Laser Care For Onychomycosis: Can It Be Effective?

Start Page: 54
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Author(s): 
John Mozena, DPM, and Brent Haverstock, DPM, FACFAS

Yes. In reviewing the early study findings and his own experience as a patient, this author says lasers have potential in the treatment of onychomycosis.

By John Mozena, DPM

Onychomycosis is one of the most commonly diagnosed foot problems that podiatrists treat. Two to 3 percent of the population is known to have onychomycosis and this incidence increases to 15 percent for those between the ages of 40 to 60.1

   Since that time, World War II and Vietnam as well as worldwide transportation have accelerated the rate of fungus infections in our country. The infection, which was at one time a rare occurrence, has became an epidemic and will probably become a pandemic in the future.2

   In the past, the profession has considered onychomycosis to be a cosmetic problem. This has led many physicians to the false belief that they should monitor this infection but do not need to treat it.

   However, recent evidence has been to the contrary. Seventy-five percent of the people who have this infection exhibit psychosocial concerns.3 These people face the dilemma of not being able to go to the swimming pool, use a public shower or even wear open toe sandals. I had a patient who would not remove her socks during her honeymoon due to embarrassment from nail fungus. Particularly concerning is the fact that 48 percent of the people with onychomycosis have foot pain.3

   The standard for diagnosing fungus infections is the KOH test, which unfortunately has many false negatives and positive results. Fungal cultures have a much higher specificity but their sensitivity rates are not great. The best technique for sensitivity is a histological biopsy with a periodic acid-Schiff (PAS) stain but this is very expensive. Clinical diagnosis is certainly acceptable for instituting a treatment plan but verifying the existence of fungus helps one utilize the correct modality.

An Overview Of The Established Treatment Options

Until recently, the options for onychomycosis treatment included debridement, topical medications, oral medications and surgical destruction of the nail and nail bed. While nail debridement can facilitate patient comfort via debulking of the nail and a more cosmetically pleasing appearance, debridement does not really treat the fungus.

   There are multiple topical medications but the only one with any proven efficacy is ciclopirox lacquer 8% (Penlac, Sanofi Aventis).4 It is capable of penetrating the nail bed and getting to the source of the infection. Multiple oral medications are available with terbinafine (Lamisil, Novartis) being the most potent agent with a cure rate around 34 percent. Unfortunately, recurrence rates of 22 percent are reported after drug therapy.5

   The last option for treatment that exists for nail fungus is surgical destruction of the nail itself. Although this is a very effective treatment option, the cosmetic appearance and the fact that this can be a painful procedure makes many patients hesitate before moving forward with the procedure.6

What Promise Does Laser Treatment Hold?

Recently, the emergence of new technology has brought about another option for the treatment of onychomycosis. Podiatry is no stranger to laser surgery. Lasers have been in use for the last several years in our profession for warts, dermal lesions and matrixectomy of ingrown nails.

   The newest laser application in podiatry is the ablation of a fungus infection within a toenail. Utilizing very specific wavelengths, the newer lasers are able to cause photo damage and/or ablation of the fungus within the toenail.
The two lasers that I believe have the greatest potential are the Noveon laser (Nomir Medical) and the PinPointe FootLaser (PathoLase). Early studies with these devices show high efficacy rates.7,8

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