Combined Oral Terbinafine and Long-Pulsed 1,064-nm Nd: YAG Laser Treatment Is More Effective for Onychomycosis Than Either Treatment Alone

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.

Combination Therapy Should Be Reserved as Second-Line Treatment of Onychomycosis: A Systematic Review of Onychomycosis Clinical Trials

Onychomycosis is the most common nail disease encountered in clinical practice. Its importance extends well beyond aesthetics, often causing pain, difficulty with ambulation and performing daily activities, and impairing quality of life. Many patients fail to achieve cure with antifungal monotherapy and recurrences are common. Combination therapy has therefore gained considerable interest, given the potential for drug synergy and prevention of antifungal resistance, but it has not been well studied. A systematic review of onychomycosis medication only, as well as medication and procedural (laser, debridement, photodynamic therapy), clinical or randomized controlled trials evaluating combination vs. monotherapies was performed. After exclusions, 30 studies were included in the final analysis. There were conflicting results for medication-only trials, with some showing significant benefit of combination therapy over monotherapy, however, trials were not robustly designed and lacked sufficient follow-up. Procedural studies also lacked long-term follow-up, and failed to demonstrate efficacy in some severe onychomycosis cases. Considering the high cure rates demonstrated in pivotal antifungal monotherapy trials, and conflicting results, costs, and safety concerns associated with combination therapy, we recommend that combination therapy be reserved as second-line treatment options in patients with poor prognostic factors or for those who failed monotherapy for onychomycosis.

Race reporting and representation in onychomycosis clinical trials: A systematic review

BACKGROUND

Onychomycosis is the most common nail disease seen in clinical practice. Inclusion of diverse groups in onychomycosis clinical trials subjects is necessary to generalise efficacy data.

OBJECTIVES

We aimed to systematically review race and ethnicity reporting and representation, as well as, treatment outcomes in onychomycosis clinical trials.

METHODS

A PubMed search for onychomycosis clinical trials was performed in August 2020. Primary clinical trial data were included and post hoc analyses were excluded. Categorical variables were compared using chi-squared and Fisher's exact tests. Statistical significance was set at p < .05. Photos in articles were categorised by Fitzpatrick skin type.

RESULTS

Only 32/182 (17.5%) trials reported on race and/or ethnicity and only one trial compared treatment efficacy in different subgroups. Darker skin colours were infrequently depicted in articles. Topical treatment, location with ≥1 US-based site, industry funding type and publication date after 2000 were significantly associated with reporting of racial/ethnic data (p < .05 for all comparisons).

LIMITATIONS

Demographics on excluded subjects and methods of recruitment were not available. Assigning Fitzpatrick skin type is inherently subjective.

CONCLUSIONS

This study highlights a need for consistent reporting of races and ethnicities of onychomycosis clinical trial participants with subgroup analyses of treatment efficacies.

Big toenail onychomycosis features associated with response to 1064 nm Nd: YAG laser treatment

BACKGROUND

A few studies discussed the factors correlated to response in laser treatment of onychomycosis.

OBJECTIVE

This study aimed to seek big toenail onychomycosis features that correlate with response to 1064 nm Nd: YAG laser treatment.

METHODS

This single-center, retrospective study included patients who had only one big toenail onychomycosis, with a confirmed mycological diagnosis and/or a high clinical suspicion. Patients had three sessions 1 month apart. The following characteristics were collected from the patients' files: age, sex, smoking and arterial hypertension statuses, results of baseline mycological culture, Onychomycosis Severity Index (OSI) score at baseline and at the end of the 6-month follow-up, as well as the reported side effects.

RESULTS

We included 105 patients, 86 women and 19 men, with a mean age of 43 years. Demographics have shown that 73.6% of patients were smokers, 17.9% had arterial hypertension, 61.9% had a culture positive for Trichophyton species, and 9.4% had a culture positive for Candida species. According to the OSI score, onychomycosis was mild in 18.9%, moderate in 39.6%, and severe in 41.5% of patients. At 6 months, clinical cure was achieved in 57.1% of patients.

CONCLUSION

The OSI decrease after 3 sessions of Nd: YAG laser was significantly more important in women and in patients with positive mycology culture, smaller affected area of the nail, no subungual hyperkeratosis, and no nail matrix involvement. Age, smoking, hypertension, and side effects were not shown to significantly correlate with the decrease of the OSI score.

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.

A Practical Guide to Curing Onychomycosis: How to Maximize Cure at the Patient, Organism, Treatment, and Environmental Level

Onychomycosis is a fungal nail infection caused by dermatophytes, non-dermatophyte molds, and yeasts. Treatment of this infection can be difficult, with relapse likely to occur within 2.5 years of cure. The objective of this article is to review factors that can impact cure and to suggest practical techniques that physicians can use to maximize cure rates. Co-morbidities, as well as disease severity and duration, are among the many patient factors that could influence the efficacy of antifungal therapies. Furthermore, organism, treatment, and environmental factors that may hinder cure include point mutations, biofilms, affinity for non-target enzymes, and exposure to fungal reservoirs. To address patient-related factors, physicians are encouraged to conduct confirmatory testing and treat co-morbidities such as tinea pedis early and completely. To combat organism-focused factors, it is recommended that disruption of biofilms is considered, and drugs with multiple routes of delivery and unique mechanisms of action are prescribed when traditional agents are not effective. Extending follow-up periods, using combination treatments, and considering pulse regimens may also be of benefit. Through these practical techniques, physicians can maximize cure and limit the risk of relapse and re-infection.

Global perspectives for the management of onychomycosis

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophyte molds, and yeasts. This difficult-to-treat chronic infection has a tendency to relapse despite treatment. This paper aims to offer a global perspective on onychomycosis management from expert physicians from around the world. Overall, the majority of experts surveyed used systemic, topical, and combination treatments approved in their countries and monitored patients based on the product insert or government recommendations. Although the basics of treating onychomycosis were similar between countries, slight differences in onychomycosis management between countries were found. These differences were mainly due to different approaches to adjunctive therapy, rating the severity of disease and use of prophylaxis treatment. A global perspective on the treatment of onychomycosis provides a framework of success for the committed clinician with appreciation of how onychomycosis is managed worldwide.

Treatment of onychomycosis using a 1064-nm diode laser with or without topical antifungal therapy: a single-center, retrospective analysis in 56 patients

Background

Currently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects. Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. Against this background, we performed a systematic retrospective analysis of our clinical experience of 4 years of onychomycosis treatment applying a long-pulsed 1.064-nm diode laser.

Methods

We retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1.064-nm diode laser (FOX, A.C.R. Laser GmbH, Nuremberg) during the time period of July 2013–December 2016 with or without concomitant topical antifungals. Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3.9 laser treatments at 2–6-week intervals. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy.

Results

Clinical improvement was achieved in 56% of patients treated with laser only after a mean of 4.5 treatments and in 69% of patients treated with laser in combination with topical antifungals after a mean of 3.6 treatments. Cultural healing was detected in 63% of patients treated with laser only after a mean of 5.4 treatments, vs. 86% of patients treated with laser and concomitant topical antifungals after a mean of 4.8 treatments. Microscopic healing (complete healing) with the absence of fungal pathogens was achieved in 11% of patients after a mean of 4.7 treatments with laser only, vs. 21% of patients treated with laser and concomitant topical antifungals after a mean of 4 treatments. No relevant adverse effects were observed.

Conclusions

The 1.064-nm diode laser is an effective and safe option for the treatment of onychomycosis. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach. Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments.

Challenges and Opportunities in the Management of Onychomycosis

Onychomycosis is an increasingly common fungal nail infection, chiefly caused by dermatophyte fungi. The disease is notoriously difficult to treat due to the deep-seated nature of fungi within the nail plate, prolonged treatment requirements, poor patient adherence and frequent recurrences. Given the poor efficacy of currently available topical and systemic therapies, there is a renewed interest in exploring alternative treatment modalities for onychomycosis. Natural therapies, physical treatments and various combination therapies have all shown potential for the management of onychomycosis, though research on many of these methods is still in preliminary stages. Further large, well-designed, randomised controlled trials are necessary to confirm the efficacy of these novel treatments in order to make formal recommendations regarding their use in the management of onychomycosis.

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.

Onychomycosis in the 21st Century: An Update on Diagnosis, Epidemiology, and Treatment

Onychomycosis accounts for 50% of all nail disease cases and is commonly caused by dermatophytes. Diabetes, human immunodeficiency virus, immunosuppression, obesity, smoking, and advancing age are predisposing factors of this fungal infection. Potassium hydroxide and culture are considered the current standard for diagnosing onychomycosis, revealing both fungal viability and species identification. Other diagnostic tests currently available include periodic acid-Schiff staining, polymerase chain reaction techniques, and fluorescent staining. Across 6 recently published epidemiology studies, the global prevalence of onychomycosis was estimated to be 5.5%, falling within the range of previously reported estimates (2%-8%). Newly approved onychomycosis treatments include efinaconazole, tavaborole, and laser therapy with lasers only approved to temporarily increase the amount of clear nail. Additional onychomycosis treatments being investigated include iontophoresis and photodynamic therapy with small open-label studies reported thus far. Preventative strategies, to help decrease recurrence and reinfection rates, include sanitisation of footwear and prophylactic topical antifungal agents.

The Effect of Long-Pulsed Nd:YAG Laser for the Treatment of Onychomycosis

BACKGROUND

Topical onychomycosis therapies are usually inadequate, and patient compliance to systemic therapies is poor. Recently, interest in laser therapy for the treatment of onychomycosis has increased. We sought to investigate the efficacy of long-pulsed Nd:YAG laser therapy for onychomycosis.

METHODS

Thirty patients with mycologically confirmed onychomycosis received long-pulsed 1064-nm Nd:YAG laser therapy, moving the beam in a spiral pattern over the whole nail plate two times, with a 1-minute pause between passes. Laser therapy was performed with a spot diameter of 4 mm at a speed of 25 mm/sec once weekly for 4 weeks using fluencies ranging from 40 to 60 J/cm², depending on the thickness of the nail plate. Patients were evaluated in terms of clinical improvement and mycologic cure.

RESULTS

Thirty patients started and 15 completed the study. Mycologic cure was achieved in nine patients (60%), of whom eight (89%) were infected with Trichophyton sp. Complete clinical improvement was achieved in seven patients (47%), all of whom were infected with Trichophyton sp. Mycologic cure was not achieved in one of two patients infected with Epidermophyton or in either patient in whom the agent was Candida or Aspergillus; complete clinical improvement did not occur in any of these patients. No serious adverse events were observed.

CONCLUSIONS

Based on these results, long-pulsed Nd:YAG laser can be used as an effective treatment for onychomycosis, but further studies are needed to draw firmer conclusions.

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.

Treating onychomycosis with the short-pulsed 1064-nm-Nd:YAG laser: results of a prospective randomized controlled trial

BACKGROUND

The role of the short-pulsed 1064-nm-Nd:YAG laser in treating onychomycosis has been the subject of controversial discussion ever since it received FDA approval in 2010. Research to date provides no valid conclusions supporting its use from an evidence-based perspective.

OBJECTIVE

In this prospective randomized controlled pilot study, we analysed the effect of the short-pulsed 1064-nm-Nd:YAG laser on the rate of mycological remission and clinical improvement after excluding relevant confounders with regard to our previous studies.

PATIENTS AND METHODS

Twenty patients with a total of 82 mycotic toenails were randomized to the treatment group (short-pulsed 1064-nm-Nd:YAG laser) or control group (no laser treatment). We conducted four laser treatments at 4- to 6-week intervals. In both groups, a local antimycotic agent was applied to the sole of the foot, the area between the toes and the skin directly surrounding the nails. The primary endpoint was complete remission of the onychomycosis after 12 months (fungal culture and histology); secondary endpoints included clinical improvement (Onychomycosis Severity Index, OSI) and the occurrence of pain or other adverse events.

RESULTS

Mycological remission was not achieved in either study group. A comparison of both groups yielded no difference in the OSI score, both at the beginning of the trial (P = 0.9873) and after 12 months (P = 0.4317). In the treatment group, the OSI score worsened by a mean 2.0 points, and in the control group, by a mean 3.5 points. On a visual analogue scale (0 = 'no pain' to 10 = 'most intense pain'), pain in the treatment group was indicated at a mean score of five. Other adverse events were not reported.

CONCLUSIONS

The short-pulsed 1064-nm-Nd:YAG laser shows no long-term efficacy as a monotherapy. Its role as an adjuvant therapy should be investigated in upcoming trials.

Improving Cure Rates in Onychomycosis

Background:

Onychomycosis is a persistent fungal nail infection that is notoriously hard to treat. Approximately 20% to 25% of patients with onychomycosis do not respond to treatment, and 10% to 53% of patients relapse. As such, successful treatment is imperative for long-term disease management.

Objective:

To identify ways to improve cure rates for onychomycosis.

Method:

The literature on onychomycosis treatment and recurrence was reviewed to summarize treatment approaches and suggest strategies to increase cure rates.

Results and Conclusion:

To improve treatment success in onychomycosis, we suggest the following measures be followed: (1) onychomycosis must be correctly diagnosed, (2) the treatment regimen should be tailored to the individual patient, (3) the efficacy of antifungals must be maximized, and (4) recurrence must be prevented.

Onychomycosis: Evaluation, Treatment Options, Managing Recurrence, and Patient Outcomes

Onychomycosis is the most common nail disease seen in podiatric practice. Effective long-term management remains problematic. We need to treat onychomycosis effectively to prevent its progression into a severe, debilitating, and painful condition, and to manage recurrence. With new agents now available and greater discussion on management strategies, this article reviews the appropriate evaluation of the disease, treatment options, and optimal patient outcomes.