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

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.

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.

Efficacy of Two-Stage Treatment of Onychomycosis Using a Long-Pulsed Nd:YAG 1064-nm Laser

OBJECTIVES

Onychomycosis is a fungal infection of the nail bed, nail matrix, and nail plate. Lasers have recently been studied as future clinical options for onychomycosis. We sought to evaluate the efficacy of the long-pulsed Nd:YAG 1064-nm laser on onychomycosis using a two-stage treatment.

METHODS

A total of 100 affected nails (88 toenails and 12 fingernails from 22 patients) were treated using a long-pulsed Nd:YAG 1064-nm laser. The self-controlled treatment schedule included the first stage (1 session per week for 8 weeks) and the second stage (1 session every 4 weeks for 16 weeks). Patients were followed up with for 12 weeks after the last laser treatment. Direct microscopy, cultures, and clinical assessments were performed at various time points.

RESULTS

Of the nails studied, 84% were infected by Trichophyton rubrum, while others were coinfected with T. rubrum and other fugal strains. The mycological clearance rate and the clinical efficacy rate of the nails were 29% and 21% after the first stage, 69% and 35% after the second stage, and 67% and 39% during follow-up, respectively. The second stage of laser treatment significantly improved the mycological clearance and clinical efficacy.

CONCLUSION

Long-pulsed Nd:YAG 1064-nm laser two-stage treatment was effective for onychomycosis, with significantly improved mycological clearance and clinical efficacy. This trial is registered with ChiCTR 1900021669.

Combined long-pulsed Nd-Yag laser and itraconazole versus itraconazole alone in the treatment of onychomycosis nails

Background: Oral antifungal therapies are effective for onychomycosis but it was complicated by systemic effects. Effective and safe therapy is needed to improve esthetic appearance of nails.Objective: The present study is an attempt to evaluate and compare the efficacy of of combined treatment of onychomycosis with 1,064-nm long-pulsed Nd-Yag laser and pulse itraconazole therapy versus pulse itraconazole alone.Methods: Thirty onychomycosis patients were divided into two groups: Groups I and II. Patients of Group I are treated by itraconazole pulse therapy. Patients of Group II received six laser sessions with long-pulsed Nd:Yag laser and itraconazole pulse therapy. The investigators rated clearance using "Onychomycosis Severity Index (OSI)", photographs, and mycology at 6 and 9 months after treatment.Results: Group I's clinical improvement response was excellent in two cases, good in six cases, moderate in five cases, and mild in two cases. Mycological improvement response was excellent in two cases, good in two cases, moderate in six cases, and mild in five cases (OSI before treatment was 13.4 ± 3.02 and after was 6.67 ± 3.6). Group II's clinical improvement response was excellent in 10, good in 3, moderate in 1, and mild in 1. Mycological improvement's response was excellent in two cases, good in two cases, moderate in six cases, and mild in five cases (OSI before treatment was 13.33 ± 3.11 and after was 5.07 ± 4.15). There were no adverse effects. The clinical response showed best results with Group II, but the mycological cure was equal in both groups.Conclusions: The use of combined long-pulsed Nd-Yag laser and itraconazole pulse therapy gives the best clinical results and patient's satisfaction.

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.

Light treatments of nail fungal infections

Nail fungal infections are notoriously persistent and difficult to treat which can lead to severe health impacts, particularly in the immunocompromized. Current antifungal treatments, including systemic and topical drugs, are prolonged and do not effectively provide a complete cure. Severe side effects are also associated with systemic antifungals, such as hepatotoxicity. Light treatments of onychomycosis are an emerging therapy that has localized photodynamic, photothermal or photoablative action. These treatments have shown to be an effective alternative to traditional antifungal remedies with comparable or better cure rates achieved in shorter times and without systemic side effects. This report reviews significant clinical and experimental studies in the field, highlighting mechanisms of action and major effects related to light therapy; in particular, the impact of light on fungal genetics.