MD Hector Ricardo Galvan Garcia

Dermatology Hospital, Dermatosurgery, Guadalajara, Jalisco, Mexico

Corresponding author:

Dermatology Hospital, Dermatosurgery, Lopez Cotilla 2261 Colonia Arcos Vallarta, C.P.44130. Guadalajara, Jalisco, Mexico. Tel. (52) 33-36163215,
Fax. (52) 33-36163315, E-mail: doctorricardogalvan@hotmail.com

 

 

ABSTRACT

Laser treatment of onychomycosis is a quick and easy method without complications. Hundred twenty patients with a KOH (+)-confirmed clinical diagnosis of onychomycosis were included in the present study. All of the patients were treated in a single session with a 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG)
q-switch laser. There was a 100% clinical response rate within the 9-month follow-up period with no side effects. Thus, this method is proposed as a novel and safe method for the treatment of this ungual pathology.

Keywords: onychomycosis, Nd:YAG laser.

INTRODUCTION

At present, laser treatment for onychomycosis is considered common practice because it is simple, quick and presents no complications (Kozarev and Vizintin, 2010). Recently, alternatives to the 1064-nm Nd:YAG laser treatment have been proposed: q-switch laser, long-pulse laser (Kozarev, 2012) and the combination of both of these methods (Alma Laser Modules, 2012). Although all of these methods yield similar results, there is a great difference in the number of sessions, settings and the necessary time that the doctor and the patient need to complete the treatment. The objective of our study was to demonstrate the effectiveness, speed and the minimum number of sessions needed to achieve the best results during laser treatment of onychomycosis.

MATERIAL AND METHODS

Hundred twenty patients were included in the study from April 2012 to December 2013. All of the patients had a KOH (+)-confirmed diagnosis of clinical onychodystrophy resulting from hand or foot ungual onychomycosis of the distal, proximal or lateral type. Patients of all ages who had not previously received any type of treatment were included. Each patient signed a consent form and permitted clinical photographs of their nails to be taken before and after the laser therapy.

Pregnant patients and patients with a subungual hematoma were excluded. In addition, patients taking photosensitive medication and patients with psoriasis, lichen or atopic dermatitis with nail involvement were also excluded.

A direct microscopic test was performed with a mix of KOH (25%) and glycerol (5%) (1 hour at 51-54°C) for lipid emulsification, and mycological structures were identified under 3400x magnification. This test was performed at the beginning and at the end of the study for each patient.

Laser therapy

Laser therapy was performed randomly with two 1064-nm Nd:YAG q-switch laser equipment. The first laser was a Monalisa Laser, Sincoheren Co., Xizhimen Beidajie, Beijing, China; the second laser was a Q-Clear TM, Light Age, Inc., Somerset, NJ, USA. The lasers’ settings were adjusted to yield a fluency of 600 mJ/cm2
(19-21 J/cm2 equivalent) over a 3-mm spot at a 3-Hz frequency in a single session. Three applications were performed in a squared form across the entire ungual plate for each case. Immediate changes after laser light application were observed (nail clearance). Treatment questionnaires and clinical revisions were scheduled at 3, 6 and 9 months after treatment.

RESULTS

Hundred twenty patients were included in the clinical study, 98 women and 22 men. Patients were between 6 and 79 years of age, including 118 adults and 2 children (6 and 10 years old, both female). A total of 733 nails were treated, 714 toenails and 19 fingernails. Four patients had both affected toenails and affected fingernails affected. There was a 93% clinical response rate within 3 months of the initial laser treatment. There was a 100% clinical response rate at 6 months. At 9 months, there was a 100% clinical and mycological response (KOH -) rate (Figs. 1, 2, 3 and 4). There were no recorded side effects.

DISCUSSION

The greatest advantages of laser treatment for onychomycosis compared with traditional treatments such as oral or topical medications are the ease of application, negligible contraindications and overall absence of side effects.

In our study, we decided to test our patients only with KOH and not to perform cultures because various prior publications have shown that the KOH test shows a higher specificity (60-80% vs. 30-60% for cultures) (Nazar et al., 2012, Shemer et al., 2007, Meral et al., 2003, Weinberg et al., 2003). Moreover, there was a high incidence of T. rubrum in these studies as the main causative agent of onychomycosis.

In previous studies (Gupta et al. 2000 and Smijs and Schuitmaker 2003), the inhibition of T. rubrum has been described in colonies exposed to 1064-nm Nd:YAG q-switch laser radiation at 4 and 8 J/cm2. Moreover, Meral and Tasar (Meral et al. 2003) have reported a significant in vitro reduction of C. albicans growth using this laser therapy.

During the laser therapy, we observed near-instantaneous clearance of the affected nails, particularly nails that showed a brown-black or dark green pigmentation (Figs. 5 and 6). In addition, we observed the clearance of the characteristic “cracking” sound in the fungus-affected areas of the ungual plate and in the clinically free zones where there was no sound after the treatment. The Nd:YAG q-switch laser has been described under this name because it generates high-energy peaks with many repetitions. It does not warm the tissue (it is painless); thus, it produces impact energy that mechanically damages only the objective of interest (pigment-fungi)

Based on the above-mentioned clinical findings, we suggest that laser therapy acts via “selective photothermolysis” that works according to the type of pigment, type of light used and pulse frequency (light + heat + impact power).

CONCLUSIONS

The present study confirmed the efficacy of laser therapy for the treatment of onychomycosis in all of its clinical manifestations, including in the hands and feet and in all age groups, without side effects. This therapy was quick and effective, and only a single session with a 1064-nm Nd:YAG q-switch laser was required.
No differences were found in the therapeutic responses between the different lasers utilized.
BIBLIOGRAPHY

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Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian Let al (2003). Comparision of Diagnostic Methods in the Evaluation of Onychomycosis. J Am Acad Dermatol, 2003; 49(2):193-197.