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.

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.

Evaluation of efficacy and tolerability of four weeks bifonazole treatment after nail ablation with 40% urea in mild to moderate distal subungual onychomycosis

BACKGROUND

The aim of this study was to verify efficacy and tolerability of sequential therapy with 40% urea paste followed by 1% bifonazole urea in mild to moderate distal subungual onychomycosis of the toenails.

METHODS

It was an seven weeks open study. Sequential patients affected by mild to moderate distal subungual onychomycosis of the toenails agreed to apply on the affected nail 40% urea paste in occlusion overnight for the first three weeks, with gentle scraping with a spatula the following day, followed by 1% bifonazole cream once a day for 4 weeks. Efficacy evaluation was based on mycology, clinical photography and investigator and patient assessment. Tolerability assessment included subjective and objective evaluations.

RESULTS

The ten patients enrolled (mean age 57.5 years) completed the study. Onychomycosis was caused in nine cases by dermatophytes and by Scopulariopsis brevicaulis in one patient. At the end of the study, mycological examination was negative in all 10 patients. Clinical photographs showed a reduction of the percentage of the nail affected by onychomycosis in 8 cases, cure in 2 and considerable reduction of the nail thickness, already evident after 7 days. All patients reported to be satisfied by the treatment, which was judged easy to perform and well tolerated.

CONCLUSIONS

Treatment with urea and bifonazole is effective and well tolerated, and easy to do also by elderly patients.

Long-pulse Nd:YAG 1064-nm laser treatment for onychomycosis

BACKGROUND

Recent research shows that lasers can inhibit fungal growth and that Nd:YAG 1064-nm lasers can penetrate as deep as the lower nail plate. The aim of this study was to observe the effect of a long-pulse Nd:YAG 1064-nm laser on 154 nails of 33 patients with clinically and mycologically proven onychomycosis.

METHODS

Thirty-three patients with 154 nails affected by onychomycosis were randomly assigned to two groups, with the 154 nails divided into three sub-groups (II degree, III degree, and IV degree) according to the Scoring Clinical Index of Onychomycosis. The 15 patients (78 nails) in group 1 were given eight sessions with a one-week interval, and the 18 patients (76 nails) in group 2 were given four sessions with a one-week interval.

RESULTS

In group 1, the effective rates at 8 weeks, 16 weeks, and 24 weeks were 63%, 62%, and 51%, respectively, and the effective rates in group 2 were 68%, 67%, and 53% respectively. The treatment effect was not significantly different between any sub-group pair (P > 0.05).

CONCLUSIONS

Long pulse Nd:YAG 1064-nm laser was effective for onychomycosis. It is a simple and effective method without significant complications or side effects and is expected to become an alternative or replacement therapy for onychomycosis.

Treating onychomycoses of the toenail: clinical efficacy of the sub-millisecond 1,064 nm Nd: YAG laser using a 5 mm spot diameter

BACKGROUND

Onychomycosis is a relatively common fungal infection. Current treatments have limited applicability and low cure rates. Recently introduced laser therapy has shown to be a safe and effective treatment for onychomycosis. In this study, we evaluate a submillisecond Nd:YAG 1,064 nm laser for treating onychomycoses of the tonail.

METHODS

Thirteen subjects (9 female, 4 male) with 37 affected toenails received 1 to 3 treatments 4 and/or 8 weeks apart with a sub-millisecond 1,064 nm Nd:YAG laser. Diagnosis of onychomycosis was confirmed with microscopy. Average follow-up time was 16 weeks post-final treatment. Photos were taken and degree of turbidity was determined using a turbidity scale (ranging from "0 = clear nail" to "10 = completely turbid nail") at each visit. Improvement in turbidity was determined by comparison of turbidity scores at baseline and 16-week follow-up on average. Efficacy was assessed by an overall improvement scale (0 to 4), which combined improvement in turbidity scores and microscopic examination. Overall improvement was classified as "4 = complete clearance" if the turbidity score indicated "0 = clear nail" accompanied by a negative microscopic result. No microscopic examination was performed unless the turbidity score showed "0 = clear nail."

RESULTS

Treatments were well tolerated by all subjects and there were no adverse events. Of the 37 toenails treated, 30 (81%) had "moderate" to "complete" clearance average of 16 weeks post-final treatment. Nineteen toenails (51%) were completely clear and all tested negative for fungal infection on direct microscopic analysis. Seven (19%) toenails had significant clearance and four (11%) had moderate clearance.

CONCLUSIONS

The preliminary results of this study show this treatment modality is safe and effective for the treatment of onychomycosis in the short term. Additional studies are needed to more fully assess the clinical and mycological benefits as well as optimize the treatment protocol and parameters.

The impact of aggressive debridement used as an adjunct therapy with terbinafine on perceptions of patients undergoing treatment for toenail onychomycosis

OBJECTIVE

To determine whether adding aggressive debridement to oral terbinafine for treating toenail onychomycosis impacts patient-reported outcomes (PROs).

MATERIALS AND METHODS

A total of 504 patients were randomized to receive 12 weeks of terbinafine 250 mg/day with or without debridement, with an additional 36-week follow-up. The OnyCOE-t, a validated disease-specific PRO questionnaire, was completed at baseline and weeks 6, 12, 24, and 48. It included six multi-item scales (symptom frequency, appearance problems, physical activities problems, stigma, and treatment satisfaction), and one single-item scale: overall problem. Longitudinal analysis of change was conducted to assess treatment effect. Repeated-measures models adjusted for visit, age, sex, baseline scores, severity and duration of infection; treatment interactions were also tested.

RESULTS

Symptom frequency and treatment satisfaction significantly improved in the terbinafine + debridement group compared with terbinafine alone (p = 0.0395 and p = 0.0077, respectively). Age and sex were often significant explanatory variables, and further analysis of change scores at 12 weeks revealed that females treated with terbinafine + debridement reported significantly less improvement in the physical activities problems (p = 0.0021) and overall problem (p = 0.0112) scores.

CONCLUSIONS

Aggressive debridement, when used as an adjunct therapy with oral terbinafine, improved treatment satisfaction and reduced symptom frequency. The observed sex differences warrant further investigation.

Fungal nail infections: diagnosis and management

1) Fungal nail infection, or onychomycosis, mainly affects toenails. Infections are generally asymptomatic. Spontaneous regressions, but also complications, appear to be rare. Discomfort and cosmetic complaint are occasionally reported; 2) After a review of the literature based on the standard Prescrire procedure, we examined the diagnosis and management of fungal nail infections; 3) Clinical signs of fungal nail infections are non-specific. Alternative diagnoses include psoriasis and nail microtrauma. Nail hyperkeratosis and leukonychia are useful diagnostic pointers. Matrix involvement has important implications in the choice of treatment; 4) Detection of fungal structures by direct examination of a nail sample is strongly suggestive of fungal nail infection. In contrast, cases of negative direct examination with positive culture must be interpreted with caution, as contamination is frequent; 5) Antifungal lacquers (5% amorolfine and 8% ciclopirox) applied to the nails cure about 30% of fungal infections and sometimes cause mild irritation. There is no firm evidence that these solutions are any more effective than other topical antifungals applied daily to the affected nail. Trimming, filing or grinding the nail, in addition to these drug treatments, is likely to be beneficial, but these measures have not been evaluated; 6) Chemical nail destruction with a combination of urea and bifonazole, followed by treatment with an antifungal ointment, can be used when the nail is markedly thickened. Non-comparative trials have shown cure rates close to 70% at three months when the matrix is not involved, and 40% with matrix involvement. Drug application is inconvenient and local reactions are frequent. Surgical nail avulsion carries a risk of local infection and permanent nail dystrophy; 7) Oral terbinafine is effective in more than 50% of cases but its cutaneous, hepatic and haematological adverse effects are severe in about 1 in 2000 patients and can be life-threatening; 8) It is better to treat Candida nail infections with oral azoles (ketonazole, itraconazole) than with terbinafine. These treatments carry a risk of serious adverse effects and numerous drug interactions; 9) Fungal nail infections are usually mild. Treatments with potentially severe adverse effects must therefore be used with caution. It is better not to treat fungal nail infections if the risks outweigh the expected benefits.

How should fungal nail infection be treated?

Many people consulting dermatologists for nail problems have a fungal nail infection (onychomycosis). This may be asymptomatic and not merit prolonged treatment, particularly since relapse after such intervention is common. On the other hand, fungal nail infection is sometimes a treatable risk factor for more serious bacterial infections including cellulitis. Here we discuss the management of adults with fungal nail infection.

Combination of surgical avulsion and topical therapy for single nail onychomycosis: a randomized controlled trial

BACKGROUND

Conventional therapy of onychomycosis is prolonged and often frustrating, which is why combination therapy involving topical, oral and surgical measures has been advocated as the treatment of choice. There are no controlled studies evaluating the efficacy of nail avulsion followed by topical antifungal therapy.

OBJECTIVES

To evaluate the efficacy of combined surgical and topical therapy for onychomycosis.

METHODS

Forty patients with single nail onychomycosis [28 with distal and lateral subungual onychomycosis, seven with total dystrophic onychomycosis (TDO) and five with proximal subungual onychomycosis] were randomly assigned to four treatment groups. Each group received avulsion of the involved nail, followed by ketoconazole 2% cream without (group I) or with occlusion (group II), or oxiconazole 1% cream without (group III) or with occlusion (group IV). Topical therapies were applied twice daily. The patients were reviewed monthly and treatment was continued until the regrowth of completely normal nail (mycologically negative). In cured cases, further monthly review was carried out for at least 6 months, without any form of therapy. At each visit direct microscopic examination was repeated.

RESULTS

There was a high dropout rate, with seven patients (group I), six patients (group II), six patients (group III) and eight patients (group IV) completing the treatment protocol. Out of these, mycological cure was achieved in three (43%) patients in group I, four (67%) in group II, two (33%) in group III and six (75%) in group IV. All the cases of TDO failed to respond to this therapy. Overall, 15 of 27 (56%) patients were cured with this approach. On further follow up, recurrence of onychomycosis was recorded in two patients in group I. No side-effects or long-term complications of the nail avulsion were encountered. Important limitations encountered in the present study included a small sample size, a high dropout rate (32%) and poor patient compliance.

CONCLUSIONS

Contrary to earlier reports, surgical nail avulsion with topical antifungal agents was not found to be a very encouraging modality for the treatment of onychomycosis. Both oxiconazole and ketoconazole delivered comparable results. Occlusion improved the treatment outcome, although the difference was not statistically significant. As a subtype, TDO showed poorest response. Surgical nail avulsion followed by topical antifungal therapy cannot be generally recommended for the treatment of onychomycosis.

Onychomycosis

The guideline on onychomycosis, as passed by the responsible German medical societies, is presented in the present study.

Great toenail onychomycosis caused by Syncephalastrum racemosum

Nondermatophyte molds are fungi found in soil and decaying plant debris and are generally considered to be uncommon or secondary pathogens of diseased nails. Prevalence rates of onychomycoses caused by nondermatophyte molds range between 1.45 percent and 17.60 percent. The most common nondermatophyte molds associated with nail disease are Scopulariopsis, Scytalidium, Fusarium, Aspergillus and Onychocola canadensis. Syncephalastrum racemosum, a nondermatophyte mold, belongs to the class Zygomycetae. Only one well-documented case of human disease attributed to this organism has been described. We describe a 45-year-old man with culture proven toenail onychomycosis due to Syncephalstrum racemosum.

Pediatric nail disorders

This article lists common pediatric nail disorders seen in infancy and adolescence. The diagnosis of pediatric nail disorders can be a sign of systemic disorders and diseases. The surgical treatment of young children and the treatment of pediatric patients are presented for those who do not frequently treat pediatric patients. The analysis of pediatric onychomycosis is presented, and the incidence and prevalence in the population is discussed.

Management of onychomycosis: examining the role of monotherapy and dual, triple, or quadruple therapies

The high prevalence of onychomycosis warrants effective lasting treatment. Currently available monotherapeutic options in the United States include surgical or chemical nail avulsion/debridement, a topical antifungal nail lacquer, and systemic antifungal agents. Failure to respond to therapy and relapse rates of approximately 25% to 50% both point to the need for a shift in the approach to treating this chronic disease. In vitro data indicate synergistic and additive effects when combining certain antifungal agents, eg, ciclopirox and terbinafine. Clinical reports suggest that combining topical and oral antifungal agents (eg, ciclopirox nail lacquer and oral terbinafine), administered for a shortened duration compared with the standard regimen, may yield cure rates as good as, if not better than, the indicated oral monotherapy regimen. Drug penetration to different parts of the nail unit and complimentary modes of action may contribute to the success of combination therapy.

Onychomykose

Onychomycosis is an infection of the finger-and/or toenails by fungal microorganisms. If untreated, the process advances and destroys the nail plate. It may spread to involve the skin and does not heal spontaneously. There are different clinical presentations of onychomycosis which vary with the nature of the fungus and how it invades the nail unit. These different clinical forms require different therapeutic approaches. The successful treatment of onychomycosis requires special knowledge of the various clinical presentations, of the differential diagnosis and of recent advances in medical mycology. Therefore onychomycosis is best treated by dermatologists.

Silicone gel sheeting for the management and prevention of onychocryptosis

BACKGROUND

Onychocryptosis, commonly referred to as ingrown nails, has many therapeutic alternatives for its management. Although mild cases can be treated conservatively, in severe cases, surgical treatment is preferred. Silicone gel sheeting is found to be effective in the treatment of hypertrophic scars and keloids.

OBJECTIVE

To document the effectiveness of silicone gel sheeting in the management of patients with onychocryptosis and in the prevention of the recurrences by breaking the devil's circle, which usually took place after the surgical procedures used in the treatment of the onychocryptosis.

METHODS

Fourteen patients were enrolled in the study. Entry criteria required the presence of slight (2 patients), moderate (2 patients), or severe (10 patients) onychocryptosis. The simple technique used in the study was the excision of the one-quarter part of the lesional side of the nail plate without excising the granulation tissue. After 24 hours, the silicone was placed on the granulation tissue and the exposed nail bed. Silicone gel sheet was bandaged loosely without applying any pressure. Patients entering the study were given detailed instructions in applying and using the gel for 12 hours during the daytime. The study lasted for 14 months and was composed of a treatment period of 4 months and a follow-up period of 10 months. The patients were evaluated every 2 weeks in the first month and then monthly. The change in thickness of granulation tissue was evaluated by comparing them with the baseline photographs and those taken at each visit.

RESULTS

The management and prevention of onychocryptosis were achieved in 12 of 14 patients (85.71%). The silicone gel sheeting treatment was well tolerated except for an occasional transient exudation, which was resolved when the treatment was withdrawn.

CONCLUSION

The results show that the new method that we used for the treatment of onychocryptosis is successful in reducing the thickness of the hypertrophic nail fold and prevents the recurrence of the condition during the regrowth of the nail plate by breaking the devil's circle. The advantage of this method is that it is not destructive to the nail matrix and the adjacent tissue.

Fungal nail infection: assessing the new treatment options

Onychomycosis can be improved or eradicated with appropriate treatment. Newer oral antifungal drugs are highly effective and have few adverse effects, although care in prescribing is needed because of potential drug interactions and hepatobiliary dysfunction.

Nail regeneration by elongation of the partially destroyed nail bed

Patients with partially destroyed fingernails tend to hide them, and such patients often do not find help because fingernails are considered of little functional value. To improve the aesthetic appearance of such nails, a simple excision of the destroyed nail matrix can stimulate the growth of the residual healthy matrix and regenerate the nail. Prerequisite is a healthy nail residue of at least the lunula. An excision of an en bloc, crescent-shaped, full-thickness scar, 5 mm at its greatest width and extending from one lateral nail fold to the other, increases the length of the nail plate. Together with the matrix, the nail will grow about 4 mm distally. A second crescent-shaped excision 1 to 2 months later will further lengthen the nail until it has gained full length. Normal nail growth was achieved in 11 patients who had partially scarred nail beds after mycosis or trauma.

[Diversified treatments of Tinea unguium]

Antifungal agents and therapeutic approaches for tinea unguium have been increasing in number. Itraconazole, terbinafine and fluconazole were developed in the 1990s, and many useful methods with them for tinea unguium have been reported, including pulse therapy and short duration therapy. There have been many reports of not only oral treatments but also contrived topical treatments, in most of which improvement rates were high. However, each treatment has had some drawbacks and did not seem to gain the complete compliance of patients. Many patients dropped out, still having affected nails. It seems important to us to understand thoroughly the merits and demerits of each diversified treatment for tinea unguium and to provide the preferential treatment for each patient.

The future of onychomycosis therapy may involve a combination of approaches

Onychomycosis is a fungal infection of the nail unit, most commonly caused by the anthropophilic dermatophyte fungi. It is generally accepted that this disease is increasing in prevalence despite the introduction of new and efficacious antifungal drugs. Several studies have documented health-related quality-of-life issues associated with onychomycosis and it is clear that patient treatment is both necessary and desirable. The aetiology and pathogenesis of onychomycosis is coming under increasing scrutiny and work in this field has grown substantially in recent years. This is reflected by the increased assurance with which clinicians can now prescribe treatment and be confident of improvement in a majority of their patients. However, a significant proportion of patients, perhaps as many as 25-40% of those encountered in clinical practice, are classified as treatment failures. Clinical indicators for poor prognosis include the development of residual foci of subungual fungal growth, onycholysis and severe disease. These observations have led to a resurgence of interest in combination treatments for use in patients at risk of failure/relapse. Several types of combination can be considered, including the use of oral or topical drugs and the concomitant use of surgical techniques, all of which have a place in the treatment of onychomycosis.

Onychogryphosis in elderly persons: an indicator of long-standing poor nursing care? Report of one case and review of the literature

A 92-year-old immobilized white woman under the daily nursing care of a private ambulatory nursing service displayed acquired deformities of the toenails resembling a ram's horn. In light of a rapidly growing elderly population, this case report illustrates the need for close monitoring of the quality of care that nursing services provide to older persons. In addition, it reviews the clinical aspects of onychogryphosis, as well as its pathomechanisms and treatment options.

Onychomycosis: an analysis of 50 cases and a comparison of diagnostic techniques

Onychomycosis is an extremely common condition that is increasing in prevalence. Although often innocuous, it may be complicated by discomfort and secondary bacterial infections. Recently introduced oral medications may be highly effective in the eradication of this condition; however, they may carry with them significant expense and potentially serious side effects. Prior to the initiation of antifungal oral therapy, definitive diagnosis is mandatory. This study compares the sensitivity of potassium hydroxide (KOH) preparations, surgical pathology diagnostic testing (SPDT), and culture techniques for the detection of onychomycosis in 50 cases of clinically suspected onychomycosis. Analysis showed that SPDT was significantly more sensitive when compared to KOH and culture. The results suggest that SPDT may be the true gold standard for the diagnosis of onychomycosis.

Ciclopirox nail lacquer and podiatric practice

Ciclopirox 8% nail lacquer has recently been approved by the US Food and Drug Administration (FDA) for the management of mild-to-moderate dermatophytic onychomycosis not involving the lunula. Previously, the agents that were approved for the treatment of dermatophytic pedal onychomycosis--griseofulvin, itraconazole, and terbinafine--were administered orally. When ciclopirox nail lacquer is used, it is recommended that the infected nail undergo debridement by a health-care professional as frequently as monthly. It is important to be aware of the circumstances under which debridement of the mycotic nail may be considered medically necessary and therefore potentially eligible for reimbursement by third-party payers. For many nail presentations, nail debridement is an important component of a treatment protocol involving either the oral medications or the topical lacquer, as it serves to reduce the fungal load and ameliorate symptoms. With the availability of a new FDA-approved topical treatment alternative, it remains to be seen if podiatrists will embrace the definitive treatment of onychomycosis using the newer oral agents, the new nail lacquer, or both in combination with nail debridement to treat the disease.

Multiple-digit onychomycosis: a simple surgical cure

The management of intractable onychomycosis involving multiple fingernails continues to be optimized. Failure of pharmacological treatment necessitates operative intervention. Current surgical procedures are complex and have frequent donor site complications. This report describes a safe, simple, and effective surgical treatment that eradicates the disease, results in low morbidity, and yields high patient satisfaction.

A modified approach to the phenol and alcohol chemical partial matrixectomy

The phenol and alcohol matrixectomy is a frequently used technique for treating onychocryptosis in healthy patients. This article describes a modification of this common procedure. The modified version provides a quick and easy method of removing an ingrown nail.

A retrospective cost-effectiveness analysis of the treatment of onychomycosis in general practice

Analysis of the computer records of 100 general practices from the CompuFile Doctors Independent Network revealed 1492 patients receiving treatment for onychomycosis in the first 6 months of 1994 with terbinafine, tioconazole, amorolfine or griseofulvin. These records indicated the average treatment time for each agent, number of general practitioner consultations and incidence of hospital referrals and minor surgery. Applying standard costs to this resource consumption gave the direct costs for each of these four agents. Published clinical and mycological cure rates allowed a cost per success to be calculated. These were as follows: terbinafine (n = 511) pound258, amorolfine (n = 315) pound312, griseofulvin (n = 196) pound356 and tioconazole (n = 470) pound520. Sensitivity analysis showed that terbinafine remained the most cost-effective option despite variations in resource costs. The cost impact on a typical practice for switching from a less to a more cost-effective treatment is discussed.

Surgical treatment of mycotic toenails

The authors present several options for the surgical treatment of painful and dystrophic mycotic toenails. The procedures include total and partial nail avulsion as well as chemical and excisional matrixectomies, both partial and total. Adjunctive treatment with topical and oral antifungal agents is also discussed.

Update on the management of onychomycosis: highlights of the Third Annual International Summit on Cutaneous Antifungal Therapy

Onychomycosis is an increasingly common fungal infection of the nail, which has traditionally been difficult to diagnose and treat and has physical and psychological consequences for the patient. Onychomycosis can be caused by dermatophytes, nondermatophytic filamentous fungi, and yeasts. The relative percentages of cases due to these etiologic agents vary with geographic location; however, in the United States, dermatophytes are the most common pathogens. Toenails are affected four times as often as fingernails. Microscopy and culture are the diagnostic "gold standards" for onychomycosis, although biopsy of the nail may be required to obtain a definitive diagnosis when conditions that mimic onychomycosis, such as psoriasis, are suspected. The treatment of onychomycosis includes a combination of topical therapy, surgical or chemical nail avulsion, and systemic therapy. The new generation of systemic agents (itraconazole, fluconazole, and terbinafine) is associated with a higher cure rate and shorter courses of treatment than are the older systemic antifungal drugs (i.e., griseofulvin and ketoconazole); these characteristics have sparked new interest in onychomycosis. Of these newer antifungals, itraconazole and terbinafine are the only agents currently approved by the U.S. Food and Drug Administration for the treatment of onychomycosis.

Onychomycosis. Agents of choice

The management of onychomycosis has changed considerably in the past few years. The main trends have been improvement in the choice of evidence and cover of infections other than dermatophytosis, shortening of periods of oral therapy, and introduction of topical agents designed to treat nail disease. At present there have been almost no comparative studies of these different approaches, and choice is therefore largely based on enlightened guesswork coupled with personal experience. It is hoped that within the next few years such studies will be carried out to allow dermatologists to make an accurate choice based on appropriate scientific data.

Inhalation of nail dust from onychomycotic toenails. Part I. Characterization of particles. 1984

Nail dust particles were analyzed by scanning electron microscopy for size and topography. The percentage of "fines" that could be inhaled and deposited in the alveoli and bronchioles were determined by quantitative particle size analysis. Distribution representing the largest total mass was graphed between 1 and 2 microns. The authors found that 86% of nail dust would reach the bronchioles and alveoli, and 31% could be expected to deposit in these areas.

Nail dust aerosols from onychomycotic toenails. Part II. Clinical and serologic aspects. 1984

The podiatric procedure of burring hyperkeratotic fungal infected toenails results in large quantities of nail dust aerosols. An extremely large percentage (31%) of podiatrists who were analyzed for immunoglobulin E (IgE) by antibody radioimmunoassay were found to have abnormally high levels. Incidence of precipitin antibodies to Trichophyton rubrum in sera of those in practice from 0 to 15 years was 23%, and those in practice 16 years or more was 29%. In this study, podiatrists who were chronically exposed to nail dust aerosols after years of practice presented with symptoms of conjunctivitis, rhinitis, asthma, coughing, hypersensitivity, and impaired lung function.

Silent stroke associated with minor podiatric surgery

Life-threatening intraoperative complications during minor podiatric surgery are rare. This paper presents a case of a "silent stroke," which occurred during total matrixectomies of hallux nails. The podiatric physician must be aware of the risk factors involved in each case and must be prepared to treat any complications that may arise.

[Treatment of tinea unguium]

The modes of spread of fungal infection on the nails are discussed stressing the essential importance of the knowledge of this mode for finding of effective treatment of ungual trichophytosis. On the basis of own observations and reports of other authors combined operative and pharmacological treatment of trichophytosis is discussed and its usefulness is confirmed by the results of treatment and investigations. In 90 patients treated with griseofulvin 88.9% cures were obtained. In the light of these results the methods suggested by other authors for treatment of trichophytosis without surgical removal of nail plates are discussed.

Carbon dioxide laser use for certain diseases of the toenails

The CO2 laser has facilitated the treatment of many toenail conditions. Satisfactory wound healing and cure rates have been equivalent to current standards of treatment. Pain was markedly diminished as compared with pain in traditional methods of treatment, and time until comfortable ambulation was dramatically shortened. Healing times were consistent with those in other methods of treatment. The protocol for CO2 treatment of nail conditions has been thoroughly described. Evaluation of 50 patients after 4 years from treatment date is tabulated. The CO2 laser must be strongly considered as a treatment modality for toenail pathology. Because of markedly reduced pain, minimal disability, and satisfactory long-term results, the laser is becoming a valuable treatment of choice for pathologic conditions of the nail.

Matricectomy utilizing negative galvanic current

An established technique for matricectomy procedures has been described with the effects of negative galvanic current on tissue being elucidated. An ongoing prospective study is in progress to verify previous claims. This procedure appears to offer distinct advantages over conventional procedures and now appropriate instrumentation is readily available, being manufactured specifically for this technique.