July 2010

New Study Shows Efficacy Of Laser Therapy For Onychomycosis

By Brian McCurdy, Senior Editor

Given the common prevalence of onychomycosis, the emergence of new laser devices to help treat this disease has been an intriguing development. A recently published study suggests that laser therapy may have a role in the treatment armamentarium for onychomycosis.

   Published in the Journal of the American Podiatric Medical Association (JAPMA), the study examined the use of laser therapy on 26 toes with mycologically confirmed onychomycosis. There were 10 mild cases of onychomycosis, seven moderate cases and nine severe cases. Researchers included patients with diabetes without neuropathy or peripheral vascular disease. The Noveon (Nomir Medical) treatments consisted of a four-minute exposure of simultaneously applied wavelengths of 870 and 930 nm and a second exposure of 930 nm for two minutes, according to the study.

   After a 180-day follow-up period, researchers found that 65 percent of the treated toes demonstrated at least 3 mm of clear nail growth and 26 percent showed at least 4 mm of clear nail growth, according to the study. The authors also noted that of the 16 toes with moderate or severe onychomycosis, 63 percent showed clear nail growth of at least 3 mm.

   Warren Joseph, DPM, sees “great promise” in using lasers for onychomycosis.

    “The ‘Holy Grail’ of onychomycosis treatment has been to develop a totally safe, effective, convenient and cost-effective therapy without the risks, as minimal as they may have been, of toxicities and drug-drug interactions that may be found with the use of oral agents,” notes Dr. Joseph, a Fellow of the Infectious Diseases Society of America. “Light based therapies have the potential to meet those criteria.”

A Closer Look At The Pros And Cons Of Lasers

Adam Landsman, DPM, PhD, the lead author of the study, notes two issues with onychomycosis treatment: penetration of the nail plate and the need to reach fungus hidden away at the nail root. He notes that historically, topical therapies focus on clever techniques to reach the fungus deep beneath the nail whereas oral therapies focus on an “inside-out” approach.

   Since oral antifungals rely on the liver for metabolism, Dr. Landsman says there has always been some concern for injury to the liver associated with oral therapy.

   Laser technologies appear to be much more effective at penetrating the nail plate and are thought to reach a short distance beneath the nail fold to damage existing fungus there as well, according to Dr. Landsman, an Assistant Professor of Surgery at Harvard Medical School in Cambridge, Mass.

   Furthermore, he says lasers can accomplish this goal with only one to four treatments and with none of the risks associated with oral therapy.

   However, Dr. Landsman does note some downsides to the laser approach. He cites the potential for burns to the nail bed, primarily associated with heat-based systems. With heat-based systems, he also notes the potential for nails that are free from fungus but retain a distorted appearance. He notes this can be due to chronic damage to the nail root, nail beds that no longer adhere to the nail or even nail distortion caused by the laser.

   Although thermal injury and distortion of the nail appear to be rare, Dr. Landsman says one should discuss the possibility of these risks of the laser procedure with potential candidates.

   In addition, he notes that lasers for onychomycosis are not currently covered by insurance and costs can be high in comparison to other topical or oral treatments.

   As Dr. Joseph notes, the Noveon clinical trial is the first on the subject to be published in the peer-reviewed, indexed literature. It remains to be seen if the published clinical results will be reflected in more generalized “real world” usage, comments Dr. Joseph, who is affiliated with the Roxborough Memorial Hospital in Philadelphia. He adds that he has been a consultant for Nomir Medical.

Poll: Conservative Care Works For Most Plantar Fasciitis Cases

By Brian McCurdy, Senior Editor

In a recent Podiatry Today online poll, 75 percent of DPMs said 10 percent or less of their patients with plantar fasciitis failed conservative care. Out of a total number of 347 podiatrists polled, only 5 percent (18 votes) noted that more than 25 percent of their patients with plantar fasciitis failed conservative therapy.

   Zeeshan Husain, DPM, first assesses the patient’s level of pain on a 0 to 10 scale. If the pain is 5 or more on a scale of 10, Dr. Husain offers patients a cortisone injection (Kenalog, Bristol-Myers Squibb) and NSAIDs of their choice. If the patient takes the injection, Dr. Husain reevaluates the patient two weeks later with the expectation of 50 to 80 percent pain relief.

    “Unless the patient still has pain above 5 (on the 0 to 10 scale), he or she may request a second injection but I rarely have to do this,” explains Dr. Husain, the Assistant Residency Director for the Podiatric Surgical Residency Program at the Detroit Medical Center in Detroit.

   Dr. Husain says all his patients with plantar fasciitis must use OTC arch supports and night splints. If patients say OTC supports are not working well enough, he offers them custom orthoses.

   For those patients who decline an initial cortisone injection, Dr. Husain reevaluates those patients at one month and expects an approximate 50 percent improvement with the use of the OTC arch supports and night splints. If patients do not show adequate improvement, Dr. Husain offers physical therapy. He notes the Graston technique has worked well to mobilize the equinus deformity and break down excessive scar tissue around the heel.

   In the last seven years, Dr. Husain has only had to perform surgery on three patients with plantar fasciitis. He says he has “abandoned” the plantar fasciotomy as he believes it may destabilize the mechanics of the foot. Instead, Dr. Husain uses the gastroc recession to address the equinus component and also employs the radiofrequency Coblation technique (Topaz, Arthrocare Sports Medicine) percutaneously.

NYCPM To Offer Dual DPM/MPH Degree

By Brian McCurdy, Senior Editor

Starting in September, students at the New York College of Podiatric Medicine (NYCPM) will be able to attain a Masters of Public Health (MPH) degree along with their DPM degree. The college recently announced it is partnering with the Mount Sinai School of Medicine to offer the dual degree.

   The student body and alumni have expressed “much interest” in the dual degree program, according to Michael Trepal, DPM, the Vice President of Academic Affairs and Dean of NYCPM. He cites the myriad benefits of having two degrees.

    “Obtaining a dual DPM/MPH degree from two prestigious institutions will give significant value to the degree holder and place him or her at the forefront of the profession in terms of research capabilities and credibility, as well as public health consulting opportunities, and will open doors to leadership positions in venues such as hospitals and healthcare systems, government and private industry,” explains Dr. Trepal.

   The primary reason students appear to be pursuing dual degrees is interest in hospital administration, notes Dr. Trepal. He notes another reason for the interest is the documentation of the training and the ability to perform independent research. Dr. Trepal says students will be appropriately trained and credentialed to conduct clinical and translational research, and the dual degree will put them in a better position to compete for research dollars.

   In addition to enhanced skill sets, Dr. Trepal cites enhanced perception of those with the dual degree.

    “Individuals with the dual degree place themselves at the head of the line in competing for administrative and/or leadership roles,” he says. “The added value will positively affect the podiatric profession as more and more DPMs attain decision-making positions in both the public and private sectors.”

In Brief

Barry University’s Yucatan Crippled Children’s Project (YCCP) recently received $24,575 in grant support from three separate foundations.

   Two $10,000 donations came from the Frank J. Lewis Foundation of Riviera Beach, Fla., and the International Foundation of Fairfield, N.J., and the Northwest Podiatric Foundation donated $4,575, according to the university.

   Barry University notes that in the last 14 years, the Yucatan Crippled Children’s Project has treated more than 6,700 crippled children in Mexico.

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