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All data and materials can be found in the material section or can be accessed via Dr. Weber and Prof. Currently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects.
Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. We retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1. Laser GmbH, Nuremberg during the time period of July —December with or without concomitant topical antifungals.
Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy.
No relevant adverse effects were observed. The 1. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach.
Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments. It is a fungal nail infection primary caused by dermatophytes [ 3 ]. The presence of previous nail trauma, diabetes mellitus and advancing age, as well as restricted peripheral circulation represent risk factors for onychomycosis [ 4 — 6 ].
Finally, in particular, patients with compromised immune function are at an increased risk of fungal nail diseases and are susceptible to secondary infections such as cellulitis or generalized tinea corporis. The main clinical characteristics of onychomycosis are focal parakeratosis, subungual hyperkeratosis with onycholysis detachment of the nail plate from the nail bed and thickening of the subungual region. Secondary superinfecting bacteria and nondermatophytic molds can give the nail plate a yellowish brown appearance.
Advanced infections can then lead to total destruction of the nail plate [ 7 , 8 ]. Current recommendations for the treatment of onychomycosis include the atraumatic extraction of onychomycotic nail material, e. Yet, available treatments are limited by moderate efficacy or other restraints. Topical antifungals such as amorolfine, ciclopiroxolamine or terbinafine nail lacquer often take a long time to eradicate the infection and barely penetrate the nail plate at fungicidal concentrations [ 10 , 11 ].
Systemic antifungals such as fluconazole, itraconazole or terbinafine have been associated with relevant side effects such as congestive heart failure, hepatotoxicity and systemic drug interactions [ 4 , 12 , 13 ]. To conclude, long duration of treatment, bad compliance, severity of side effects or simply patient refusal of a systemic therapy, as well as patients not responding to treatment represent the main challenges in onychomycosis therapy.
Against this background, almost a decade ago non-ablative laser therapy was introduced as a novel treatment option for onychomycosis. In , the FDA approved the use of a 1.
Since then, a broad range of different laser systems for the treatment of onychomycosis were introduced into the market [ 15 ]. This heating is proposed to cause the destruction of fungal structures and thereby to eradicate the fungal infection of the nail [ 16 — 22 ]. An alternate hypothesis proposes an unspecific effect of tissue heating with a subsequent increase in circulation due to vasodilatation and stimulation of an immunological cure of the infection [ 23 ].
Today, laser therapy of onychomycosis is discussed controversially. Several case series, comments and studies published in the past decade report divergent results and conclusions with regard to efficacy, adverse effects and safety or even necessity of the treatment [ 15 , 24 , 25 ]. Of note, a systematic assessment of these published data also shows great inhomogeneity with regard to treatment protocols, endpoints, techniques, time points of analysis, and many other factors, which makes it difficult to compare results and to support drawn conclusions.
Taken together, it can, however, be concluded from published data that sole laser treatment is likely less effective than pharmacological therapies. To date, analyses assessing potential synergies of laser therapy in combination with topical or systemic antifungals are sparse [ 25 ]. It is obvious that, in particular, patients with contraindications against systemic antifungals could benefit from such a multimodal approach. Here, we retrospectively analyzed clinical improvement and healing by assessing the records of 56 patients with onychomycosis of the toenails that were treated in our clinic with laser therapy alone or with laser therapy in combination with topical antifungals.
In our retrospective analysis, we evaluated the records of all patients with proven onychomycosis caused by dermatophytes and affecting the toenails, including at least one hallux, which we treated with laser therapy in the time period of July —December All patients enrolled in this study had a histologically and microbiologically proven diagnosis of onychomycosis caused by dermatophytes. We identified a total of 56 patients that fulfilled these criteria and included them in our analysis.
In total, 27 patients received laser treatment alone and 29 patients received laser treatment plus topical antifungals ciclopirox, or amorolfine nail lacquer or cream as indicated by the manufacturers.
The mean patient age was To standardize our analysis, we focused only on the toenail of one affected hallux. In all cases, fungal culture was positive for dermatophytes. In total, patients received an average rate of 3. During every visit clinical courses were documented by standardized photography. Laser treatment was performed with a 1.
Prior to each laser session visible dystrophic nail material was mechanically removed by a podiatrist. Clinical and microbiological endpoints were systematically assessed. In addition, an independent dermatologist evaluated all photographs that had been taken before every session and at the final visit.
The primary endpoint, clinical improvement, was defined as a significant clinical improvement evaluated by the patient himself and assessment of the photographic documentation by an independent physician. Furthermore, at the end of the last laser treatment, a final fungal culture and microscopic assessment of mechanically removed nail material were performed. Direct fluorescence microscopy assay was used for microscopic examination. Therefore, Blankophor was used as a fast fluorescent whitener and direct detection of fungal elements was determined using a Zeiss Axioplan fluorescence microscope.
Mycological cure was defined as both negative microscopy and negative culture. A total of 56 patients were treated with a 1. The average number of treatments was 3. Eleven patients received 1 laser session, 22 patients received 2—4 sessions, and 23 patients received more than 5 sessions. Figure 1 shows representative clinical courses.
Patients treated with laser only received an average of 4. Patients treated with combination therapy received an average of 3. For nails treated with laser plus topical antifungals, this result was achieved after an average 4. During therapy, besides mild pain and reported heat, no significant side effects were observed. Clinical courses of hallux toenails treated with laser only or laser plus topical antifungals. Displayed are representative images of four patients before left panel: a , d , f , h and after right panel: c , f , g , i treatment with a 1.
The role of non-ablative laser therapy for the treatment of onychomycosis is discussed controversially. Published data and conclusions range from effective [ 25 ] to mostly ineffective [ 23 , 24 ]. This heterogeneity of published data goes in line with a big heterogeneity in treatment protocols wavelength and total energy applied, combination of treatments, number and duration of therapy as well as methods of evaluation and assessed endpoints e.
This makes a direct comparison of results and the drawing of distinct conclusions difficult [ 15 , 23 , 25 — 34 ]. In particular, the clinical efficacy of multimodal approaches, applying laser and pharmacological therapies, remains ill defined. Patients included in our analysis were treated with amorolfine or ciclopiroxolamine, lacquers or ointments. Amorolfine is a topical antifungal that inhibits Deltasterol reductase and cholestenol Delta-isomerase, thereby depleting ergosterol and causing a permeability of the fungal cell membrane.
Complete cure comprising both negative direct microscopy and negative culture was achieved in Ciclopiroxolamine ciclopirox is a synthetic hydroxypyridine.
Unlike most antifungals currently available, ciclopirox does not affect sterol biosynthesis. Yet, even though these rates exceed results achieved for topical antifungals, lasers or combinations thereof, it is obvious that systemic therapy does not guarantee healing and, as noted before, in the daily practice systemic therapy is limited by contraindications, adverse events or simply refusal by patients [ 38 — 41 ]. With regard to the efficacy of laser therapy, in , Raulin et al.
The nm diode laser systems assessed in our analysis were also used in a clinical study performed by Renner and colleagues. Herein, 82 onychomycotic nails were treated with the respective nm diode laser as well as in combination with topical antifungals. The treatment protocol did not include microscopic or cultural analyses of fungal pathogens [ 25 ]. Also patients that did not benefit from a prior topical pharmacologic antifungal therapy showed an improvement in combination with laser therapy.
This observation suggests that the efficacy of laser therapy is positively correlated to the overall number of laser treatments, and hence the outcome of therapy can be improved by increasing the number of laser sessions. Accordingly, we advise our patients to undergo at least three laser sessions before the individual response is evaluated.
If a clinical improvement has been achieved up to this point, a continuation of laser therapy can be suggested until complete cure or until no further improvement may be observed. While this effect could also be attributed to the sole continuation of pharmacologic measures, the timely correlation to the start of laser therapy suggests that mycological cure in these cases is indeed rather the result of combination therapy.
Adverse effects of laser therapy for onychomycosis reported in the literature range from pain up to tissue necrosis [ 24 , 43 ]. However, if performed responsibly it can be considered as safe and effective, as highlighted by our experience presented here.
Our results show that the application of a 1. This multimodal approach is of particular interest for patients that are limited by contraindications against systemic antifungals. If performed responsibly laser therapy causes minimal to no side effects and comes along with a high patient satisfaction. In our hands, the overall efficacy of the therapy positively correlated with the total number of laser sessions.
Prospective, ideally intra-individually half-side controlled trials with relevant numbers of patients are still urgently needed to establish better treatment protocols and to support the proposed relevance of a multimodal, pharmaco-physical approach for the management of onychomycosis.
EB performed the statistical analysis and participated in its design. All authors read and approved the final manuscript. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Weber, Email: ed. Firouzi, Email: ed. Baran, Email: ed.
2015, Number 1
Profesional 1064nm onicomicosis nd yag hongos de uñas láser/el hongo de las uñas de tratamiento
long pulse nd:yag 1064 nm 532nm nd yag laser onicomicosis