Laser and light therapy for onychomycosis: a systematic review

Efficacy of Laser Therapy in Comparison With Other Methods for the Treatment of Onychomycosis: A Systematic Review and Meta-Analysis

Onychomycosis, a fungal infection of the nails, presents a significant challenge in clinical management due to its chronic nature and resistance to conventional therapies. This study aims to evaluate the efficacy of laser therapy in treating onychomycosis compared to traditional methods such as terbinafine. A systematic review and meta-analysis were conducted to analyze existing literature on the subject. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram illustrates the selection process of studies. Findings suggest that laser therapy demonstrates promising results in the treatment of onychomycosis, with comparable efficacy to terbinafine and fewer adverse effects. Further large-scale randomized controlled trials are warranted to validate these findings and establish laser therapy as a standard treatment option for onychomycosis.

Long-pulsed 1,064-nm gallium arsenide laser surgical device treatment for improving symptoms of onychomycosis: a comparative analysis

BACKGROUND

Onychomycosis is the most common infective nail disease, and treatment includes topical and systemic antifungal medications. Recently, laser therapy has emerged as a therapeutic option for patients who are unable to take oral antifungal agents. We investigated the effectiveness and safety of a novel long-pulsed 1,064-nm gallium arsenide (GaAs) laser surgical device for onychomycosis.

METHODS

This 24-week single-center, single-blind, active-controlled exploratory clinical study comparatively evaluated the long-pulsed 1,064-nm GaAs laser (Healer1064) with the short-pulsed Nd:YAG laser surgical device in 20 participants randomly assigned to receive either test or control treatment at 4-week intervals during the 12-week treatment period. The rate of clinical improvement was evaluated by two independent dermatologist evaluators using the Onychomycosis Severity Index-score (OSI-score) and Turbidity Scale with standard photographs. Overall improvement and patient satisfaction were evaluated. Safety evaluation included pain intensity and adverse events.

RESULTS

In 44 (test: 25; control: 19) cases in 19 participants who completed treatment, the clinical improvement rate in the test and control groups was 52.00% (13/52 cases) and 44.44% (9/19 cases), respectively, with significantly lower pain scores in the test than the control group for every treatment visit (P < 0.05) and without severe adverse events.

CONCLUSIONS

The novel long-pulsed 1,064-nm GaAs laser showed greater, albeit nonsignificant, clinical improvement and was associated with less pain during treatment. Thus, the Healer1064 can provide satisfactory treatment outcomes through painless and effective improvement in onychomycosis symptoms.

Q-switched Nd:YAG laser versus itraconazole pulse therapy in treatment of onychomycosis: A clinical dermoscopic and mycologic study

BACKGROUND

Onychomycosis (OM) represents about 50% of nail disorders. Oral antifungals have proven efficacy in the treatment of onychomycosis but their associated side effects limit their use. Accordingly, there is an increased need for a safe and effective therapy to induce clearance and improve the esthetic appearance of diseased nails.

OBJECTIVE

The current study is an attempt to evaluate and compare the efficacy of Q-Switched Nd:YAG (1064 nm) laser as monotherapy versus pulse itraconazole in the clearance of onychomycosis.

METHODS

In this prospective study, 40 onychomycosis patients were equally divided into two groups: Groups I (laser group) and II (Itraconazole group). Patients of Group I are treated with six biweekly sessions of Q-Switched Nd:YAG (1064 nm) laser. Patients of Group II are treated with itraconazole pulse therapy. The assessment of clearance was rated using the "Onychomycosis Severity Index (OSI)", photographs, dermoscopy, and mycology. All 40 patients were followed up for 3 months after the end of treatment.

RESULTS

Group I's clinical improvement response was a marked improvement in 19 cases and moderate improvement in one case (OSI before treatment was 24.5 and after was 0). A dermoscopic cure occurred in 19 cases. Mycological cure was obtained in 19 cases. Group II's clinical improvement response was marked in 15 and moderate in 5 (OSI before treatment was 24 and after was 0). Dermoscopic cure occurred in 15 cases. Mycological cure was obtained in 15 cases. There were no adverse effects. The clinical response, the dermoscopic cure, and the mycological cure were equal in both groups, with no significant difference found between them.

CONCLUSION

Q-Switched Nd:YAG (1064 nm) laser can be used as an effective and safe modality in the clearance of nail onychomycosis, particularly in patients who have a contraindication to or refuse the use of oral antifungals.

Growth inhibition of Trichophyton rubrum by laser irradiation: exploring further experimental aspects in an in vitro evaluation study

BACKGROUND

According to the results of the clinical trials, laser therapy is effective for the treatment of onychomycosis, but the in vitro findings are inconsistent among studies. This study aimed to explore the experimental conditions of laser for the inhibition of Trichophyton rubrum growth in vitro. A 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser was used to irradiate colonies using a small (6-mm diameter) or large (13-mm diameter) area, and using 300, 408, or 600 J/cm². The surface temperature of the colony was measured after irradiation and every 2 min. The growth area was calculated until the 7th or 10th day of incubation daily.

RESULTS

For the small area group, at 300 J/cm², the immediate surface temperature was 25.2 ± 0.2°C, but without effect on growth (P = 0.516). At 408 J/cm², the immediate surface temperature was 32.0 ± 0.4°C; growth was inhibited for 7 days (P < 0.001). At 600 J/cm², the immediate surface temperature was 38.1 ± 0.4°C; the growth was completely stopped for at least 10 days (P < 0.001). For the large area group, the temperature patterns were similar to those of the small area group, but the highest temperature was lower than in the small area groups, and no growth inhibition effect was observed (all P > 0.05).

CONCLUSIONS

When the irradiation area is small, a 1064-nm Nd:YAG laser at 408 or 600 J/cm² can be effective in suppressing T. rubrum growth in vitro.

Efficacy of Lasers for the Management of Dermatophyte Toenail Onychomycosis

BACKGROUND

Onychomycosis is a chronic fungal nail infection caused predominantly by dermatophytes, and less commonly by nondermatophyte molds and Candida species. Onychomycosis treatment includes oral and topical antifungals, the efficacy of which is evaluated through randomized, double-blind, controlled trials for US Food and Drug Administration approval. The primary efficacy measure is complete cure (complete mycologic and clinical cure). The secondary measures are clinical cure (usually ≤10% involvement of target nail) and mycologic cure (negative microscopy and culture). Some lasers are US Food and Drug Administration approved for the mild temporary increase in clear nail; however, some practitioners attempt to use lasers to treat and cure onychomycosis.

METHODS

A systematic review of the literature was performed in July of 2020 to evaluate the efficacy rates demonstrated by randomized controlled trials of laser monotherapy for dermatophyte onychomycosis of the great toenail.

RESULTS

Randomized controlled trials assessing the efficacy of laser monotherapy for dermatophyte toenail onychomycosis are limited. Many studies measured cure rates by means of nails instead of patients, and performed only microscopy or culture, not both. Only one included study reported mycologic cure rate in patients as negative light microscopy and culture (0%). The combined clinical cure rates in short- and long-pulsed laser studies were 13.0%-16.7% and 25.9%, respectively. There was no study that reported the complete cure rate; however, one did report treatment success (mycologic cure [negative microscopy and culture] and ≤10% clinical involvement) in nails as 16.7%.

CONCLUSIONS

The effectiveness of lasers as a therapeutic intervention for dermatophyte toenail onychomycosis is limited based on complete, mycologic, and clinical cure rates. However, it may be possible to use different treatment parameters or lasers with a different wavelength to increase the efficacy. Lasers could be a potential management option for older patients and onychomycosis patients with coexisting conditions such as diabetes, liver, and/or kidney diseases for whom systemic antifungal agents are contraindicated or have failed.

Non-thermal atmospheric plasma treatment of onychomycosis in an in vitro human nail model

BACKGROUND

Onychomycosis affects almost 6% of the world population. Topical azoles and systemic antifungal agents are of low efficacy and can have undesirable side effects. An effective, non-invasive therapy for onychomycosis is an unmet clinical need.

OBJECTIVE

Determine the efficacy threshold of non-thermal atmospheric plasma (NTAP) to treat onychomycosis in an in vitro model.

METHODS

A novel toe/nail-plate model using cadaver nails and agarose media inoculated with Candida albicans was exposed to a range of NTAP doses.

RESULTS

Direct exposure of C albicans and Trichophyton mentagrophytes to 12 minutes of NTAP results in complete killing at doses of 39 and 15 kPulses, respectively. Onset of reduced viability of C albicans to NTAP treatment through the nail plate occurs at 64 kPulses with 10× and 100× reduction at 212 and 550 kPulses, respectively.

CONCLUSIONS

NTAP is an effective, non-invasive therapeutic approach to onychomycosis that should be evaluated in a clinical setting.

Laser treatment for onychomycosis: A systematic review and meta-analysis

BACKGROUND

Laser systems are a common treatment choice for onychomycosis. They exert their effects on inhibiting the growth of the fungus by selective photothermolysis but efficacy is dependent on the specific type of apparatus used. To systematically review the available published literature on the curative effects and safety of laser treatment for onychomycosis.

METHODS

Databases including PubMed, web of science, China National Knowledge Internet (CNKI), WanFang Database and VIP were searched systematically to identify relevant articles published up to July 2018. Potentially relevant articles were sourced, assessed against eligibility criteria by 2 researchers independently and data were extracted from included studies. A meta-analysis was performed using R software.

RESULTS

Thirty-five articles involving 1723 patients and 4278 infected nails were included. Meta-analysis of data extracted from these studies revealed that: the overall mycological cure rate was 63.0% (95%CI 0.53-0.73); the mycological cure rate associated with the 1064-nm Nd: YAG laser was 63.0% (95%CI 0.51-0.74); and that of CO2 lasers was 74.0% (95%CI 0.37-0.98). The published data indicate that laser treatment is relatively safe, but can cause tolerable pain and occasionally lead to bleeding after treatment.

CONCLUSION

Laser treatment of onychomycosis is effective and safe. The cumulative cure rate of laser treatment was significantly higher for CO2 lasers than other types of laser. Laser practitioners should be made aware of potential adverse effects such as pain and bleeding.

Inhibition of Trichophyton rubrum by 420-nm Intense Pulsed Light: In Vitro Activity and the Role of Nitric Oxide in Fungal Death

Trichophyton rubrum is a common dermatophyte of the skin. The aim of this experiment was to explore the role of nitric oxide (NO) in the inhibition of T. rubrum growth induced by 420-nm intense pulsed light (IPL). This study found that nitric oxide synthase (NOS) and NO levels were increased, whereas asymmetric dimethylarginine (ADMA) level, keratinase activity, and fungal viability were decreased after IPL treatment compared with the control condition in vitro. Moreover, micromorphology was damaged by IPL treatment. Fungal viability was increased, and the damage to the fungal structure was reduced after pretreatment with an NOS inhibitor (L-NMMA) compared with IPL treatment alone. Compared with IPL alone, pretreatment with L-NMMA decreased NOS expression and NO level and increased keratinase activity. We found that 420-nm IPL treatment can inhibit the growth of T. rubrum by regulating NO in vitro.

Clinical retrospective analysis of long-pulsed 1064-nm Nd:YAG laser in the treatment of onychomycosis and its effect on the ultrastructure of fungus pathogen

The objective of this study was to analyze retrospectively the clinical efficacy and fungal clearance of long-pulsed 1064-nm Nd:YAG laser for treating onychomycosis and explore the inhibitory effects of laser on the fungus pathogen-induced onychomycosis in vitro. We performed a systematic retrospective analysis of clinical patients (162 effected nails) of onychomycosis treatment applying laser with or without topical ketoconazole ointment and followed up 3 months after treatment. Trichophyton rubrum- and Trichophyton mentagrophytes-induced onychomycosis was irradiated with laser superimposed for different cumulative energy, respectively; then, the areas of fungus colonies and growth curve in different days were showed, and changes in ultrastructures were observed under SEM and TEM. The clinical effective rate and fungal clearance rate in the combined group were higher than those in the laser group; however, there was no significant difference between the two groups. In vitro, the areas of T. rubrum colonies were significantly reduced at days 1, 3, and 5 after irradiation with cumulative laser energy ≥ 6400 J/cm². When irradiated with cumulative laser energy ≥ 25600 J/cm², significant difference in the areas of T. mentagrophytes colonies was found at day 5. And ultrastructure of the two strains before and after laser irradiation was damaged at different degrees. This study confirmed that long-pulsed 1064-nm Nd:YAG laser is effective for treating onychomycosis, and the laser irradiation can inhibit the colony growth of T. rubrum and T. mentagrophytes and change their cellular ultrastructures. The mechanism of laser treatment of onychomycosis may be related to direct damage of fungus pathogen.

Raman Microspectroscopy as a Tool to Elucidate the Efficacy of Topical Formulations Containing Curcumin

The success of the onychomycosis treatment is directly associated with factors such as the choice of the medication, the administration route, and the pharmaceutical formulation. Photodynamic therapy (PDT) is an emerging and promising technique indicated for onychomycosis treatment. For this application, the main challenge is the efficient delivery of the photosensitizer (PS). Curcumin is widely used as a PS, however it is an unstable molecule and it is a challenge to develop a formulation with good penetration into the nail plate, maintaining the stability of curcumin. In this study, the molecular mechanisms underlying the efficacy of two topical formulations containing curcumin used in a clinical trial for onychomycosis treatment were analyzed by Raman microspectroscopy. It is shown that curcumin is present in both formulations in aggregated and non-aggregated states, and in aggregates it is present in different conformations, depending on the interaction with the solvent. This proves to be critical for efficient and uniform PS delivery to the nail and its complete use during the treatment. These analyses are showing how promising Raman microspectroscopy is in understanding the molecular mechanisms of the efficiency of photosensitizers and are helping to improve the development of pharmaceutical formulations.

Enhancement of the antidermatophytic activity of silver nanoparticles by Q-switched Nd:YAG laser and monoclonal antibody conjugation

The objective of this research was to investigate the effect of silver nanoparticles (AgNPs), free or conjugated with monoclonal antibody and mediated by Q-switched Nd:YAG laser on five dermatophytes. The laser was applied for 45 s at 532 nm and 0.8 J/cm2. The application of AgNPs combined with laser caused an increase in fungal susceptibility compared to application of AgNPs alone. The MIC50 and MIC100 recorded 3 and 9 μg/ml in the case of E. floccosum (the most susceptible species), 10 and 19 μg/ml for T. rubrum (the most tolerant species), respectively. A decrease in keratinase activity reaching 76.1, 67.1, and 62.4% was attained in the case of M. gypseum, T. rubrum, and T. mentagrophyte, respectively, on application of 10 μg/ml AgNPs combined with Nd:YAG laser. Under the same conditions of application, a steady increase in leaked materials coupled with reduction in ergosterol synthesis was reached. The structural alterations occurred to the fungus were more observed on the application of AgNPs in combination with laser where the conidia and hyphae lost their cellular integrity, become flaccid, permanently destructed, and completely killed. The monoclonal antibody conjugated AgNPs did not result in significant variation in in vitro experiments compared with that produced by nonconjugated nanoparticles. However, the conjugates achieved significantly more curing of M. canis-inoculated guinea pigs compared with nonconjugated nanoparticles.

Determining the optimal parameters of 420-nm intense pulsed light on Trichophyton rubrum growth in vitro

The effect of and the optimal parameters for intense pulsed light (IPL) with a 420-nm filter on an isolate of the fungus Trichophyton rubrum (T. rubrum) were examined in vitro. Colonies of T. rubrum were irradiated by using 420-nm IPL with various pulse numbers and energies. Colony areas were photographed and compared with those of untreated colonies to assess growth inhibition. Statistically significant inhibition of T. rubrum growth was detected in colonies treated with 12 pulses of greater than or equal to 12 J/cm². The optimal parameters of 420-nm IPL were 12 pulses of 12 J/cm². However, more in vitro and in vivo studies are necessary to investigate and explore this mechanism to determine whether IPL would have a potential use in the treatment of fungal infections of the skin.

Randomized Clinical Trial to Evaluate the Efficacy and Safety of Combination Therapy with Short-Pulsed 1,064-nm Neodymium-Doped Yttrium Aluminium Garnet Laser and Amorolfine Nail Lacquer for Onychomycosis

Background

Onychomycosis is one of the most prevalent fungal diseases in the general population. However, treatment is of limited effectiveness and must be administered for long periods of time. Systemic antifungal agents are associated with adverse effects.

Objective

We evaluated the clinical efficacy and safety of a 1,064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser with amorolfine nail lacquer to treat onychomycosis.

Methods

The 128 patients were randomly divided to 2 groups: 64 in the experimental group were treated with 1,064-nm Nd:YAG laser therapy and amorolfine nail lacquer; the other 64 were in a control group treated with topical amorolfine lacquer monotherapy. The laser treatment was 4 sessions at 4-week intervals and amorolfine lacquer was applied once a week for 16 weeks. Efficacy was assessed as response rate from standardized photographs with ImagePro®Plus (Media Cybernetics, Inc., USA) analysis, microscopic examination, and subjective evaluation.

Results

At 16 weeks, the experimental group showed a significantly higher cumulative cure rate than the control group (71.88% vs. 20.31%, p<0.0001). Clinical therapeutic effects were linked to patient satisfaction. The percent of “very satisfied” or “satisfied” responses was higher in the test group than the control group (81.25% vs. 23.44%). The treatment regimen was well tolerated, with transient discomfort observed in the test group.

Conclusion

The 1,064-nm Nd:YAG laser with amorolfine nail lacquer was effective and safe for treating onychomycosis. This therapy should be considered an alternative treatment, especially for patients with contraindications to systemic antifungal agents.

A Comparative Study of 660 nm Low-Level Laser and Light Emitted Diode in Proliferative Effects of Fibroblast Cells

Introduction: In recent years, low-power lasers have been widely used in medicine. With the introduction of affordable light emitted diode (LED), clinical application of LED light has become more and more popular. However, some researchers believe that due to lack of coherence of the LED light, it can be different in terms of biological effects, in comparison with laser. In this study, the biological effects of low-level laser (LLL) to those of LED light are compared and discussed. Methods: Human skin fibroblast cell line Hu02 was irradiated with LLL and LED light with a wavelength of 660 nm, power output of 35 mW and in continuous mode and the control group was not irradiated. The biological effects were compared through analysis of cell proliferation, production of reactive oxygen species (ROS) within the cell and rate of cell division. Results: Our findings showed that production of ROS within the cell was linearly increased both in the LED and laser light irradiated cells. However, laser light is more incremental in comparison to LED light. The MTT results showed that laser light at low energy density (less than 5 J/cm²) increased the rate of cell proliferation after 24 hours. Although, the rate of cell division was increased in energy density of 1 J/cm² compared to the control group, this increase was not statistically significant. Discussion: The findings indicated that the coherence properties of laser light provided more energy for the cells, and in a constant energy density, laser light created more oxidative stresses in comparison with LED light.

Self-controlled Study of Onychomycosis Treated with Long-pulsed Nd:YAG 1064-nm Laser Combined with Itraconazole

Background:

Onychomycosis is a fungal infection of the nail plate and subungual area. In this study, we examined the efficacy of laser treatment using self-controlled study programs involving a long-pulsed Nd:YAG 1064-nm laser combined with oral medication.

Methods:

Self-controlled strategies were followed in this study. The patients received treatment with oral itraconazole in conjunction with long-pulsed Nd:YAG 1064-nm laser treatment at the nails of the unilateral limb once a week for a total of four times. A total of 84 affected nails were divided into Group A (mild to moderate) and Group B (severe) according to disease severity. Affected nails with the same Scoring Clinical Index for Onychomycosis scores were selected to compare the therapeutic effects of the pure medication treatment group and the combination treatment group with a 24-week follow-up period.

Results:

In Group A, at the 8^th, 16^th, and 24^th weeks of follow-up, the efficacies in the pure medication treatment group were 81.0%, 81.0%, and 90.5%, respectively, while those in the combination treatment group were 100%, 95.2%, and 90.5%, respectively. The differences between groups were not significant (8^th week: χ² = 4.421, P > 0.05; 16^th week: χ² = 2.043, P > 0.05; 24^th week: χ² = 0.00, P > 0.05). In Group B, at the 8^th, 16^th, and 24^th weeks of follow-up, the efficacies in the pure medication treatment group were 61.9%, 66.7%, and 52.4%, respectively, while those in the combination treatment group were 95.2%, 90.5%, and 100%, respectively. The differences between groups at the 8^th and 24^th weeks of follow-up were statistically significant (8^th week: χ² = 6.929, P < 0.05; 24^th week: χ² = 13.125, P < 0.05).

Conclusions:

For patients with mild or moderate onychomycosis, we recommended a pure medication treatment or combination treatment with medication and laser. For those patients with severe onychomycosis, we recommended a combination of medication and laser therapy.

Long-Pulsed 1064-nm Nd:YAG Laser for the Treatment of Onychomycosis

OBJECTIVE

The aim of this study is to evaluate the efficacy of long-pulsed 1064-nm Nd:YAG laser in penetrating tissue and targeting the fungal overgrowth in the nail plate.

BACKGROUND

Onychomycosis is the most frequent nail disorder. Current treatments include oral and topical antifungal agents, photodynamic therapy, and surgical approaches such as mechanical, chemical, or surgical nail avulsion. Moreover, the use of lasers to treat nail diseases has been approved in the United States by the Food and Drug Administration (FDA). Wide literature has been produced to assess the effectiveness of these devices, but, because the opposing results emerging from current studies, more data are still needed on the long-lasting efficacy and safety of this procedure.

METHODS

Twenty consecutive, unselected patients were enrolled in the study and treated, at intervals of 1 week, for a total of four sessions, using a long-pulsed 1064-nm Nd:YAG laser. In each session, three passages across each nail plate were performed with 1-min pause between each passage. A special lens for dermatoscopy, connected to a digital camera, was used for dermoscopic images.

RESULTS

In fourteen patients (70%; 12F; 3M), excellent results were obtained with an important reduction of chromonychia, onycholysis, opacity, longitudinal striae, and jagged proximal edge. Better results were observed in severe cases in the 2-month follow-up visit.

CONCLUSIONS

Data for treating nail onychomycosis with laser and light therapy seem to be positive. The promising results of our study identify long-pulsed 1064-nm Nd:YAG laser as a possible alternative option for the treatment of onychomycosis. However, increasing subject data, improving study methodology, and output parameters may become an important next step of study in the treatment of nail onychomycosis.

Real-World Efficacy of 1064-nm Nd:YAG Laser for the Treatment of Onychomycosis

Background:

Onychomycosis is a cosmetic and, at times, medical concern; therefore, effective and safe alternatives to treatment are needed.

Objective:

To determine the efficacy of a 1064-nm Nd:YAG laser for the treatment of onychomycosis in a real-world setting.

Methods:

A single-centre retrospective chart review was conducted between 2012 and 2013. One hundred consecutive patients with a culture- and/or potassium hydroxide–confirmed diagnosis of onychomycosis were treated at least twice. Baseline and follow-up photographs were taken, and the change in degree of clinical nail involvement of the subject’s great toenail was determined by a blinded reviewer using validated planimetry measurement.

Results:

A total of 199 hallux nails from 100 subjects were assessed. The mean infected area decreased from 53.2% at baseline to 50.8% at the end of the study (paired t test, P = .054; Wilcoxon signed rank test, P = .006). Degree of nail involvement was statistically significantly associated with amount of improvement; subjects who had the greatest degree of nail involvement improved the most, while those with less severe disease showed a worsening of nail appearance (Kruskal-Wallis test, P < .001). Three-quarters (72.6%) of nails that had more than 67% nail involvement showed statistically significant improvement (χ2 test, P = .001). Adverse events were limited to mild to moderate pain at the time of therapy. A total of 76 subjects were assessed for treatment satisfaction: 60% were very satisfied with treatment despite limited clinical improvement in some cases.

Conclusions:

Laser therapy has a very limited positive clinical effect on the appearance of onychomycosis after 2 treatment sessions.

The efficacy of fractional carbon dioxide (CO2) laser combined with luliconazole 1% cream for the treatment of onychomycosis: A randomized, controlled trial

BACKGROUND

To evaluate the efficacy of fractional carbon dioxide (CO2) laser combined with luliconazole 1% cream for the treatment of onychomycosis and to compare it with that of fractional CO2 laser alone.

METHODS

This was a randomized, parallel group, 2-arm, positive-controlled, single-center, superiority trial with a 1:2 allocation ratio. Sixty patients with clinical and mycological diagnosis of onychomycosis were enrolled from the Dermatology Department of the First Affiliated Hospital of Nanjing Medical University in Nanjing, China from March 2015 to May 2015. Patients were randomized following simple randomization procedures (computerized random number generator) into 2 groups; L group only received 12 sessions of laser treatment at 2-week interval for 6 months, while L + D group received 12 sessions of laser treatment at 2-week interval combined with luliconazole 1% cream once daily for 6 months. This was not a blind trial. The main outcome measures were the clinical efficacy rate (CER) assessed from the percentage of fully and >60% normal-appearing nails and the mycological clearance rate (MCR) assessed from the percentage of nails with negative fungal microscopy. There were no changes to trial outcome measures after the trial commenced.

RESULTS

A total of 60 patients (N = 233 nails) completed treatments and follow-up, and were randomized and divided into 2 groups: L group (31 patients, N = 108 nails) and L + D group (29 patients, N = 115 nails). The CER and MCR of L + D group were 69.6% and 57.4%, respectively. L + D group showed significantly higher CER (69.6% vs 50.9%; χ = 8.1, P = 0.004) and MCR (57.4% vs 38.9%; χ = 7.6, P = 0.006) compared with those in L group. Some patients experienced mild pain during laser treatment, but there was no bleeding or oozing during or after treatment. There were no adverse effects reported during the observation period.

CONCLUSION

Fractional CO2 laser treatment combined with 1% luliconazole cream for 6 months was an effective and safe method for the treatment of onychomycosis, and had a higher efficacy than fractional CO2 laser treatment alone.

Laser Therapy for Onychomycosis: Fact or Fiction?

Onychomycosis is a common fungal infection, afflicting some 10% of the adult population in industrialized countries. Aside from cosmetic concerns, onychomycosis can be the cause of toe and foot pain, as well as the underlying etiology for serious secondary bacterial infections and traumatic ulcerations. In select populations, such as diabetics, the latter conditions may even result in loss of all or part of the lower extremity. Thus, a simple, cost-effective and safe treatment for onychomycosis is highly desirable. Although both topical and oral systemic antifungal agents are available for this purpose, they are not always effective, carry some medical risks, are associated with potentially significant drug-drug interactions, and may be unacceptable to patient and healthcare provider alike. Physical modalities, such as laser therapy, therefore appear appealing. The question is whether laser treatment is sufficiently efficacious and safe to warrant the current high cost per treatment. The readily available literature on this controversy will be reviewed herein.

Onychomycosis: A Review

Onychomycosis is the most common nail infective disorder. It is caused mainly by anthropophilic dermatophytes, in particular by Trichophyton rubrum and T. mentagrophytes var. interdigitale. Yeasts, like Candida albicans and C. parapsilosis, and molds, like Aspergillus spp., represent the second cause of onychomycosis. The clinical suspect of onychomycosis should be confirmed my mycology. Onychoscopy is a new method that can help the physician, as in onychomycosis, it shows a typical fringed proximal margin. Treatment is chosen depending on the modality of nail invasion, fungus species and the number of affected nails. Oral treatments are often limited by drug interactions, while topical antifungal lacquers have less efficacy. A combination of both oral and systemic treatment is often the best choice.

Laser therapy of onychomycosis

Since 2010 the FDA has approved laser systems as capable of producing a "temporary increase in clear nails" in patients with onychomycosis. Fungal eradication is probably mediated by heat in infrared laser systems; their efficacy has been confirmed thermographically, histologically and in electron microscopy. Another approach to decontaminate the nail organ is to disrupt fungi and spores by q-switched pulse applications. Recently specific combinations of wavelengths have been tested for their ability to disrupt the mitochondrial transmembrane potential at physiological temperatures by generating ATP and ROS. While clinically extremely high clearance rates of approximately 87.5-95.8 % have been reported, in-vitro investigations have failed to confirm the clearance. The variety of systems and advised parameters hampers a systematic evaluation. Recommendations for safe and practical treatment protocols, informed consent items, and combination with conventional treatment options are all areas of active work. Currently there is a lack of data concerning the long-term efficacy of laser therapy of onychomycosis; certified treatment protocols are needed.