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Laser treatment for nail fungus

Discussion in 'General Issues and Discussion Forum' started by Cameron, Jan 4, 2009.

  1. Paul Bowles

    Paul Bowles Well-Known Member

    Martin thanks for the article - this is sort of what I was getting at. I have no doubt we are achieving temps above 45+ degrees Celsius (add that to the list of studies I need to do!). If human core body temp is 37.5 and the peripheral temperature sits just below that, it doesnt take much to feel pain above the 37.5 mark I would assume. The constant here seems to be temperature - all patients in our first study received the same same debridement by the same podiatrist back to levels where the nail was considerably thinner with no appearance of gryphosis (I can get you an example of this if you want). The laser was then applied after this. As the nail is thin my theory would be the laser penetration is better resulting in sub ungual heating allowing temps of +45 degrees. I have seen several patients who have had failures from other clinics where the nail was not even debrided pre application. The temp measures on the cutera are completely useless in terms of actual temperature and I dont think we are interested in surface temp anyway, its sub ungual temp thats the important factor. In terms of exposure/duration - I believe we are getting continuous exposure over a 3-5min range delivering the 700J, I have had no patients report it was "comfortable" all have stated it was either "uncomfortable" or "painful", from memory one may have said it was "unbearable" (but they continued with the treatment anyway - go figure!) I believe we have VAPS scales as well for during and post treatment. Regardless - it hurts! At the same setting we use on patients it quite easily burns through ink marked paper instantly - yes its that hot! I wouldn't want to be waving this around like a lightsaber in your clinic. Luckily there are several safety switches on the device so its darn near impossible to fire unless you really want it to.

    Interesting stuff thanks!
     
  2. itlittle

    itlittle Member

    Where can I purchase a PinPointe Foot Laser? How much is it? thanks
     
  3. Paul Bowles

    Paul Bowles Well-Known Member

    Hi itlittle - there are LOTS of lasers on the market, i'd try as many as I could prior to making a purchase.
     
  4. Mart

    Mart Well-Known Member

    Hi All

    I did a cursory audit of our study records - here's some info which is somewhat interesting.

    the machine we used had a IR skin surface temperature measurement system - I do not know any specs of the measurement system such as sample rate or accuracy - these are unpublished as far as I know.

    the upper limit of tolerable measured skin temp was within range 32 - 38 degree C

    Once we noticed intolerance to our planned rate of dose we altered the methodology to gradually reduced pulse rate until temp was just below pain theshold.

    The pain at that threshold was always sufficient to create a withdrawal responce and I think it unlikely that most people would have been happy to "put up" with that. The machine controls were extemely sensitive and seemed to tune the dose very precisely.

    the doses were with a fluence of 14 J/cm2, pulse width 0.3 msecs and frequency of range 1.2 to 3 Hz as tolerated. Total dose was 400 pulses for hallux - 200 for lesser toes. In all cases nails were thoroughly debrided to nail bed before exposing to laser. When necessary bleeding from nail bed was cauterised with agno3 - in those cases the laser caused "pluming" presumabley because of increased energy absorption at caurerised sites. We did a couple of cases with total dose of 1000 pulses. To re-iterate there was no measurable visible improvement at 2 and 4 months in ANY of 80 cases. Cases were selected as severe (full thickness with >50% involvement).

    I believe that to have increased the dose rate to achieve a measured 40 degs C a nerve block would have been needed in all cases.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  5. Paul Bowles

    Paul Bowles Well-Known Member

    Martin looking at those stats I cannot explain why 0 out of 80 had no results. It makes absolutely no sense at all. If you were generating enough heat to create a "withdrawal" response then I would imagine the heat generated would have been enough. Some questions I would ask of your stats: 32-38 degrees Celsius is at or below central body temp. I am definitely no expert in this area but I would imagine 32-38 degrees would not cause a "withdrawal" response, well not one due to pain anyhow! I just tested this theory - in our house we have a digitally controlled hot water system - we can dial up the temp of the water coming out of the tap to. I just set it to 38 degrees, ran the tap for a minute and put my hand under it. Hardly enough to even make me notice. I then dialed it up to 45 degrees - still tolerable but getting very warm. Now I realize this is hardly scientific - however the numbers 32-38 to me don't make a whole lot of sense. You were using a "cutera" machine right? I have used one of these on an occasion and from memory the IR skin temp measure was hardly accurate. It had to have been measuring temp on top of the nail and it couldn't have been measuring the sub nail surface temp. I believe a study needs to be done on a cadaver using temp sensors placed sub ungually- this would help enormously. Of curse we could always go with the alternate hypothesis - it aint temp doing this?

    Your stats of 0 out of 80 are astounding. Do you have any photos of pre and post? I'm intrigued as to what possibly could have gone so wrong as to not see any results. Did all your patients in the study have pathology done prior?
     
  6. Mart

    Mart Well-Known Member

    Hi Paul

    I agree and likewise have assumed that energy absorption from laser was likely higher under skin/nail surface and temperatures therefore higher at nerve endings. Regardless we provided the highest tolerable dose rate.

    Since you have started revealing your findings I have started to think about this again. Another idea I have is that perhaps, and ironically, because we did such thorough pre-treatment debridement, this may have reduced the tolerance to heating within the nail because the nail bed absorbed most of energy and or heated relatively rapidly compared to a full thickness nail. Also we removed most of the fungal elements and accompanying pigmentation by doing this debridement so may have reduced photon absorption within the infected nail. On the other hand we might reasonably assume that fungal elements were present within superficial nail bed and these would need destroying if lasting efficacy was to be produced so that is a little inconsistent. If your study actually does demonstrate decent efficacy I think that might be most plausible explanation regarding why we had such poor results.

    What we did was really a clinical evaluation rather than a trial. It was not rigorous science more of a clinical audit of what we noticed with standardized tx protocol. That being said the results were unequivocal. Subsequently we really lost interest in the idea; published studies so far are not impressive for outcomes or quality of study, anecdotal reports from patients for efficacy are widespreadly poor.

    I believe that the laser did demonstrate targeting of blood vessels and pigmented areas nicely, we used it for treating some pretty nasty warts and in some cases the damage was incredibly localized. We didn't treat sufficient warts for me to be comfortable generalizing outcomes - I can say that in some cases it seemed impressive and others not - that seems the nature of wart treatments generally and remains poorly understood.

    We did standardize photography and I will post some pictures when I am back in the clinic. No we did not perform lab tests but the inclusion required clinical appearance of the nails to be highly suggestive for dermatophytes with little suspicion for psoriasis.

    It would be a inappropriate for me to say which machine we used. The company were very helpful and I think responsible in their approach to allowing us to do what we did. If we had conducted a rigorous study with an understanding that we would publish data that would be different. Since our findings are so far unexplained it would be wrong if anyone interpreted our findings as an indication that the machine was somehow inadequate.

    There is one study I read which claimed that antifungal effect of laser was to trigger creation of intracellular ROS rather than thermal damage - I can dig that out if you want

    cheers


    Martin
     
  7. Paul Bowles

    Paul Bowles Well-Known Member

    This is an extremely interesting point. There is no doubt photon absorption in darker more pigmented areas is MUCH higher! So I would question aggressive debridement and the need for it.

    I also agree about the cautery ability - it cauterizes very very well. We havent used it much for warts as yet mainly due to the fact that setting it up with the required suction and viral filter is a headache most of the time!

    I understand about naming the laser you used, however personally I do not believe your results are "the norm" - I think what happened in your case was simply a cascade of events which all contributed to poor outcomes. Laser is laser - It sounds like the machine was performing adequately from what you have reported thus far.

    I also don't believe all of your subjects could have been psoriatic - I will try and post pics next week of a patient who has psoriatic nail pre and post treatment. Amazingly - several of her nails cleared up! Several didn't though - could dermatophytes also be present in psoriatic nail? Obviously our results may allude that the answer to that is YES! Thanks Martin for indulging in discussion on this, I think we can only further the knowledge base by putting our heads together on this!
     
  8. drsarbes

    drsarbes Well-Known Member

    NAIL FUNGUS!!!!

    I see these patients, usually when I'm treating them for something else, and they want a cure for their nail fungus....or more realistically, they want their nails to LOOK normal.

    I have never had much luck Rx-ing oral antifungals, although I still do for patients who are young and healthy.

    I also have not had much long term success with nail avulsions followed by oral and/or topical antifungals.

    I do not own a laser nor do I intend to get into the nail laser business.

    I am not prepared to see these patients weekly for a debridement in hopes of curing their infection.

    Lacquers...never tried them but many patients I have seen have related using them ad nauseam with poor results.

    In this day and age of advanced medical treatments for everything from Lupus to baldness....why isn't there a good, affordable, successful, available treatment for this common malady?

    Steve
     
  9. Mart

    Mart Well-Known Member

    Hi Steve


    Because it is hard to penetrate the nail chemically without risking skin injury, hard to load the nail with a drug at sufficient concentration via blood stream without risk of side effects and not many ways to harm dermatophytes without harming human cells. That makes it pretty hard.

    Because it is so pervasive and people don't like it - effective treatment is a nice little earner, as many who have wasted their money have discovered.

    BTW are you using your Terason much these days?

    Cheers

    Martin
     
  10. Paul Bowles

    Paul Bowles Well-Known Member

    There is - between oral terbinafine and topical laser I think a good proportion of this disease is covered. Neither has to be expensive.
     
  11. Jenpod

    Jenpod Member

    I have read with great interest the above posts. I am seriously considering buying a Fotona laser for the treatment of onychomycosis and verrucae. I have done my research carefully and consistantly critiquing where possible the different lasers for these treatments. I by far favour the Fotona. I totally agree with the above for and against but from all I have read, researched and the course I've been on to learn more I stand by Hamish's posts.

    If anyone has any information that is negative as regards fotona lasers please private message me.

    Many thanks and great to have this forum.

    Jennifer
     
  12. Walking1

    Walking1 Member

    We purchased an Arc laser 2 months ago and so far our results are very encouraging. I will be better informed with another months growth but up to now I am impressed and most importantantly so our patients.
    I have read with interest the discussion on the Laser . After some research by myself and my associates we decided it was worth the investment and as stated it seems to be working. As far as terbinafine is concerned it has too many potential side effects for me to recommend it, I tried it nyself and I was not able to tolerate it.
     
  13. itlittle

    itlittle Member

    that sounds great where can you buy the Arc Lser from, whom is the supplier , I'm in Canada ? look forward to your reply. thanks T344y
     
  14. Paul Bowles

    Paul Bowles Well-Known Member

    Glad someone dug this thread up - I need to post some follow up pics in here....will do so over the next day or so!
     
  15. Paul Bowles

    Paul Bowles Well-Known Member

    Here is the updated pic taken 6 months post 2 laser applications. This is 6 months after the initial laser application. Only 2 applications have been issued (as per above). We are monitoring this patient up until the 12 month mark. I think you will agree that in direct comparison to the images on the previous page there is a drastic change.

    [​IMG]
    Pic C - 6 months post original laser - 2 applications 1064nm as per previous post

    Just to continue the follow through on this topic.

    :rolleyes:
     
  16. Walking1

    Walking1 Member

    I am in Australia so I have no idea who would supply you in Canada, the unit is German made and it is called The Fox ARC laser.
     
  17. Walking1

    Walking1 Member

    The pictures show a great result Paul. This goes along with our results so far.
     
  18. healthynails

    healthynails Welcome New Poster

    I am seriously considering purchasing the Lunula cold laser machine for treating onychomycosis. The Lunula combines 2 wavelengths 405and 635 nm. The 635 stimulates local immune cells and increases blood flow to fight onychomycosis-
    causing fungus. The 405 Possesses antimicrobial effect by upregulating the production of cytotoxic Ros to kill onychomycosis causing fungus.

    Have any of you had experience with this or aware of actual success rates (as opposed to its marketers published success rates).
     
  19. Paul Bowles

    Paul Bowles Well-Known Member

    I was under the impression that the desired wavelength was 1064nm?
     
  20. Walking1

    Walking1 Member

    Yeh I also thought that most of the research points to 1064nm being the most efficient.
     
  21. Blarney

    Blarney Active Member

    Now cheaper than a flight to Dublin - €79!

    Glad I didn't spend €000's on laser equipment.

    Justin

    podiatry.ie

    "Where people with foot pain come to get it fixed."
     
  22. Paul Bowles

    Paul Bowles Well-Known Member

    Justin why does it have to be expensive? We have had it very cheap in our clinic for over a year now...... Do you have expensive orthotics in your clinic? ;)
     
  23. Blarney

    Blarney Active Member

    Just a follow up post to the one I posted February '12.

    How low will laser fungal treatment prices go?


    Your not still treating with orthotics are you?



    Justin

    podiatry.ie

    "Where people with foot pain come to get it fixed."
     
  24. feedme

    feedme Welcome New Poster

    Paul Bowles - I'd love to see more before and after pictures!! Minus the wait if possible!

    Also looking for advice. Mid-20s, healthy female with 2nd toe isolated onychomycosis with what appears to be a small brown spike/dermatophytoma and nail matrix involvement. Nail is moderately thickened had initial nail clipping from PCP with PAS stain negative for fungal hyphae. Failed 2 separate courses of terbinafine with minimal improvement seen but no clearance from bottom of nail in either course. I'm wondering if laser + debridement would be a waste of time and would not offer clearance from the the nail matrix. I know the jury is still out in effectiveness. A provider I talked to stated the Fotona laser was more effective than the PinPointe and that time would be wasted with the other. Thoughts on this?

    I can post a picture if it helps. Thanks.
     
    Last edited: Apr 18, 2013
  25. blinda

    blinda MVP

    Always.
     
  26. itlittle

    itlittle Member

    hello,
    what a reponse for the laser fungal nail treatment , confused as ever, still don't know which is the best system related to cost wise, any suggestions out there I am in Canada so cost is important. thanks everyone.
     
  27. PORTAL Education

    PORTAL Education Active Member

    WRONG SECTION - apologies mis post!
     
  28. newsouth

    newsouth Member

    NEW? it seems that nearly 100 are installed now

    They have offered it to me last week. Seems to be very well supported by an university with an 18 months clinical trial
    Podylas S30 do u know it?

    ONYCHOMYCOSIS Excellent results in 3 treatments
    PLANTAR WARS Good results if there is a vascular base
    HELLOMAS Excellent results
    SMALL SURGERY Cut, coagulation, vaporization with a minimal nechrosis
    VASCULAR PERCUTANEOUS Photocoagulation of small vessels
    LLLT Biostimulation for antialgic and antinflammatory effects
    PORTABLE
    MAINTENANCE FREE
     
  29. newsouth

    newsouth Member

    From what I have seen about all the lasers in the market and spoken with KOl in fungus, you need at least 20 W to do the treatment.
    Im going to try the Podylas next week. Seem sthey are presenting an excellent 18 months clinical study in the worldwide congress in Rome.
    I have tested the Lunula too and the KLaser.
     
  30. For all of those of you who aren't practicing podiatry in the USA, here is what I got in my e-mail inbox today. This kind of gives you an idea of the stuff we receive on a daily basis and also what it is like to practice podiatry here in the good ol' US of A.

    Comments?
     
  31. blinda

    blinda MVP

    http://vimeo.com/57338243

    Actually, `money` is not the root of all evil. Rather, it is LOVE of it.

    1 Tim 6:10
     
  32. citychiropody

    citychiropody Member

    saw this this morning...

    reads the second paragraph carefully !
     

    Attached Files:

  33. That ad is pretty funny, especially considering what they, and the podiatrists who bought into it, were claiming about its results early on in the game.

    Here is one of first postings I made on this thread, over 3.5 years ago on September 12, 2009:

    ...and then a few days later...

    Now PinPointe says the following in their ad?:

    No longer is PinPointe Foot Laser claimed to "cure onychomycosis", which was claimed by many podiatrists using the device. Now you must pay $800.00 for a "temporary increase of clear nail"?:bang::wacko:

    Maybe PinPointe is trying to avoid the same type of multimillion dollar lawsuits that Vibram FiveFingers and Skecher Shape-Up shoes were hit with when they also made false health claims about their products.

    What does everyone else think?
     
  34. healthynails

    healthynails Welcome New Poster

    What were your findings with the lunula laser?
     
  35. Paul Bowles

    Paul Bowles Well-Known Member

    I think they are a company trying to sell a product. If you are trying to do that you aren't exactly going to say it doesn't work are you? Maybe they realized their marketing was overly aggressive?

    Can't be any worse in my opinion than Loceryl 5% which is on TV every 30 seconds here in Australia claiming it is clinically proven to cure nail fungus. In almost 20yrs as a Podiatrist i've never seen Loceryl cure anything except an overladen wallet. Cost of that treatment around $100AUD.

    Canesten is another topical which is advertised heavily here - again i'm yet to see anything positive come from patients using this.

    I've used pin pointe but not for extended periods of time so have no idea what their results are like.

    Clinically i'll stick with what works. To date the only two conservative things I recommend to my patients to try are oral terbinafine and 1064nm laser. Surgical removal of the nail and phenolization of the nail plate (not matrices) is also discussed in those cases where the nail is already so separated from the tissue underneath that it is painful and causing paronychia.

    I have no idea why people are charging copious amounts for 1064nm laser in their clinics - it really makes no sense. Then again I could say the same about custom foot orthotics in the majority of cases as well! I reviewed a patient last week who was referred to me by a Physiotherapy colleague who had been charged $375AUD by a Podiatrist for a pair of off the shelf formthotics with a $4 heel raise stuck on and a vinyl cover badly applied. They had been given the orthotics because they had a corn on the PMA - the corn had never been debrided! They were told it would go away if they purchased the orthotics. Go figure.

    There are lots of things we could be scrutinizing in and amongst our own profession.

    To the poster above - apologies I haven't fulfilled your request I have been flat out at some conferences (LA, Sydney, Liverpool) over the last few months. I'll ask our practice manager to delve into the photos today and send me a few so I can post. I'm also happy to post poor results if anyone is interested in them? Yes eehh gad they do occur....with both laser and terbinafine!

    :D
     
  36. Paul Bowles

    Paul Bowles Well-Known Member

    Apologies for not replying sooner. Here is another patient. 36yo male. Three applications 1064nm laser 10.0W, 10/5MS 700J each session. Minimal debridement in length pre laser on each occasion.

    Pre - Laser:

    [​IMG]


    12 months Post:

    [​IMG]
     
  37. Suzannethefoot

    Suzannethefoot Active Member

     
  38. Mart

    Mart Well-Known Member

    Can anyone give a plausible reason why, even if this laser device can achieve these effects in vivo, that this would damage dermatophyes in the nail where there is no blood supply? Also where in this picture are the ROS supposed to be up-regulated?

    cheers Martin
     
  39. Paul Bowles

    Paul Bowles Well-Known Member

     
  40. Mart

    Mart Well-Known Member

    Paul

    You seem to be nicely navigating your way through the uncertainty around this issue whilst stimulating some worthwhile interest - "fair crack of the whip" :)

    cheers Martin
     
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