The effectiveness of lasers in the treatment of 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.

In vivo Guinea Pig Model Study for Evaluating Antifungal Effect of a Dual-Diode Laser with Wavelengths of 405 Nm and 635 Nm on Dermatophytosis

Background

Various laser- and light-based devices have been introduced as complementary or alternative treatment modalities for dermatophytosis, particularly for finger or toenail onychomycosis.

Objective

This study aimed to comparatively evaluate the antifungal effects of 405-nm and 635-nm dual-band diode lasers using an in vivo guinea pig model of dermatophytosis.

Materials and Methods

A guinea pig model was developed by the repetitive application of fungal spore preparations to the back skin of guinea pigs. Dual-diode laser treatment was delivered to the guinea pig skin at a power of 24 mW at a wavelength of 405 nm and 18 mW at 635 nm for 12 min. The treatments were administered three times weekly for 2 weeks, and a mycological study was performed.

Results

Mycological studies using scraped samples obtained from treatment groups A (N = 8) and B (N = 8) after dual-diode laser treatment revealed that seven of eight (87.5%) samples in each group had negative results for direct potassium hydroxide microscopy and fungal culture studies. Skin specimens from each infected laser-untreated guinea pig exhibited spongiotic psoriasiform epidermis with parakeratosis. Meanwhile, skin specimens from infected laser-treated guinea pigs in groups A and B demonstrated thinner epidermal thickness than those from infected untreated controls but thicker than those from uninfected treated controls without noticeable inflammatory cell infiltration in the dermis.

Conclusion

The guinea pig dermatophytosis model can be used to comparatively evaluate the efficacy and safety of various treatment modalities, including dual-diode lasers, for superficial fungal skin infection.

Inactivation of Dermatophytes Causing Onychomycosis and Its Therapy Using Non-Thermal Plasma

Onychomycosis is one of the most common nail disorders. Its current treatment is not satisfactorily effective and often causes adverse side effects. This study aims to determine the optimal conditions for non-thermal plasma (NTP) inactivation of the most common dermatophytes in vitro and to apply it in patient`s therapy. The in vitro exposure to NTP produced by negative DC corona discharge caused full inactivation of Trichophyton spp. if applied during the early growth phases. This effect decreased to negligible inactivation with the exposure applied six days after inoculation. In a group of 40 patients with onychomycosis, NTP therapy was combined with nail plate abrasion and refreshment (NPAR) or treatment with antimycotics. The cohort included 17 patients treated with NPAR combined with NTP, 11 patients treated with antimycotics and NTP, and 12 patients treated with NPAR alone. The combination of NPAR and NTP resulted in clinical cure in more than 70% of patients. The synergistic effect of NPAR and NTP caused 85.7% improvement of mycological cure confirmed by negative microscopy and culture of the affected nail plate. We conclude that NTP can significantly improve the treatment of onychomycosis.

Different Numbers of Long-Pulse 1064-nm Nd-YAG Laser Treatments for Onychomycosis: A Pilot Study

Purpose

To examine the benefits of different numbers of 1064-nm Nd-YAG laser treatments in patients with onychomycosis.

Methods

This was a pilot study of patients with onychomycosis who were divided into three groups: four treatment sessions (group A), eight sessions (group B), and 12 sessions (group C). Only infected nails of degrees II–III (Scoring Clinical Index for Onychomycosis) were included. Treatment was given once a week using a long-pulse Nd-YAG 1064-nm laser. Patients were followed at 8, 16, and 24 weeks after the first treatment. Side effects were recorded.

Results

Treatments were completed for 442 nails in 102 patients. The efficacy rates at 8, 16, and 24 weeks were 35.5%, 38.7%, and 37.4% for group A; 31.4%, 41.7%, and 44.0% for group B; and 27.7%, 50.0%, and 55.4% for group C, respectively. There was a significant difference in the efficacy rate at 24 weeks (P = 0.016) between groups A and C, but not for groups A vs. B, or for groups B vs. C. No difference in the efficacy rate at 8 or 16 weeks was observed among the three groups. In all three groups, the efficacy was better for degree II nails than for degree III nails (all P = 0.016) between groups A and C, but not for groups A vs. B, or for groups B vs. C. No difference in the efficacy rate at 8 or 16 weeks was observed among the three groups. In all three groups, the efficacy was better for degree II nails than for degree III nails (all

Conclusions

The 1064-nm Nd-YAG laser had clinical benefits against onychomycosis. Higher numbers of treatments provided better long-term (24-week) benefits, but had no impact on the short-term outcomes. The efficacy of laser treatment on degree II onychomycosis was better than for degree III.

Topical and device-based treatments for fungal infections of the toenails

BACKGROUND

Onychomycosis refers to fungal infections of the nail apparatus that may cause pain, discomfort, and disfigurement. This is an update of a Cochrane Review published in 2007; a substantial amount of new research warrants a review exclusively on toenails.

OBJECTIVES

To assess the clinical and mycological effects of topical drugs and device-based therapies for toenail onychomycosis.

SEARCH METHODS

We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials of topical and device-based therapies for onychomycosis in participants with toenail onychomycosis, confirmed by positive cultures, direct microscopy, or histological nail examination. Eligible comparators were placebo, vehicle, no treatment, or an active topical or device-based treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were complete cure rate (normal-looking nail plus fungus elimination, determined with laboratory methods) and number of participants reporting treatment-related adverse events.

MAIN RESULTS

We included 56 studies (12,501 participants, average age: 27 to 68 years), with mainly mild-to-moderate onychomycosis without matrix involvement (where reported). Participants had more than one toenail affected. Most studies lasted 48 to 52 weeks; 23% reported disease duration (variable). Thirty-five studies specifically examined dermatophyte-caused onychomycosis. Forty-three studies were carried out in outpatient settings. Most studies assessed topical treatments, 9% devices, and 11% both. We rated three studies at low risk of bias across all domains. The most common high-risk domain was performance bias. We present results for key comparisons, where treatment duration was 36 or 48 weeks, and clinical outcomes were measured at 40 to 52 weeks. Based on two studies (460 participants), compared with vehicle, ciclopirox 8% lacquer may be more effective in achieving complete cure (risk ratio (RR) 9.29, 95% confidence interval (CI) 1.72 to 50.14; low-quality evidence) and is probably more effective in achieving mycological cure (RR 3.15, 95% CI 1.93 to 5.12; moderate-quality evidence). Ciclopirox lacquer may lead to increased adverse events, commonly application reactions, rashes, and nail alteration (e.g. colour, shape). However, the 95% CI indicates that ciclopirox lacquer may actually make little or no difference (RR 1.61, 95% CI 0.89 to 2.92; low-quality evidence). Efinaconazole 10% solution is more effective than vehicle in achieving complete cure (RR 3.54, 95% CI 2.24 to 5.60; 3 studies, 1716 participants) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53; 2 studies, 1655 participants) (both high-quality evidence) and is probably more effective in achieving mycological cure (RR 2.31, 95% CI 1.08 to 4.94; 3 studies, 1716 participants; moderate-quality evidence). Risk of adverse events (such as dermatitis and vesicles) was slightly higher with efinaconazole (RR 1.10, 95% CI 1.01 to 1.20; 3 studies, 1701 participants; high-quality evidence). No other key comparison measured clinical cure. Based on two studies, compared with vehicle, tavaborole 5% solution is probably more effective in achieving complete cure (RR 7.40, 95% CI 2.71 to 20.24; 1198 participants), but probably has a higher risk of adverse events (application site reactions were most commonly reported) (RR 3.82, 95% CI 1.65 to 8.85; 1186 participants (both moderate-quality evidence)). Tavaborole improves mycological cure (RR 3.40, 95% CI 2.34 to 4.93; 1198 participants; high-quality evidence). Moderate-quality evidence from two studies (490 participants) indicates that P-3051 (ciclopirox 8% hydrolacquer) is probably more effective than the comparators ciclopirox 8% lacquer or amorolfine 5% in achieving complete cure (RR 2.43, 95% CI 1.32 to 4.48), but there is probably little or no difference between the treatments in achieving mycological cure (RR 1.08, 95% CI 0.85 to 1.37). We found no difference in the risk of adverse events (RR 0.60, 95% CI 0.19 to 1.92; 2 studies, 487 participants; low-quality evidence). The most common events were erythema, rash, and burning. Three studies (112 participants) compared 1064-nm Nd:YAG laser to no treatment or sham treatment. We are uncertain if there is a difference in adverse events (very low-quality evidence) (two studies; 85 participants). There may be little or no difference in mycological cure at 52 weeks (RR 1.04, 95% CI 0.59 to 1.85; 2 studies, 85 participants; low-quality evidence). Complete cure was not measured. One study (293 participants) compared luliconazole 5% solution to vehicle. We are uncertain whether luliconazole leads to higher rates of complete cure (very low-quality evidence). Low-quality evidence indicates there may be little or no difference in adverse events (RR 1.02, 95% CI 0.90 to 1.16) and there may be increased mycological cure with luliconazole; however, the 95% CI indicates that luliconazole may make little or no difference to mycological cure (RR 1.39, 95% CI 0.98 to 1.97). Commonly-reported adverse events were dry skin, paronychia, eczema, and hyperkeratosis, which improved or resolved post-treatment.

AUTHORS' CONCLUSIONS

Assessing complete cure, high-quality evidence supports the effectiveness of efinaconazole, moderate-quality evidence supports P-3051 (ciclopirox 8% hydrolacquer) and tavaborole, and low-quality evidence supports ciclopirox 8% lacquer. We are uncertain whether luliconazole 5% solution leads to complete cure (very low-quality evidence); this outcome was not measured by the 1064-nm Nd:YAG laser comparison. Although evidence supports topical treatments, complete cure rates with topical treatments are relatively low. We are uncertain if 1064-nm Nd:YAG laser increases adverse events compared with no treatment or sham treatment (very low-quality evidence). Low-quality evidence indicates that there is no difference in adverse events between P-3051 (ciclopirox hydrolacquer), luliconazole 5% solution, and their comparators. Ciclopirox 8% lacquer may increase adverse events (low-quality evidence). High- to moderate-quality evidence suggests increased adverse events with efinaconazole 10% solution or tavaborole 5% solution. We downgraded evidence for heterogeneity, lack of blinding, and small sample sizes. There is uncertainty about the effectiveness of device-based treatments, which were under-represented; 80% of studies assessed topical treatments, but we were unable to evaluate all of the currently relevant topical treatments. Future studies of topical and device-based therapies should be blinded, with patient-centred outcomes and an adequate sample size. They should specify the causative organism and directly compare treatments.

Fractional CO2 laser plus topical antifungal versus fractional CO2 laser versus topical antifungal in the treatment of onychomycosis

Onychomycosis is an important medical disorder affecting both health and quality of life of patients. This study was done to compare the efficacy of CO₂ laser in combination with topical tioconazole versus CO₂ laser only versus topical tioconazole alone in onychomycosis. A total of 120 patients with onychomycosis were randomly assigned to three groups. Group A patients were treated with fractional CO₂ laser followed by topical tioconazole 28% for five sessions with 3 weeks interval. Group B patients were treated with only fractional CO₂ laser for five sessions with 3 weeks interval. Group C patients were treated with only topical tioconazole 28% for 16 weeks. The clinical effect, KOH examination, and culture for the affected nails in the three groups were analyzed. One month after the last session, regarding clinical response, 55% showed complete clinical improvement in Group A versus 30% in Group B versus 25% in Group C with a significant difference in between. There was a significant difference between the three studied groups as regard KOH test and culture after treatment. Fractional CO₂ laser combined with topical antifungal is a safe and effective treatment for onychomycosis.

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.

ONYCHOMYCOSIS: A Review of New and Emerging Topical and Device-based Treatments

Onychomycosis is a challenging nail condition to treat. The gold standard treatment relies on long-term systemic therapy, which carries risks of potential side effects and drug interactions. Topical alternatives exist; however, treatment outcomes remain disappointing. In this article, we review newer topical formulations that are approved by the United States Food and Drug Administration, as well as other topical drugs that are still undergoing clinical trials. Lasers and energy-based devices have also been used for the treatment of onychomycosis; however, standardized parameters and clear treatment endpoints have yet to be specified. Currently, device-based therapies are considered as options for improving the cosmetic appearance of nails. The use of lasers to improve the penetration of topical antifungal treatments as possible combination treatments is also reviewed.

Recent advances in therapies for onychomycosis and its management

Onychomycosis is the most common affliction of the nail. It may be caused by dermatophytes, yeasts, and non-dermatophyte molds. Traditionally, oral antifungal treatments have been used to treat the fungus, although they can be accompanied by side effects and drug interactions. Topical treatments provide an alternative modality, bypassing the systemic effects of oral drugs; recent research has centered on topical drug improvement and development. Physical and laser treatments are being used in conjunction with topicals, which may help penetrate the thick nail plate. In this review, techniques from all categories are outlined: both novel experimental approaches and progress and effectiveness of recently developed treatments. More long-term studies are required to determine the efficacy of various treatments, but cure rates are improved when patients adhere to treatments and follow preventative measures to avoid disease recurrence.

The use of urea for the treatment of onychomycosis: a systematic review

Background

Onychomycosis, a fungal infection affecting the nail plate, is a common condition often requiring prolonged treatment regimens, with low success rates. Urea is one treatment option, which is thought to improve the efficacy of topical and oral antifungal agents. Despite a theoretical basis for the use of urea for the treatment of onychomycosis, the evidence-base for this treatment has not been systematically reviewed.

Aim

The purpose of this study was to conduct a systematic literature review to determine the efficacy and safety of urea as a monotherapy and as adjunct therapy, compared to other treatment regimens for onychomycosis.

Method

A systematic literature search of ten electronic databases was conducted. Only studies that used microscopy and culture or other validated laboratory-based testing method to confirm the presence of a fungal infection before treatment were included. The outcome measures assessed were efficacy (defined in terms of mycological, clinical and complete cure) and safety (defined as self-reported adverse events).

Results

The systematic search yielded 560 unique studies for review. Of these, only six were eligible for inclusion. All studies were observed to have methodological concerns, most studies consisted of small sample sizes and were difficult to compare given heterogeneity in outcome measures and follow-up time. Despite this, a trend was observed to suggest that urea, when added to topical or oral antifungal treatment regimens, improved efficacy of the treatment.

Conclusion

This review suggests that topical urea, as an adjunct to topical and oral antifungal treatment regimens, may improve the efficacy of treatment. However, further research is needed.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0332-3) contains supplementary material, which is available to authorized users.

Journal of Foot and Ankle Research: the first ten years

Journal of Foot and Ankle Research (JFAR) was launched in July 2008 as the official research publication of the Society of Chiropodists and Podiatrists (UK) and the Australasian Podiatry Council, replacing both the British Journal of Podiatry and the Australasian Journal of Podiatric Medicine. This editorial celebrates the 10 year anniversary of the journal.

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.

Ultrasound-Enhanced Drug Delivery for Treatment of Onychomycosis

OBJECTIVES

The aim of our study was to determine the effectiveness of using ultrasound (US) to increase the permeability of the nail, with the goal of improving outcomes in the treatment of onychomycosis.

METHODS

Porcine nails were used because of their similarity to human nails. A hydrophilic blue dye was used as a drug-mimicking compound. Two sets of experiments were performed: luminosity experiments to assess the dye levels inside the nail after US and sham treatments and diffusion cell experiments for determination of changes in nail permeability due to US application. In both sets of experiments, planar US transducers were used to sonicate the nails at frequencies of 400, 600, and 800 kHz and 1 MHz, an intensity of 1 W/cm² , and a duration of 5 min in a continuous mode. Modeling studies were also performed to assess the safety of US application to the human toe for later clinical studies.

RESULTS

In the luminosity experiments, application of US at frequencies of 600 and 800 kHz led to statistically significant results (P < .05), with an increase in dye delivery into the nail of up to 95% compared to control values. The diffusion cell results found statistical significance (P < .05) at all applied frequencies, with up to a 70% increase in the nail permeability compared to the control. Safety modeling studies found a maximal temperature increase of 4.4 °C in the bone.

CONCLUSIONS

Our proposed US method may offer an alternative for improved treatment of onychomycosis. The current maximal temperature increase was found to be at the safety limit, and so pulsing and other alternatives will be investigated to minimize this temperature increase.

1340nm LASER THERAPY FOR ONYCHOMYCOSIS: Negative Results of Prospective Treatment of 72 Toenails and a Literature Review

Onychomycosis is an infection of the nail plate by fungal microorganisms. This infection has an important social impact on women and men and poses a major challenge for its treatment. The traditional treatment of onychomycosis involves the use of topical and oral antifungal agents. However, the presence of adverse effects frequently associated with oral antifungals, their high cost, and their potential interactions with other drugs reflect some of the problems associated with conventional therapy. The current report details the evaluation of a 1340nm laser as monotherapy for toenails affected by onychomycosis. A 1340nm, neodymium-yttrium:yttrium-aluminum-perovskite (Nd:YAP) (e) laser (Etherea, Industra technologies, Brazil) was used with the following treatment parameters: a spot size of 6mm, pulse duration of 5ms, fluence of 22 to 25J/cm2, and repetition rate of 1.5 to 2.5Hz. In all, 72 toenails were evaluated in 30 patients who had clinical and laboratory confirmation of onychomycosis. The efficacy of treatment was measured by the degree of patient satisfaction on a scale of 0 to 10 and by mycological cure evidenced by direct mycological exam and culture. Considering three applications of laser therapy and a clinical/laboratory follow-up period of 12 weeks, monotherapy with 1340nm laser was not effective, since 93.3 percent of the assessed patients remained without clinical and mycological cure. Despite reports of variable success rates with the use of different lasers for the treatment of onychomycosis, it is not yet possible to state that this therapeutic alternative is indicated for the treatment of these infections, mainly due to the limited number of patients and/or nail plates evaluated and the controversial results described in the literature.

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.

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.

Transungual permeation: current insights

Nail disorders are beyond cosmetic concern; besides discomfort in the performance of daily chores, they disturb patients psychologically and affect their quality of life. Fungal nail infection (onychomycosis) is the most prevalent nail-related disorder affecting a major population worldwide. Overcoming the impenetrable nail barrier is the toughest challenge for the development of efficacious topical ungual formulation. Sophisticated techniques such as iontophoresis and photodynamic therapy have been proven to improve transungual permeation. This article provides an updated and concise discussion regarding the conventional approach and upcoming novel approaches focused to alter the nail barrier. A comprehensive description regarding preformulation screening techniques for the identification of potential ungual enhancers is also described in this review while highlighting the current pitfalls for the development of ungual delivery.

Toenail Onychomycosis—A Canadian Approach With a New Transungual Treatment

Background:

Onychomycosis is a difficult-to-treat infection whose current treatment paradigm relies primarily on oral antifungals. The emergence of new topical drugs broadens the therapeutic options and prompts a re-evaluation of the current Canadian treatment strategy.

Objective:

To define a patient-centred Canadian treatment strategy for onychomycosis.

Methods:

An expert panel of doctors who treat onychomycosis was convened. A systematic review of the literature on treatments for onychomycosis was conducted. Based on the results, a survey was designed to determine a consensus treatment system.

Results:

First-line therapy should be selected based on nail plate involvement, with terbinafine for severe onychomycosis (>60% involvement), terbinafine or efinaconazole for moderate onychomycosis (20%-60% involvement), and efinaconazole for mild onychomycosis (<20% involvement). Comorbidities, patient preference and adherence, or nail thickness may result in the use of alternative oral or topical antifungals.

Conclusion:

These guidelines allow healthcare providers and patients to make informed choices about preventing and treating onychomycosis.

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.