Case Studies In Laser Therapy

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Grace Torres-Hodges, DPM

   At the August 7, 2012 follow-up appointment, an examination revealed marked improvement at the second digit, which demonstrated a flatter nail plate without evidence of striations in the nail texture. The left hallux nail also showed improvement with no evidence of discoloration and an adhered nail plate. Superficial lysis was present at the distal hallux. The patient was pleased with progress but requested a second treatment to the left hallux. An additional treatment to the left hallux consisted of exposure of 176 pulses with 142 joules.

In Conclusion

The laser I used in these cases was an A.R.C. Fox Laser set at 4 watts at a 1,064 nm wavelength and a pulse length/interval of 200 ms.

   In both cases, the use of laser therapy for onychomycosis was effective. The initial treatment eradicated the mycotic infection and cleared the nail. Additionally, without the presence of subungual infection, the nail plate growth was able to restore itself to the underlying surface and provide a more aesthetically pleasing result.

   It is also imperative that one follow the proper steps for diagnosis of onychomycosis and avoid using this treatment for contraindicated conditions such as infection, melanoma, cellulitis, osteomyelitis, fracture, melanoma or other pathologies at risk for metastasis.

   Podiatrists should consider offering this treatment to patients with onychomycosis. It will not work for all patients and it is essential that you make that clear to patients before initiating treatment. It is also important to educate patients that treating onychomycosis is a process. Remind them that average nail growth is 3 mm/month and that preventing re-infection is as critical to achieving success as the laser treatment itself.

   Dr. Torres-Hodges is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, a Fellow of the American Professional Wound Care Association and a Podiatry Fellow with the Council on Nail Disorders. She is in private practice in Pensacola, Fla.

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Myron Bodmansays: January 16, 2013 at 9:55 am

I read your interesting article and found an article that conflicts with the statement:
"Remind them that average nail growth is 3 mm/month and that preventing re-infection is as critical to achieving success as the laser treatment itself. "

J Eur Acad Dermatol Venereol. 2010 Apr;24(4):420-3. Epub 2009 Sep 8.
The average fingernail growth rate was faster than that of toenails (3.47 vs. 1.62 mm/month, P < 0.01). This study was in younger adults reporting 1.62 mm per month.

In my experience, in older patients, it slows to about 1 mm or less per month for the great toenails. Patient do need to understand the very slow regrowth rates. An entire nail that has not been avulsed takes typically 12 or more months to grow out completely.

I am interested in your thoughts.

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gthodges.dpmsays: January 18, 2013 at 4:01 pm

Thank you, Myron, for taking the time to read the case studies.

I am in agreement with you that I have found patients' toenails to take approximately 12-18+ months to grow out after being avulsed completely. However, my use of "3mm/month" was assuming an ideal fast rate scenario because clinically, I have found quite a variability in growth is also dependent on the age of the patient, his or her concurrent systemic medical condition, the degree of infection with damage to the nail plate and environmental factors like the weather. Unfortunately, I do not have any measurement studies myself.

I do find that serial photos of the nail have been very convincing in demonstrating to patients the degree of variability in rates of growth, among the same patient and even in the toes on the same foot.

Regarding your comment about conflicting information about average nail growth, I must admit that there seems to be a general consensus among the articles that fingernails have a faster average growth rate than toenails.

In addition to the article that you quoted, I also used the other two references.

from Wikipedia - Nail (anatomy)
"In humans, nails grow at an average rate of 3 mm (0.12 in) a month (as they are a form of hair). Fingernails require three to six months to regrow completely, and toenails require 12 to 18 months. Actual growth rate is dependent upon age, sex, season, exercise level, diet, and hereditary factors. Nails grow faster in the summer than in any other season. Contrary to popular belief, nails do not continue to grow after death; the skin dehydrates and tightens, making the nails (and hair) appear to grow.

Canadian Family Physician. 2011 Feb; 57(2): 173-181.
"Nail plate growth rates of fingernails and toenails normally average 3.0 and 1.0 mm/mo respectively. With advancing age, starting at the age of 25 years, this rate tends to decrease by approximately 0.5% per year."

Historically, one of the earliest research specifically about toenail growth was written in 1937 by LF Edwards at Ohio State University. That study had 70 patients and caliper measurements over a 30-day period.

Here is the link to that article -


Grace Torres-Hodges, DPM

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