 4.5 million Americans suffer from this autoimmune disorder that attacks the hair follicles and damages the nails. One of the first signs, even before any hair loss has occurred, is a change to the nail surface. For instance, the nails often lose their shine and develop a pitted, almost sandpaper-like texture.

Why See a Specialist?

Primary care physicians often lack the equipment to test for the presence of fungus or an alternate diagnosis. It’s much easier for them to chalk it up to a fungus and write a prescription—which your child may or may not need. With physician office visits averaging just 10 minutes, your child is not going to get the quality care he or she deserves. Here at the Center for Pediatric Care and Sports Medicine, we spend as much time with a patient as he or she needs, never rushing anyone out the door. We have advanced diagnostic equipment and experience in diagnosing and treating a wide range of nail conditions.

How Are Children Treated For Toenail Fungus?

Oral antifungals must be used for 6-12 weeks on children with toenail fungus, which is why it’s so important to take a culture sample to know exactly what’s being treated. Most often, toenail fungus is treated with an oral dose of terbinafine or itraconazole, though it’s technically an “off-label use” in children. The use of Griseofulvin has fallen out of favor due to the length of treatment, which can take up to a year. Topical lacquers are considered ineffective because the nail plate is designed to prevent topical agents from seeping into the nail bed. To prevent recurrence of toenail fungus in children, parents are strongly urged to sanitize all socks, sheets, towels, and shoes. Laundering at a very high temperature and using germicidal UV light are two of the most effective ways to achieve this goal. At The Center For Pediatric Care and Sports Medicine in NYC, we also offer laser toenail fungus removal. Contact us today to learn more about treatment options.


If you have any foot problems or pain, contact The Center for Podiatric Care and Sports MedicineDr. Josef J. GeldwertDr. Katherine Lai, Dr. Ryan Minara and Dr. Mariola Rivera have helped thousands of people get back on their feet. Unfortunately, we cannot give diagnoses or treatment advice online. Please make an appointment to see us if you live in the NY metropolitan area or seek out a podiatrist in your area.