Keys To Using Lasers When Treating Onychomycosis

Patrick DeHeer DPM FACFAS

After researching our electronic medical records, I have found that I’ve treated over 1,500 cases of onychomycosis throughout the past four years. I make it constant practice to critically analyze my outcomes and strive to look for ways to make those outcomes more predictable. (Please note that I have no financial interest in any of the products I will be discussing.)

I use the VariaBreeze laser (CoolTouch), which is a 1064 nm-pulsed Nd:YAG laser. The Food and Drug Administration has approved this laser for the temporary increase of clear nails in patients with onychomycosis. I have been very pleased with this specific laser.

I am not here to recommend one laser over another. I do not know if there is a significant difference between the FDA-approved lasers and other lasers. However, I would like to share some of the conclusions I have reached over these past four years.

First, I firmly believe one treatment is not enough. I do three treatments that are spread out 10 to 12 weeks apart. Initially, I spread the treatments apart every four weeks but I have come to the anecdotal conclusion that it is best to spread the treatments out more to cover the growth of the nail evenly.

I use 40°C as my minimum temperature to treat the nail with the machine maximum at 45°C. If I reach 45°C, the cryogen spray cools the nail off. I make three passes over the infected nail with each visit. I will administer the laser with at least the minimum of 40°C or until I hit the maximum of 45°C twice, which results in the cryogen spray. Patients respond very differently to heat. I believe that you must reach 40°C before moving on to another nail. This is also why I do not laser normal nails. It is very difficult to hit 40°C on a normal nail plate before the patient experiences significant discomfort.

It is important to laser the medial/lateral nail folds, the eponychium and the hyponychium. On the great toenails or large, lesser digital toenails, I use a cross-hatching approach to cover the nail evenly.

Most patients have some form of chronic tinea pedis and this requires treatment for optimal results. If left untreated, success rates are lower and recurrence rates are higher. I use a fungicidal topical medication for four to six weeks, making sure to treat the entire plantar surface of the foot and medial, lateral and posterior sides per the manufacturer’s directions. I most recently have been using FungiFoam (Tetra).

Additionally, when a patient presents with fungal elements on the feet, there are higher levels of fungus in the shoe to treat. Otherwise, the recurrence rates are higher. I use Clean Sweep (Tetra) for this.

I use topical medications concurrently with laser therapy. I only use oil-based medications. I recommend using the topical medications for the entire outgrowth of the nail. The nail is susceptible to spore germination while the spores are still present on the nail plate, which is approximately nine to 12 months. After the third laser treatment, I typically recommend that patients continue topical therapy for four to five months. I use Formula 3 (Tetra), although I have used all commercially available oil-based products in the past, including Fungal Free Nails (R&S Research) and Cidacin (Pedicis) and been equally satisfied with each.

In more severe cases, manual debridement is beneficial for both laser penetration and topical medication penetration. This may require professional podiatric debridement for every 10 to 12 weeks as needed.

It is important to follow up with the patient four months following the third laser treatment. You can evaluate the nails for further treatment recommendations. I will not hesitate to recommend more laser treatment, continuing the topical medication or adding oral medication to the therapy. My job is to assist the patient in treating the onychomycosis and if I have to throw the “kitchen sink” at it, I will. I believe treatment must continue until conclusion. The worst-case scenario is for the patient to get almost better and then have the infection come roaring back because treatment was not complete.

I do not know my cure rates. I do know I am stubborn and will not give up unless the patient wants to give up. I will continue to treat until resolution. Patient education is of paramount importance. Practitioners much explain the process and components of treatment thoroughly. I believe it is important to do a nail biopsy (I use a periodic acid Schiff examination) to confirm onychomycosis prior to laser therapy when possible.

I hope my experiences and analysis will assist those of you utilizing laser therapy for onychomycosis treatment.

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