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

Gallic acid loaded self-nano emulsifying hydrogel-based drug delivery system against onychomycosis

Aim: To developed and investigate gallic acid (GA) loaded self-nanoemulsifying drug delivery systems (SNEDDS) for treating onychomycosis via transungual route. Materials & methods: The SNEDDS were prepared by direct dispersion technique and were evaluated for characteristics parameters using Fourier transform infrared, differential scanning calorimetry, confocal microscopy, transmission electron microscopy and zeta sizer. Furthermore, the safety of prepared formulation was evaluated via Hen's egg test-chorioallantoic membrane study and stability was confirmed using different parameters. Also, its effectiveness was evaluated against fungal strain Trichophyton mentagrophytes. Results: The SNEDDS displayed a particle size of 199.8 ± 4.21 nm and a zeta potential; of -22.75 ± 2.09 mV. Drug release study illustrated a sustained release pattern with a release of 70.34 ± 0.20% over a period of 24 h. The penetration across the nail plate was found to be 1.59 ± 0.002 µg/mg and 0.97 ± 0.001 µg/mg for GA loaded SNEDDS and GA solution respectively. An irritation score of 0.52 ± 0.005 and 3.84 ± 0.001 was reported for GA loaded SNEDDS hydrogel and GA solution, indicating a decrease in the drug's irritation potential from slightly irritating to non irritating due to its entrapment within the SNEDDS. Conclusion: GA loaded SNEDDS has potential to address limitations of conventional treatments, enhancing the drug's efficacy and reducing the likelihood of resistance in the treatment of Onychomycosis.

[Dermatomycoses: topical and systemic antifungal treatment]

Topical antifungals with activity against dermatophytes include amorolfine, allylamines, azoles, ciclopiroxolamine, and tolnaftate. Polyene antimycotics, such as amphotericin B and nystatin, alternatively, miconazole are suitable for yeast infections of the skin and mucous membranes. For severe yeast infections of the skin and mucous membranes, oral triazole antimycotics, such as fluconazole and itraconazole, are used. Pityriasis versicolor is treated topically with antimycotics, and in severe forms also orally with itraconazole, alternatively fluconazole. Terbinafine, itraconazole and fluconazole are currently available for the systemic treatment of severe dermatophytoses, tinea capitis and onychomycosis. In addition to proven therapeutic regimens, unapproved (off-label use) intermittent low-dose therapies are increasingly being used, particularly in onychomycosis. Oral antimycotics for the treatment of tinea capitis and onychomycosis in children and adolescents can only be used off-label in Germany. In general, any oral antifungal treatment should always be combined with topical antifungal therapy. In tinea corporis and tinea cruris caused by Trichophyton (T.) mentagrophytes ITS (internal transcribed spacer) genotype VIII (T. indotineae), there is usually terbinafine resistance. Identification of the species and genotype of the dermatophyte and resistance testing are required. The drug of choice for T. mentagrophytes ITS genotype VIII dermatophytoses is itraconazole. In individual cases, treatment-refractory onychomycosis may be due to terbinafine resistance of T. rubrum. Here too, resistance testing and alternative treatment with itraconazole should be considered. Therapy monitoring should be carried out culturally and, if possible, using molecular methods (polymerase chain reaction). Alternative treatment options include laser application, and photodynamic therapy (PDT).

Efficacy of Fractional Versus Fully Ablative CO2 Laser for Distolateral Onychomycosis: Experience With 20 Patients

INTRODUCTION

Oral antifungals are the treatment choice for onychomycosis, and topical therapies are favored in cases of limited nail involvement. Recently, carbon dioxide (CO2) laser treatment has emerged as an option to enhance the effectiveness of topical therapies.

OBJECTIVES

Our objective was to compare the efficacy of fractional ablative and fully ablative CO2 laser treatments for distolateral subungual onychomycosis affecting a single toenail and caused by dermatophytes.

METHODS

The records of 10 patients treated with a single fully ablative CO2 session were matched with those of 10 patients who underwent a single CO2 fractional treatment. All had previously failed topical antifungal lacquers and were discharged with the prescription of topical ciclopirox nail lacquer (8%) for 3 months.

RESULTS

The clinical response rates were 80% for the fully ablative group and 60% for the fractional group. Additionally, the mean reduction in Onychomycosis Severity Index from baseline to 8.6±1.6 weeks after treatment completion was 6.9±5.4 in the fully ablative group and 3.6±6.6 in the fractional group. The relapse rate among responders was 12.5% in the fully ablative and 33.3% in the fractional group after a mean follow-up time of 29.4±2.3 weeks.

CONCLUSIONS

Fractional and fully ablative CO2 laser in combination with ciclopirox lacquer could increase the response rate in onychomycosis resistant to topical antifungals when systemic therapy is contraindicated or not yet pursued. Fully ablative mode therapy is significantly more effective than fractional (P < 0.05). Further studies are needed to identify prognostic response factors and assess the long-term effectiveness of CO2 laser treatment.

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.

Morphological and ultrastructural changes in fungal agents after LASER application

BACKGROUND

Onychomycosis is a fungal nail infection of difficult treatment due to the fungal survival capacity and reduced number of effective therapies. The present study aimed to isolate fungal agents that cause onychomycosis in immunocompetent patients and evaluate how LASER treatments affect the growth and ultrastructure of isolates.

METHODS

In total, 21 patients with positive direct microscopic examination (DME) for onychomycosis had nail samples collected for cultivation and phenotypic identification of microorganisms. From these patients, 12 underwent LASER treatment, divided in Group 1 (n = 5) treated with Nd: YAG 1,064 nm, and Group 2 (n = 7) treated with Nd: YAG 1,064 nm + Er: YAG 2,940 nm + topical isoconazole. Transmission Electron Microscopy (TEM) was performed to evaluate ultrastructural changes after treatment.

RESULTS

DME, cultivation, and phenotypic identification showed that the most identified fungus was Trichophyton rubrum spp. After LASER therapy, sample cultivation showed alterations in the fungal morphology with reduction of hyphae, conidia, and reproductive structures. Alterations in fungal cell wall structure, cytoplasm density, and organelles were observed by TEM.

CONCLUSION

LASER irradiation causes changes in the fungal cells, especially in the number of hyphae and the presence of conidia. In addition, it affects fungal growth and reproduction capacity, which interferes with their infection ability and virulence.

A focused review on laser- and energy-assisted drug delivery for nail disorders

The purpose of this review is to consolidate and summarize laser-assisted drug delivery (LADD) for nail diseases, particularly onychomycosis and psoriasis. A PubMed search was conducted in June 2023 using search terms (1) "laser assisted drug delivery" AND "nail," (2) "laser" AND "nail," and (3) "nail disorder" AND "laser treatment." References of papers were also reviewed, yielding 15 papers for this review. Fractional ablative CO2 laser (FACL) and Er:YAG laser can be used for LADD of topical medications such as amorolfine, terbinafine, and tioconazole to treat onychomycosis. A fungal culture should be performed to determine the type of dermatophyte, which will help determine which topical will be most effective. Laser settings varied between studies, but overall LADD tended to be more effective than topical treatments alone. Laser-assisted photodynamic therapy (PDT) was also found to be effective in treating onychomycosis. For psoriatic nails, LADD was used to deliver calcipotriol-betamethasone dipropionate foam, tazarotene, triamcinolone, or methotrexate into the nail. Again, LADD was found to be significantly more effective than topical treatment alone. FACL was the only laser noted for use for LADD in both diseases. Laser-assisted drug delivery for nail disease is a newer approach for onychomycosis and nail psoriasis with several benefits and drawbacks. Dermatologists should discuss the option of LADD with their patients who have recalcitrant onychomycosis or nail psoriasis.

Nd:YAG 1064 nm laser treatment for onychomycosis - is it really effective? A prospective assessment for efficiency and factors contributing to response

Onychomycosis is a highly prevalent and persistent nail disorder primarily caused by dermatophytes. The effectiveness of current topical and systemic antifungals is limited by the extent and severity of the infection, patient demographics and health status, hepatic toxicity, drug interactions and low compliance. Laser therapy is a promising modality for safe and cost-effective removal of mycotic nail. This prospective study assessed the performance of a multi-series long-pulsed Nd:YAG 1064 nm regimen (30-40 J/cm2 , 1 Hz) in the treatment of 213 mycotic nails in 31 patients. Pain and discomfort were scored at each treatment session and mycological and clinical cure rates were determined 3 months after the last treatment session. Patients presented with mostly severe (mean SCIO score: 21.9 ± 8.9), T. rubrum-positive (87.1%) infections. Most (61%) had a family history of onychomycosis and a significant proportion had comorbidities, including hypertension (38.7%), hyperlipidemia (35.5%) and/or diabetes (12.9%). Treatment was well tolerated and there were no reports of nail deformity or burns. By 3 months post-treatment, mycological cure was achieved by 4 (12.9%) and visual improvements were noted for 10 (32.3%) patients, including 3 (9.7%) with moderate to significant improvements. Clinical response correlated with baseline SCIO ≤ 20 (OR: 0.9 [0.13-6.52]), family history of onychomycosis (OR: 0.27 [0.04-1.50]) and comorbidities (OR: 0.44 [0.05-3.74]). In conclusion, Nd:YAG 1064 nm laser is safe and effective for the management of mild-to-moderate onychomycosis in diverse populations. Further studies will be necessary to adjust treatment parameters to patient and nail profiles and to determine the impact of combined laser and topical therapies.

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.

Utility of devices for onychomycosis: a review

Onychomycosis is difficult to treat due to long treatment durations, poor efficacy rates of treatments, high relapse rates, and safety issues when using systemic antifungal agents. Device-based treatments are targeted to specific regions of the nail, have favorable safely profiles, and do not interfere with systemic agents. They may be an effective alternative therapy for onychomycosis especially with increasing reports of squalene epoxidase gene mutations and potential resistance to terbinafine therapy. In this review, we discuss four devices used as antifungal treatments and three devices used as penetration enhancers for topical agents. Lasers, photodynamic therapy, microwaves, and non-thermal plasma have the capacity to inactivate fungal pathogens demonstrated through in vivo studies. Efficacy rates for these devices, however, remain relatively low pointing toward the need to further optimize device or usage parameters. Ultrasound, nail drilling, and iontophoresis aid in improving the permeability of topical agents through the nail and have been investigated as adjunctive therapies. Due to the paucity in clinical data, their efficacy in treating onychomycosis has not yet been established. While the results of clinical studies point toward the potential utility of devices for onychomycosis, further large-scale randomized clinical trials following regulatory guidelines are required to confirm current results.

Effect of the 1064 nm Nd: YAG Laser on the MICs of Antifungals Used in Clinical Practice for the Treatment of Fungal Nail Infections

Introduction: The fungal nail infection (onychomycosis) involves 18%-40% of all nail disorders, which, although not fatal, can cause mechanical, aesthetic, occupational, and economic problems. Drug treatments due to prolonged treatment periods, drug interactions, adverse effects, and slow progression may associate with numerous negative outcomes. This study aimed to evaluate the long-pulsed 1064-nm Nd: YAG laser effect on fungal colonies and subsequently possible change in the minimum inhibitory concentrations (MICs) of common antifungals compared with the same non-lasered colonies as a novel way to investigate laser and antifungal interaction. Methods: Sixty onychomycosis samples consisting of saprophyte (n=20), dermatophyte (n=20), and yeast (n=20) duplicate colonies were isolated. A series was treated by a long-pulsed 1064-nm Nd: YAG laser. Afterward, the MIC (CLSI-M38-A2 and CLSI-M27-A3) of two series against common antifungals were compared. Results: After 1064-nm Nd: YAG laser irradiation in all 20 tested saprophytes, the MICs of terbinafine (P value<0.035) were changed, and in all 20 tested dermatophytes, the MICs of voriconazole (P value<0.021) were changed. Also, in all 20 tested yeasts, the MICs of caspofungin (P value<0.037) were changed. Moreover, in saprophytes, dermatophytes, and yeasts, significant changes in the MICs of itraconazole (P value<0.032), terbinafine (P value<0.025), and caspofungin (P value<0.037) were detected. Our result showed the GM MICs of the 1064-nm Nd: YAG laser in all saprophyte, dermatophyte, and yeast groups were lower than in the control group. Conclusion: The present study indicated that the long-pulsed 1064-nm Nd: YAG laser significantly changes the MICs of antifungals in onychomycosis clinical samples.

Current therapeutic insights regarding problematic fingernails and toenails in the Republic of Korea

BACKGROUND

Problematic nails and toenails are infected by germs and increasingly have many causes.

AIMS

To investigate the types and treatment of problematic nails and toenails, we focused on bacteria that may appear in problematic nail toenail symptoms.

METHODS

We have searched for PubMed and Google Scholar and correlated the words Onychomycosis, Tinea ungium, Melanonychia, and ingrown toenail related to symptoms.

RESULTS

To measure onychomycosis, KOH tests and fungal culture tests will be used. Treatment can be treated with full-body treatment using anti-fungal agents and local treatment (laser therapy) that can minimize the side effects. A biopsy should be performed when Melanonychia is diagnosed with brown or black pigments on the patient's fingernail plate. Moreover, ingrown toenail surgical treatment can be improved by acquired lifestyle.

CONCLUSIONS

There are many different types of treatments, but many studies show that problematic nail and toenail improvement periods are long and treatment success rates are low.

Promising Treatment for Twenty-Nail Dystrophy with Combination of Fractional Carbon Dioxide Laser and Topical Therapy: A Case Report

Twenty-nail dystrophy (TND) is a trachyonychia affecting all nails which cause aesthetic complaints. The difficulty of topical medication to penetrate through the nail plate brings a great challenge for TND treatment. We reported a case of TND in a 27-year-old woman, with clinical manifestation of trachyonychia, longitudinal ridging, mottled lunula, and subungual hyperkeratosis with ragged cuticle affected all nails. She has suffered from TND for 20 years with no systemic involvement found. Histopathological examination supported the diagnosis of nail lichen planus. The patient received a mixture of topical therapy consist of tacrolimus, urea, and salicylic acid, combined with fractional carbon dioxide (CO₂) laser with pulse energy: 160 mJ, pulse duration: 8.0 ms, density level: 17, and depth level: 2. After two sessions of treatment within five weeks interval, clinical improvement was seen as refinement of nail’s texture. Treatment of TND often unsatisfactory due to difficulty of drug penetration through the nail plate. The fractional CO₂ laser creates a column of destruction down to the dermis, which aid penetration of topical medication and stimulate nail bed rejuvenation. The use of fractional CO₂ laser as a penetration enhancer can be a therapeutic option for the treatment of TND with promising result as shown in this patient. This procedure enabled combination with topical medications as long-term therapy for TND.

Evaluation of the safety and efficacy of long pulsed Nd: YAG laser in the treatment of vascular lesions in vivo

Long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers have recently been used for the treatment of vascular lesions refractory to conventional vascular lasers. The aim of this study was to evaluate the clinical efficacy and safety of long-pulsed Nd:YAG laser treatment for vascular disorders. Laser irradiation was performed using two approaches: the 532 nm Nd:YAG laser was used to irradiate the dorsal skin fold in mice and the 1064 nm Nd:YAG laser was used to irradiate the leg of mice without skin incision. The specimens were observed immediately after laser treatment using a laser Doppler perfusion imaging system. Red blood cell (RBC) extravasation and hemorrhage were observed using the hematoxylin and eosin stain. The diameter of blood vessel under 30 μm was disrupted with a laser pulse at a fluence of 12 J/cm² and a wavelength of 532 nm regardless of pulse duration. The veins and arteries of approximately 1 mm in size were ablated with laser pulses at a fluence of 140 J/cm² and above and a wavelength of 1064 nm. Selective photopyrolysis can be achieved with either 532- or 1064 nm Nd:YAG laser pulses in vascular diseases based on the depth and size of the vessel.

Lasers for cutaneous lesions: An update

There are several types of medical settings which use lasers. Dermatologists use lasers as it is non-invasive with preferential cosmetic outcomes and finer wound healing. The types of lasers are relying on their wavelengths and delivery systems. Over time, by using several distinct devices and strategies, new lasers have been generated; as a consequence, they are manipulated in a wide range of dermatological settings. In this review, laser applications in various vascular, infectious, and hyperpigmented cutaneous lesions were framed. We aimed to represent the fitness of phototherapy for each condition as well as the overall challenges that face laser. In addition, low-level laser therapy, and laser resurfacing were noted as the marketable line of lasers in the current time for cosmetic purposes.

Efficacy of laser therapy combined with topical antifungal agents for onychomycosis: a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Onychomycosis is a common fungal infection of the nail. Laser and topical antifungal agent combination therapy is an emerging treatment for onychomycosis. The objective of this study was to systematically evaluate the efficacy and safety of laser and topical antifungal agent combination therapy for onychomycosis.

METHODS

The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang and VIP databases were searched from inception to November 2021. Randomised controlled trials (RCTs) on laser therapy combined with topical antifungal agents for onychomycosis were included. The Cochrane Collaboration tool was used to assess the risk of bias, and Revman 5.3 software was used in the meta-analysis.

RESULTS

Twelve studies involving 869 patients were included in this meta-analysis. The results showed that compared with topical antifungal agents alone, laser and topical antifungal agent combination therapy was superior in terms of the complete cure rate (RR 6.04,95% CI (2.17, 16.85), P = 0.0006), mycological cure rate (RR 1.27, 95% CI (1.10, 1.48), P = 0.001), clinical effective rate (RR 1.38, 95% CI (1.20, 1.57), P < 0.00001) and patient satisfaction rate (RR 1.47,95% CI (1.17, 1.84), P = 0.0009).The subgroup analysis of outcome indicators, including mycological cure rate and clinical effective rate, demonstrated that both carbon dioxide (CO₂) laser therapy combined with topical antifungal therapy and 1064-nm neodymium-doped:yttrium aluminium garnet (Nd:YAG) laser therapy combined with topical antifungal therapy showed better results than topical antifungal therapy alone. No adverse events were identified except for three studies reporting transient burning sensation without treatment and mild to moderate pain, both of which were well tolerated.

CONCLUSION

The present study indicated that laser and topical antifungal agent combination therapy is effective for onychomycosis. However, more large-scale and well-designed RCTs are warranted.

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.

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.

Printing Drugs onto Nails for Effective Treatment of Onychomycosis

Inkjet printing (IJP) is an emerging technology for the precision dosing of medicines. We report, for the first time, the printing of the antifungal drug terbinafine hydrochloride directly onto nails for the treatment of onychomycosis. A commercial cosmetic nail printer was modified by removing the ink from the cartridge and replacing it with an in-house prepared drug-loaded ink. The drug-loaded ink was designed so that it was comparable to the commercial ink for key printability properties. Linear drug dosing was shown by changing the lightness of the colour selected for printing (R² = 0.977) and by printing multiple times (R² = 0.989). The drug loads were measured for heart (271 µg), world (205 µg) and football (133 µg) shapes. A disc diffusion assay against Trpytophan rubrum showed inhibition of fungal growth with printed-on discs. In vitro testing with human nails showed substantial inhibition with printed-on nails. Hence, this is the first study to demonstrate the ability of a nail printer for drug delivery, thereby confirming its potential for onychomycosis treatment.

Combined laser and ozone therapy for onychomycosis in an in vitro and ex vivo model

In order to develop a fast combined method for onychomycosis treatment using an in vitro and an ex vivo models, a combination of two dual-diode lasers at 405 nm and 639 nm wavelengths, in a continuous manner, together with different ozone concentrations (until 80 ppm), was used for performing the experiments on fungal strains growing on PDA agar medium or on pig’s hooves samples. In the in vitro model experiments, with 30 min combined treatment, all species are inhibited at 40 ppm ozone concentration, except S. brevicaulis, which didn’t show an inhibition in comparison with only ozone treatment. In the ex vivo model experiments, with the same duration and ozone concentration, A. chrysogenum and E. floccosum showed total inhibition; T. mentagrophytes and T. rubrum showed a 75% growth inhibition; M. canis showed a delay in sporulation; and S. brevicaulis and A. terreus did not show growth inhibition. This combined laser and ozone treatment may be developed as a fast therapy for human onychomycosis, as a potential alternative to the use of antifungal drugs with potential side effects and long duration treatments.

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.

Safety of current therapies for onychomycosis

INTRODUCTION

Onychomycosis is the most common nail disease seen in clinical practice. Treatment options include systemic and topical therapies, as well as devices. Following clinical and mycologic diagnosis, treatment must be individualized, accounting for disease severity, infecting organism(s), comorbidities, patient characteristics and drug/device efficacy. Safety is the most important consideration in choosing the most appropriate therapeutic modality.

AREAS COVERED

This review covers currently available treatments for onychomycosis, with an emphasis on safety and tolerability. Medications and devices were analyzed for side effects, drug-drug interactions, and safety during pregnancy and breastfeeding.

EXPERT OPINION

Systemic antifungals offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions. The risk of terbinafine-induced hepatotoxicity is negligible in healthy patients. Systemic therapies, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal. Thus, a detailed medication history is critical before prescribing these medications. Topical antifungals are well tolerated and generally safe, with only potential local side effects. Systemic and topical onychomycosis treatments should not be prescribed during pregnancy and breastfeeding. Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding.

Cold sub-atmospheric and atmospheric pressure plasma for the treatment of Trichophyton rubrum onychomycosis: An in-vitro study

Previous studies have suggested the applicability of cold atmospheric pressure plasma for the treatment of onychomycosis. Whether delivering cold plasma in sub-atmospheric pressure would be beneficial for this purpose is yet to be established. The current study aimed to evaluate efficacy of cold sub-atmospheric and atmospheric pressure plasma in Trichophyton rubrum growth inhibition. Bovine nails infected with T. rubrum were treated by a cold air plasma device, which enables utilizing plasma in sub-atmospheric pressures (Low = 100 millibar; High = 300 millibar) or atmospheric pressure. The infected foci were exposed to the plasma source directly or indirectly. Treatment with high sub-atmospheric pressure setting achieved T. rubrum growth reduction of 94.0% and 73.0%, for direct and indirect exposure to the plasma source, respectively (P < .001). Low sub-atmospheric pressure setting achieved similar T. rubrum growth reduction of 86.2% for direct exposure to the plasma source (P < .001), but only marginally significant 58.8% reduction rate for indirect exposure to the plasma source (P = .056). None statistically significant fungal growth reduction was attained with the use of atmospheric pressure setting. Cold plasma was shown to effectively inhibit T. rubrum nail growth, with sub-atmospheric pressure setting achieving better outcome than atmospheric pressure.