Discussing patient expectations with laser therapy and its potential role in onychomycosis treatment, this author details how laser therapy enhanced the treatment of fungal nails in a 52-year-old patient.
There have been few innovations over the years for treatment of toenail fungus. However, laser therapy now offers physicians and their patients an excellent treatment option. The key, however, is to use laser as one facet of a comprehensive treatment plan for nail fungus with an emphasis on long-term maintenance and treatment of this chronic nail and skin disease.
Podiatrists need to remain the leaders and pioneers of laser technology. This is under threat by questionable practices of some laser companies and even more so by podiatrists. This technology is not a get rich quick scheme. We need to present it to patients as a treatment for a chronic disease and we as podiatrists should not feel bad about charging cash for services that may not be 100 percent successful. We need to be completely truthful with our patients and explain realistic percentages for clearing of the nail and steps to maintain the clear nail.
Promising cures is not acceptable or truthful. Doing what is best for the patient with a full, truthful explanation establishes clear patient expectations and continues to keep podiatry in the forefront of laser toenail fungus removal. Your patients must understand that they may fail treatment and must accept that as a possible outcome. I would rather lose the patient by giving him or her the facts than end up with an unhappy patient who does not trust me.
Patients spend hundreds of dollars on over-the–counter and prescription cream and liquid products that they obtain from stores and their physicians. However, these remedies, used alone, rarely offer the results that patients desire. Many refuse or cannot take oral medications because of previous or potential side effects. In my opinion, success rates of oral medications continue to decrease because of resistance. However, oral medications, whether traditional or herbal, still play a role in offering your patient a true comprehensive treatment plan.
Comprehensive protocols should include several types of treatment at the same time with an upfront plan for maintenance treatments to treat the chronic disease. I believe that many lasers are effective. These include the 1064 nm Nd-YAG (Cutera), the Nd:YAG 1320 nm (CoolTouch, Alma Lasers), Q switched lasers (Light Age) and lasers that combine lower wavelengths such as 980 nm (V-Raser, ConBio). Some are cleared by the Food and Drug Administration (FDA) and some are not. However, most are cleared for general podiatry and dermatology, and those that are cleared for fungal nails only offer temporary partial clearing of the nail.
Well, that does not make anyone want to get up and dance. However, it does support my premise that this tool treats a chronic disease and representing it in any other way would be less than genuine. Again, the key is the protocol that needs to develop. Unfortunately, there is little in the way of protocols and studies that show consistency. In addition, company sponsored studies for lasers are not reliable in many cases and do not represent all types of lasers.
I would urge each of you to develop a protocol that works well in your hands. Take a course in laser physics and safety. Work on improving your treatment. Don’t just take the word of some company representative. I would also be a skeptic if you hear that one treatment is all that is needed. Regardless of the laser one employs, there must be treatment for the nail during several phases of nail growth and fungus growth. In my opinion, that is what is currently best for the patient.
A 52-year-old female with a history of intense athletics as a teen and a chronic history of tinea pedis recently presented to my office. She developed fungal nails in her late 20s. She tried many OTC remedies and was opposed to the use of oral antifungal medications. She still had tinea that she treated occasionally with OTC cream.
We did three laser treatments four to six weeks apart for her onychomycosis and aggressively treated the tinea. We also used an antifungal shoe spray and a topical oil-based antifungal liquid. I plan to have her come into the office three times per year for maintenance laser treatments. She still uses the aforementioned OTC products four times per week. The photos were at day one (above left) and seven months (below right) showing excellent clearing.
It is my hope that we as a profession can solidify the role of laser treatment into a unified purpose so we can be the experts with the exciting technology of lasers.
Dr. Katz is in private practice in Tampa, Fla. He is a Fellow of the American College of Foot and Ankle Surgeons.