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Case Studies In Laser Therapy

This author discusses the use of laser therapy and how it was beneficial in addressing nail deformities in patients with onychomycosis.

The use of lasers in podiatry is not new and physicians have used lasers to successfully treat many conditions other than onychomycosis. The criteria for Food and Drug Administration (FDA) approval of lasers for temporary clearing of nails and treatment of nail fungus is becoming better defined with the increased use of lasers. From a podiatrist’s perspective, we should consider lasers as part of the complement of treatment options available to patients.

   The patient’s expectations for the use of laser therapy for onychomycosis differ from those of the podiatrist. While laser treatment does not necessarily focus on eradicating an infection, it can make the nail’s appearance more aesthetically pleasing. If the nail bed has been damaged from trauma, it is unlikely that the nail plate will maintain a normal appearance. Laser therapy is not designed or expected to change the damaged nail bed. However, the nail plate that grows is subject to fungal infiltration and any modality that can reduce and prevent the further spread of fungal infiltration is a viable solution.

Case Study One: A Non-Painful Nail Deformity

A 75-year-old female presented with a complaint of deformity to the toenail on the right hallux. The patient reports trauma to the site that occurred more than five years ago. It is not painful. The toenail bothers her more because of the way it looks. An examination revealed lysis of the distal two-thirds of the toenail and evidence of a thickened, dystrophic nail plate at the base. There was evidence of subungual debris. A KOH test was positive for fungus and confirmed with a Periodic acid-Schiff (PAS) reaction.

   The patient had laser treatment to the toenail on May 4, 2012. This consisted of exposure to the right hallux nail plate of 85 pulses with 189 joules.

   On the August 8, 2012 follow-up visit, I noted an improved appearance of the patient’s right hallux toenail, including proximal clearing and evidence of decreased thickness and improved coloration at the right hallux nail plate. The patient was pleased with her progress.

Case Study Two: Discolored Nails And A Painful Digit

A 68-year-old female presented with a complaint of deformed and discolored toenails on her left great toe and second digit. She had been concerned with their darkening appearance and thickness. The second digit was painful with pressure. During the examination, I noted discoloration at the distal one-third of the hallux nail plate with associated lysis. Incurvation of the nail plate was present at the left second digit with discoloration and thickening at the distal aspect. There was evidence of subungual debris, which was KOH positive.

   The patient underwent laser treatment to the toenail on May 4, 2012. She received treatment to the left hallux nail plate of 262 pulses with 209 joules of energy and at the left second digit of 102 pulses with 81.3 joules.

   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.

Online Case Study
Grace Torres-Hodges, DPM



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.

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 - Thanks! Grace Torres-Hodges, DPM
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