Laser treatment for nail fungus

Don,
The company are not going to tell anyone their specific proprietary information, it would be commercial suicide. Howeve I can tell you this your wattage is way, way, way to low. Not only that but the ccumulated burst is not something you could emiulate.
Everything is preset by the company in accordance to their research and development. This prevents anyone from mucking about with this element of the delivery protocol and reducing efficacy.
Your CO2 laser owes something of a debt of gratitude to Dave Harris as much of his early work went into development of such lasers.

 

Gosh! 5 pages about a condition which is usually painless and easy solved with a tna.

Can't get that excited about it myself.

 

I would say that earning nearly $1million U.S. Dollars in the last 15 months treating nothing but fungus is an outstanding result!

You are under-selling yourself (sarcasm meeter just went through the roof).

I, like so many others on here, just want the research to back that up - preferably the randomized, double blinded kind of research which is not funded by the company that make the product!

Please elaborate on the "daily prevention for the rest of their lives" concept? If I paid just shy of ONE large on something, I would want it to work out of the box for a very long time! If I had to do something "daily" then I may as well treat it orally or topically....

Your office is 14 hours plane trip via a Boing 777 from mine - I will be in LA in March for DFCON can I swing by and check out your results?

 

I can understand the debate surrounding evidence and the alleged lack but I cannot believe this from you Robert. I usually see you sitting on the fence, appreciating all sides of the debate. Your above posting is so not like you and leaves me concerned.

I have never had fungal nail infection so cannot appreciate 1st hand whether the actual condition is painful or not but quite regularly the resulting nail damage looks blooming painful and from where I am sitting the soft tissue inflammation within the proximity of the nail being the dead give away. So for someone who does not respond to or cannot have appropriate OTC or POMs treatment then you are happy to suggest a TNA as the appropriate course of treatment? What other options do you discuss?

Thank you to Hamish for his continued explanations and photos regarding Pinpointe. Whilst money is a touch tight hereabouts, introducing laser as an option for fungal treatment is certainly making for interesting conversations at the footshop. I have found it heartwarming that patients once supplied with an understanding of fungal infection, the damage it causes to nails, tx and prognosis can rationalise themselves their prefered choice of treatment or indeed, more often than not, no treatment.

GB

 

I have a question, actually I have several but I will start with this one.
Who is volunteering to provide the money for a trial? All parmaceutical companies originally fund their initial trials but it is put into the hands of reputable individuals to conduct it in an acceptable and meaningful manner. This is common knowledge. I am sure that the company would be very happy for someone else to foot their bill.
Currently their trials are lodged with clincaltrials.gov, which is a service of the U.S. National Institutes of Health. Dr. Bernard Goffe M.D. Dermatologist is overseeing the trials.
Here is something about the man.
Dr. Bernard Goffe is a Dermatologist and the Founder of Dermatology Associates, PLLC, a Psoriasis Treatment & Research Center in Seattle, Washington. He is also a Clinical Professor in the Division of Dermatology at the University of Washington School of Medicine. Dr. Goffe received his medical degree from the University of Washington and is board certified in dermatology.
I have never met the man but i am prepared to believe from his CV his is honourable. All this information is on the Internet. Even telephone numbers. Perhaps you might like to contact him and tell him you think his research is not to be trusted because Patholase sponsors it.

The remark about surgery being a viable alternative to someone with heavy multiple infections is both naïve and unsympathetic to those with strong body image considerations, and it does not deal with the issue of eradication in visually unaffected but contaminated nails. It then impacts too on cost. so my second question would be what would you charge the patient to remove all ten nails, and as a rider how would you their contaminated fingernails?
There is a great deal not known about contamination of an individual by mycoses, so one consideration is the encouragement of improved hygiene and antifungal barriers. It is variable in the equation and has merit. It might even be unnecessary but for the time being it is sensible advice. This is a treatment of an infection not a cure forever. It is exactly the same principle for antisepsis and antibiotic. When I was last given an antibiotic for a chest infection it was not suggested to me that I would never get another one because I had just had an antibiotic to clear my current infection.
Currently if I have a patient with Tinea I would suggest they use antifungals in the future whenever frequenting potentially contaminated areas as a preventative. The patient can choose to accept my advice or not.

Dr. Michael Uro is not a regular reader of these pages so if you wish to ask personal questions of him you will need to do so directly. But I think you will find him to be anything but secretive.

One last thought is that most of these post revolve around “If I had”, or “if it were me”, and I wouldn’t”, concepts. This is not about yourselves but other people with their health matters making their own choices.
I personally do not smoke but I am sure many of those who visit these pages do, as I am sure a number drink more heavily than me, eat more stodge than me and exercise less than me. Some will be unhealthily overweight.
They Choose what to put in their mouths and lungs in a different manner to what I do.
Choice Gentlemen. I currently choose to post in an attempt to spread my experiential information to those who are interested and dissatisfied with the current options. I like to think I do so in a respectful and polite manner, and measure my responses accordingly.
My choice, others choose a different way. But that is their choice.

 

Sitting on the fence, that's me alright. Famed for not having strong views on anything

Not really on the fence on this one so much as in the next field over wondering what the fuss is about. Don't mistake apathy for animosity.

I have a mild interest in the theoretical aspect of evidence gathering. But as to the rest... Well I work mainly for the nhs. I'll leave cosmetic podiatry (not a phrase you hear every day ) to the patients who can afford it and the podiatrists who want to supply it. As hamish says it's all about choice.

Love the "visually unaffected but contaminated bit" btw. I guess they need treating to be on the safe side right?

Regards
unsympathetic bob

 

I know the fuss is tedious and seems based on a lack of evidence vs cost of treatment. Patient choice allows these treatment modalities to exist...thank goodness perhaps? Now that is a matter of opinion and something which Podiatry Arena exists for.

But my concern is justified. You are betwixt and between NHS and Footprintspodiatrysolutions; a bit of a schizophrenic existence, I know. One thing that is expected by private patients as well as pain relief is a consideration towards the appearance of the end result of treatment. I rather think our Podiatric Surgeons take this into consideration also but you seem to disregard. I have made this assumption on your dismissal of patients seeking "Cosmetic Podiatry" - your choice of words I think?

Is the treatment of OM cosmetic or medical? Be nice to get patient input on this.

Good luck with the private practice, Bob. I wonder how long before you consider cosmetic appearance vs practice success? Or are you sticking with the NHS for the pension?

GB

 

Can't trust the pension! But I'm sticking with the NHS because it enables me to do almost entirely the work I enjoy most, viz paeds biomechanics. One day a week private work just lets me have a bit of variety. Plus on a good week I can earn more in that one day than 4 with the NHS. But I still try to stick to the reason I trained in podiatry, to fix painful feet. If somebody comes to me wanting their feet to look nice I'll send them over the way, not really my thing. Most of my patients are just desperate to be out of pain and don't give a fig how it looks! But then pretty much all I do is biomech, VP's and IGTNs. The only cosmetic element to worry about there is with the nail surgery and a PNA generally looks quite acceptable so its not something to which I give much thought.

Thanks for your concern BTW. Neither of me thinks the schizophrenic existence is a problem. But I'm touched by your care for my well-being.

Don't get me wrong, I know fungal infections can be a pain. But looking at the photos on the last page it strikes me that the "dipped in boiling water" look was what jumped out at me as a problem. The nail rather less so! And I struggle to beleive that ALL of the skin on the foot got better because a few fungal spores on the nail got zapped. If so there would be no need for the topical antifungals would there. Was the topical regime for the skin after treatment exactly the same as what he was using on the skin before? I doubt it strongly.

Regarding the cost vs evidence, I would feel different if we were talking about a crippling or substantially painful condition. Then I might be concerned that vulnerable people were being ripped off. But its scarcely that is it! The vast, vast VAST majority of fungal nails I've seen have been asymptomatic. The ones which WERE symptomatic were almost exclusively so dystrophic that even if the fungal element were resolved the dystrophy would continue to cause problems (and I'm certain if the dystrophy was the main problem they would not be offered laser anyway right?)

If someone wants to pay £800 to have prettier big toenails who are we to argue? People probably pay that for a few years worth of pedicure and we don't get excited about that! Personally if the choice was £800 for an 88% chance of success and a lifetime of anti-fungal application to prevent recurrence or £400 for a 98% (or so) successful TNA with no need for a lifetime supply of anti-fungal and a 0% chance of the fungus returning it seems a bit of a no brainer to me. But of course that's the patients choice.


BTW George, sorry if you've covered this in earlier bits of this thread (I only scanned it) but do you use one of these things?

Kind Regards
Robert

 

I wonder how many people who post ever stop to think that the public look at this site too. I know because someone referenced me from it and was stunned at the attitude they found here. Bearing in mind this patient who chose this treatment, that others speculate on and talk about but don't offer and I do was a Consultant is of some interest to me. And it should be to others.

The photograph is offered for you to suggest your treatment plan. Remember this is a patient not yourself. This person is particular about how they look and their appearance is important to them. They tried Oral medication and were less than happy with the diarrohea. What is the cost to remove all ten nails?

 

Independent data is what we are after - non biased, untainted.

And is hence on the payroll of the company who developed it.

I am sure he is extremely honourable and I am sure he is very well qualified - but I am also sure he will attest (with all his qualifications) that independent double blind and randomized data collection is required.

Well as a Podiatrist I am not legally allowed to treat their "contaminated" fingernails anyway so that is a moot point. Isolated nails respond well to TNA with nail plate (not matrix) phenolization in my experience. For gross infection of multiple nails oral terbinafine is the product of choice.

Until the independent double blind randomized controlled trials come out showing that the laser is safe and effective.

But you were also not issued with a prophylactic regime to stop you getting another chest infection were you? No drugs, no oral inhalants, no advice on wearing masks in public places......

But why? Surely just saying wear thongs or shoes should suffice.....or even don't go into potentially contaminated areas. Using topical antifungals would be akin to taking oral penecillin prophylactically - it would be overkill I imagine.

Ahh yes but its not "choice" is it - because you are telling the patient what to do, so it is "opinion". Do you also tell your patient that there is at present limited evidence in its use? Do you explain to them the importance of independent clinical trials in establishing efficacy and then tell them that the only clinical trials at present are those directly funded by the company who make the product?

If you do - then I agree it is "choice". If you don't then it is "opinion".

You do Hamish and I think we all commend you for that here...but I also hope you can see the trend that all most of us are asking for is good quality evidence - that is our choice! You have to understand, that most people (patients and practitioners alike) simply grapple everyday with the concept of overpriced medical care. I would love to see this treatment proven with good quality evidence, I would love to be able to offer it to my patients - but I won't recommend it whole heartedly until I see some serious evidence to back it up.

 

Firstly outrule psoriatic nail with a microscopy and culture. If it is positive for mycoses then use oral terbinafine, 2 courses back to back over 12 weeks, with a pre-regime FBC including LFT and another FBC with LFT at 6 weeks into treatment. Wait 12 months.

If that fails or he doesn't like the side effects - switch back to topical lacquers such as Loceryl 5% or advice him of the options including surgical ablation and nail plate phenolization.

 

Paul,
You have neglected to include you treatment costs for your courses of treatment.
In this case the requirement for a test totally redundant because the condition was a plain as a pikestaff and if one can't diagnose from that when it is directly in front of you.. cost for the tests too. in real terms please, all of them. Include all Capital costs, not just your wages.
I stated that diarrohea was not an option so "if he does not like the side efects" is facile and sounds very unsymapthetic to a person. How long to clear the nail using topicals and what is the total cost?
You suggest nail avulsions. Again what is the cost financially including post operative care, and then you can assay the cosmetic cost. I have not seen avulsed nails never show longterm changes following the physical damage done to the tissues. Remember this is ten toes.
Next post just keep it simple and cost the financial breakdown so that I might evaluate your cost exercise for each option. Total costs ten toes. please read the patient profile again. This was a real person who had tried, topicals, oral meds experience side effects, had no psoriasis, was proud of their appearance.
For any othere readers to this post the patient had considered they had run the gamut of what is a typical approach and decided this was very much worth the risk. Particularly considering there is no post operative wound or pain, and avulsion will create ten of these for @8 weeks as well as create an far greater risk of infection. Please include all dressing costs for the healing of these ten toes too. If you are suggesting the treatment plans as state paid then it is not free. so estimate the cost to the nation, it is normally quoted without capital costs so do endeavour to factor these in.
The trials are independant of the company and there are strict rules that have to be adhered to satisfy the US National Institute of Health.
Answer please who is to conduct and finance the double blind trials, we all know that this is what is ideal, but until someone offers (without their own agenda) this is what is in play.
You state that Dr. Goffe is extremely honourable (lets be honest he is a reputable Dermatologist and knows more on this subject than all of us here put together) then you say "he is on the payroll of the company that developed it", which implies that his research is untrustworthy nad not to be trusted. Dangereous ground.
"Oral terbinafine is the product of choice". Whose choice? yours? You write a paragraph on this and in doing so contradict what you imply of me.
You see this as expensive and talk of overpriced medical care and yet put nothing about the complete alternative costs.
Wearing thongs will not protect against contamination. As a test sprinkle KMnO4 powder on a floor, walk about for a few minutes in thongs and then spray water on your feet. Expect them to change colour . These particels are not microscopic, if you can contaminate your feet and legs up to you knees with particles this size you will certainly with smaller ones.
As for not going into potentially contaminated areas that would rule out all changing rooms, hotels, sports facilities, swimming pools etc so not very practical. I clean my teeth every day using paste, floss and mouthwash twice daily. I fully expect the bacteria to build up, but I try to reduce the effect. Overkill I think not.
I have no idea whare you were going with the remark about prophylaxis because you did not finish it, so I can only assume I had not made my point clearly.
Having decided to involve myself in this area of treatment I have to accept some of the skepticism but I am starting to relaise that I know a lot about the device and its mode of treatment, not to mention seeing first hand the physical changes it creates in nails, that I cannot convey to those who have not even seen a unit, met the scientists involved , used one or seen one used first hand.
So again I will read the posts in future without replying but find little reason to share any of my findings with the wider community. Those with real interest can continue to find me, it is after all very easy.

 

Because what use would it be? Internationally it all varies in cost enormously

Just to add insult to injury then:

in Australia the drug is subsidized by the PBS scheme, my treatment is subsidized by private healthcare/Medicare and the pathology is covered by medicare....

You want a basic breakdown:

Podiatry Consult $80AUD - Cost to patient after Medicare Rebate/Private Health = $30AUD

Pathology Cost - $180AUD unsubsidized, $0 completely subsidized by Medicare

Oral Terbinafine (2 courses required) - $49.95AUD per course (after PBS subsidy) $249.95AUD per course unsubsidized.

Total cost to patient: $129.10AUD with subsidy. $759.90AUD without subsidy. Still well under the $900USD quoted previously in this thread.

If you want to consider the surgical option I would estimate well under the $900USD unsubsidized charged for the laser treatment quoted elsewhere in this thread.

Unfortunately in Australia to get oral terbinafine on the PBS scheme you require a positive pathology. No way around the test, even if you are 100% certain its mycotic. Not my rules, I just have to play by them.

I don't like having a filling either, but hey thats the price I pay for getting the problem fixed! I could just live with the problem! As could your patient, it wont kill them! (Sarcasm meter going up again).

Topical loceryl 5% (one of the most expensive treatments in Australia) is about $90AUD per bottle. One bottle will most likely last 3 months if you are liberal. At the recommended 6 month treatment that is still less than the $900USD quoted here (assuming ithe loceryl 5% works).

Just because you haven't seen it doesn't mean it doesn't exist. We routinely do this and most patients get excellent results.

Does that mean you charge more than $900 USD? Whats your charge per toe?

Is the above simple enough for you?

Can you show us the AFTER shots progressively since you document with photographic evidence so well? In this whole thread I haven't seen one BEFORE and AFTER shot - it has been requested though!

Why? From what I have seen thus far people pay cash for this treatment in the US? Hamish how do you charge? What do you charge? What is the total patients out of pocket cost? Does the NHS pay for this?

It is far easier to break it down into out of pocket costs for the patient because you are trying to compare apples (something which is subsidized) VS oranges (something which is not).

Please explain how it is "independent of the company" when it is self financed by them? As if they would allow poor results to be published (this is why this stuff is frowned upon). As soon as the head researcher gave them the prelim data and it looked bad their first reaction would be to pull funding. The trial would never even get finished and hence the results would never be published.

I have an idea for you Hamish, how about you get the company to organize a laser for me and I will get an honours student to do a study for you. Surely there are some Newcastle Students just finishing their degree who are going to do honours - prime project for you. Isn't there already a study under way which is independent?

See my offer above - hell I will do it for you if I have to. I'm bored and don;t have enough to do with my spare time!

Never - I am sure he is honest, reliable and a damn fine Doctor but as you stated his research was funded by the company that make the product (your claim not mine). So in essence they are paying him to research the topic would you not agree? No danger here - I am sure being the reputable person you say he is then he will be the first to admit its not the best way to publish research. Its not the worst either - all I am asking for is an independent double blind randomized controlled trial, in fact that is what we are all asking for.

Research - check it out. The research on Terbinafine is thorough. My patients are given all their options from topicals to orals and yes even laser (there is a Pod in Sydney who recently purchased one). They are also given all the evidence behind each of them. I am not biased, and just want the patient to choose their own path - I am happy to facilitate that by providing as much information and education as I can.

Yes but the mycoses must get under the nail plate for this to occur. Onycomyscoses 101 - nail trauma leads to onycolysis/distal nail separation and inherent infection from mycotic spores. I would go as far as to say there is resident mycoses on the skin. So what prophylaxis are you referring to? Stopping nail trauma?

No you don't! just give us the double blind randomized peer reviewed research to back up your claims. I will go buy the laser the minute I get that well researched paper.

Oh don't do that Hamish, we are all adults. You will respond to my post above because you love the fight and believe what you are doing. Just give us the evidence!!

 

hamish. You said

then

which reminded me of when YOU said

Got to laugh!

So then, since YOU raised the issue of cost, Paul has given his breakdown. What's yours? You mentioned earlier that a standard protocol was 45 mins, I presume that is for one toenail. So what will 7.5 hours worth of laser cost?

And since we are being picky what is the cost of a lifetime supply of antifungal?

I might comment on the case study later if I can be bothered.

 

The general tone of postings I find unpleasant and mocking and unneccessary.
Mr Issaacs I have mentioned in aformer thread the procdural protocol is inclusive of, evaluation administration, preparation, lasing, consultation, and two follow up procedures for further evaluation and debridement. The debridement should not be clumsy or rudimentary it must be skillful, and aesthetics is important, patients do care what it looks like. Your presumtion about 45 minute for one toe is either mischievous or sarcastic this forum would be better without either.
If it was genuine surprise then you are not asking the questions in a manner that best gets a polite reply. It takes @45-50 minutes to lase all nails. It is best policy. To descibe why would probably need a very lengthy explanation which I may post later. But surfice to say that previously unaffected looking nails can suddenly and rapidy change to one of gross infection in a short space of time. So it is better to aim for a "clean slate" scenario.
My current fee for this is £650 but will be £750 soon to better mange my high running costs. I allow over the course of the plan @2-3 hours of my time.
The remark about being bothered sounds very supercilious and dismissive and petulant. As I say the public view this thread too, and a number of them are medical professionals from other disciplines. It has already been reamrked to me that it it does not reflect well on us when people post in a rude and aggressive way.

There have been no costs listed for liver function tests and identification. Nor are the hidden Capital costs included. Government services never include the building costs in their factoring nor do they generally include the support staff cost. The same goes for the lab where the testing is done.
If Mr. Bowles is genuinely interested in my work in this area consider some manners in how you quiz me.
To consider TNA of as many nails would be a higher cost than I think you post. But in this day and age it is perhaps more barbaric than what I am trying to provide. My Computer battery is low so I might come back to this later.

 

Robert

At your pickiest best.

Have none of you bothered to read what Hamish has described?

One treatment is 45 mins for all 10 nails, I'm sure he said he treats both obviously infected and none infected nails.

Is it not time this forum recognized that different countries have different 'protocols', and therefore what is acceptable and legal in the UK may be very different in the US or even the southern hemisphere.

TNA for a fungal nail IMO is barbaric and overkill.

Lamasil tablets, evidence based succeed 68% of the time, Loceryl is not suitable for nails with matrix involvement and when still 68%.

So how about laying off Hamish he is being just as experimental as all the now VP Needling believers. And there is no evidence for that at all. Even the original paper was pure speculation.

Hey having said that I have tried it and yes it does seem to be going according to description. In fact Robert I have even referred a patient to you for the procedure.

The only difference with me is I offer a money back guarantee for Needling because I cannot prove it's use.

Hamish has massive overheads to cover I doubt he can afford to do the same.

Now to get blasted by all the people who know me.

Bob

 

Robert, is this relevant to the debate and if so would your response to my postings change dependent on a positive or negative answer?

Bob, I absolutely agree and if it is Robert's personal choice of treatment is a TNA then patients have a choice to avoid his private practice at all costs but not his NHS clinics. Tough luck if Mr Isaacs is your attending practitioner and your extensive fungal nail is causing pain, does not respond to OTC treatments and you suffer side effects with oral terbinafine. Your option is TNA or discharge.

Now if your VP is causing you distress...different matter despite what the evidence base shows.

So as an experimental procedure goes, if a patient shows interest in funding Pinpointe Laser would you support that interest or would you advise the patient to avoid at all costs?

GB

 

Jeez you guys are touchy! Thin skin!

Short memories too! Hamish, the post you found so offensive was made up almost entirely of quotes from things YOU SAID!! So what, it's ok for you to accuse someone else of aspergers like behaviour but not vice versa?!

And George, it's relevant for you to pass comment on my "schizophrenic" working arrangements and to refer to my practice in such insulting fashion,but not for me to ask you if you have one of these machines, viz a vested interest in the topic under discussion?. Seemed a civil, relevant and reasonable question to me!

So far as I'm concerned if you insist on referring to your colleagues in terms of mental illnesses you go right ahead! But don't then come back bleating about other people being "unpleasant and mocking!" If you are so desparately sensitive, perhaps you should treat others with more respect. In short, if you don't want to take it, don't dish it.


On a separate note, I'm glad you've had good results on the needling bob. I've been pleasantly surprised, even amazed by the results myself. Very exciting stuff.

 

tough luck shared by patients of every nhs trust in the country (I don't know of any which have a laser, am I wrong?) and every podiatrist who don't know have one, or the facility to refer to someone. Oh and tough luck shared by anyone who can't afford £750 to have nice looking toenails nails. Or who does not fancy using a topical antifungal for the rest of their life.

Yeah, what a monster I am .

Sorry George. Am I being mocking again? Sorry. I'll be nice from now on.

For what it's worth, if I have a patient with multiple infections which ARE painfull but NOT too dystrophic who DOES'NT mind using topicals for the rest of their life, who IS intolerant to oral antifungals, DOES'NT respond to laquers, DOES have £650 to spare, I'll certainly reccomend laser.

 

Robert,

Touchy, thin skinned?

Anyone who is not a member of the 'inner circle' of this site has to be very thick skinned to even dare to post here.

What I do not understand is why you and your buddies keep asking Hamish to provide something he keeps explaining he cannot provide.

And why I ask again is it alright for you and your buddies to promote and practice a treatment that has no evidence behind it? And are you sure your insurance covers it?

On another point how much are you charging for needling?

Bob

 

You, bob, Could never be called thin skinned. You dish it AND take it with aplomb. Although occasionally touchy. No offence like.

If you were referring to the needling then you are correct, it has no evidence yet although I and a few others are working on generating some. Mind you that just puts it in the same catagory as proceedures like removing corns and using silver nitrate on hypergran (or vps). Like most of the things we do every day it's primary recommendation is a: a solid rationale and b: a long history of successful use. I like your idea of offering money back guarentee. I've been toting with that myself! So far I've needled 26 vps, only two have not yet resolved so I could certainly stand to do that. I'm charging the process at £85 a throw. Didn't like to ask for more til I was confident of my results. I'll probably up that a bit presently.

And so far as pressing hamish, I gave that up a while back. I have no particular problem with this technique, I really don't. I just don't see it as a major breakthrough. Perhaps it's a demographic thing but OM is just not something my patients seem to have that much of a crisis with! As I said earlier in the thread, I'm pretty ambivilent about it. For some reason at that point everyone jumped down my throat! And for the life of me I don't know why!

Perhaps if this

Really is how you see things, hyperdefensive is a better word than touchy?

 

Robert

A schizophrenic existence is a description often used to describe the coexistence of differing decision making processes which at times can lead to personal conflict -your existence as an AHP in the NHS and a Podiatrist in PP is the perfect example. It is not an insult but I know you know this and are just playing to your audience. My statement was made with much empathy. I run a business and I have to make decisions as a healthcare professional which conflicts with my drive/need to make money, another schizophrenic existence.

I have no vested interest in Pinpointe; you thought I did and this has amused me. Forgive me for playing with you for a while there. It has snowed a lot hereabouts and the prevailing conditions over the last 4 weeks have not permitted much outdoor activity, so exploring other entertainment has been necessary. Childish I know. I do not have a Pinpointe Laser in my practice. The only vested interest I have is for the best of my patients. I have no vested interest in Hamish's practice. If a patient is desirous of laser for a fungal nail infection I would refer to the closest practice with such a laser and it is not the Dow Clinic. But I will defend a fellow colleague particularly a colleague I admire for his conviction to explore an alternative treatment modality.

Robert this is indeed worth a great deal to a patient who wishes to explore all options available to them and I am relieved that NHS protocol permits such discussions. This is not saracasm as I understand that as an NHS employee you must not recommend an individual to a patient but given the small number of practices with Pinpointe Laser you may only have one individual locally to recommend - a conflict but not so in private practice....ah that schizophrenic existence once again.

So far when patients have asked of me "if there is anything else they can do" after trying all viable OTC and POM options available with no success and the only option that remains is palliative care, when mentioning laser and associated costs their reaction is not printable. I work in an area with a high proportion of manufacturing and engineering industries. The impact of the economic recession is hard. Safety boots feature greatly along with nail plate stress and perfect conditions for mycoses, therefore I see a high proportion of patients with 10 infected toenails and infected skin to the point where skin integrity is breached and there is a great risk of secondary bacterial infection. For some, continuous application of topical antifungals is necessary just to maintain that skin integrity. It is possible when commissioning becomes reality, with GPs being the gate keepers, then in extreme cases of fungal infection referals may be made to Pinpointe Laser practitioners.

In your defence I will suggest TNA but I would not carry out this option as like Bob, I think it is OTT and barbaric but if a patient insists and an NHS colleague is willing then I would refer. In private practice 10 TNAs would be far more costly than the laser option Hamish quotes.

Give and take hey Robert?

GB

 

Works for me!

You're right. NHS protocol does'nt. Call me old fashioned but I don't particularly give a ***t if its what's best for my patient.

There are always ways. Its NOT ok to say "go to joe bloggs for laser". It IS ok to say "well there is this treatment which might be suitable for you. I understand there is a podiatrist in Catford on Slough who does it. Perhaps you might wish to look into that".

Its that fuzzy border between the letter of the law and common sense.

Regards
Robert

 

I included the costs above with and without subsidy - what more can I provide?

I have been nothing but courteous Hamish - any suggestion to the otherwise would be incorrect on your behalf.

Not at my clinic.

Thanks for posting your costs Hamish. So what you are saying is that the cost of one course of treatment is $13350 AUD for 2-3 hours of your time? Exactly what type of debridement are you referring to? All the videos I have seen on you tube of this laser show no debridement - just application. Exactly what do you debride and are you referring to lowering with a burr of any gryphotic components of the nail?

I think all the people backing the "laser" here because they own one are missing the point. Charging extraordinarily high prices for a medical treatment with little evidenced based research behind it is what people are picking on. Hamish can you please post before and after pictures from that patient you showed earlier - if possible progression in sequence over time, I am interested to see the results (also if possible pre and post debridement as you describe it interests me as well).

As I have stated categorically - show me the evidence and I will buy the machine tomorrow no questions asked. I see more onycomycoses than you could poke a stick at, and although there are good treatment options available if this works as easily and as effectively as Hamish describes with good evidence to back it up, I would be more than happy to actually have one in my practice. What is the total cost of the laser Hamish (including training costs)? Is their a yearly license fee? I would appreciate a breakdown o the intrinsic costs involved in purchase. I am assuming you base that $13350AUD fee on your costs? How many patients have you used the laser on? Whats your clinical success rate?

Let's get down to the nitty gritty of this - if no one can provide me with research based, peer reviewed evidence then lets look at the clinical evidence. As yet I still haven't seen any of that posted either.

At some point, something has to give - and either someone presents something which shows some type of tangible evidence or we all pack up shop and go home until the double bind randomized and peer reveiwed research is released: Because lets face it without some "proof" we are all just arguing about nothing......

Shades of ECSWT here..........

 

Read all the posts please.
My repeating myself is even boring me.
I have previously explained how long I have had it for and therefore where this exists in the review process.
I do not exist to furnish this forum with a constant update of my data. Nor do I exist to do anyones bidding I.E. get them to send me one so I can......
Someone must have mistaken me for one of their employees or students.

To further avoid confusion, I graduated in 1981 and am 50 years old. I suggest if someone wants one, THEY get in touch with the appropriate people, not me.
I see no reason why it should be free as it costs me and all the other providers a substantial fee. If you want to know the costs, I think I have covered those apart from the advertising costs which are not cheap either. Go back re read the posts.

You can't buy one, Your colleague has not bought one, but you will be able to converse with him in person, he is either about a mile away from the campus you work on or @ 12 miles depending which one it is. As a fellow Podiatric Surgeon, Paul W Bours M Pod (Curtin) Podiatric Surgeon FACPS FAAPSM will no doubt be able to speak to you face to face. I would be amazed if you did not already know him.

Page 4 pictures no.1 presentation, no.2 Predebridement (Debride: To remove dead, contaminated or adherent tissue or foreign material. Origin from the French debrider, to remove the bridle; as from a horse) no.3 post debridement at 4 months.
Just for youI will include to more pictures that show presentation and post debridement prep'ed for laser.
No one posting here owns one, no one posting here has one other than me. All other providers in the UK think I am wasting my time on this forum, they largely have no wish to get involved but just wish to get on with their lives and their work.
All providers in this country are Podiatrists, all providers in the USA are Podiatric Surgeons.

 

Hamish:

I admire your conviction and courage to continue defending your practice of laser fungal toenail treatment. Since there are about 3 or 4 podiatrists within a ten mile radius of me advertising in the newspaper or on the radio here in the Sacramento area about their ability to "cure fungal toenails" with a laser, I do get a lot of inquiries from my patients about my opinions regarding the laser fungal toenail treatment.

Here is what I tell them:

"The laser is said to work by the people who use these lasers for fungal toenail treatment, but there are currently no studies published by an independent source that actually supports how well the laser actually works. It costs about $1,000 to $1,200 for treatment of all 10 nails, and there are no guarantees that the nail infection won't come back, and, in fact, many patients who have contacted me privately via e-mail over the past few months, have complained that their nail fungus was not cured by this expensive treatment. In addition, if the nail fungus does come back, then the doctor doing your treatment will again expect you to pay to retreat it, again without any guarantee, and without any help from the insurance company that you send your money to every month for medical treatment.

I can, however, treat these toenail infections for you with a much less expensive topical treatment called Penlac Nail Lacquer (ciclopirox 8% topical solution) that needs a prescription, costs about $25.00 a bottle and would probably require about a bottle every one to two months to treat your toenail infections. It is very safe, there are no significant side effects, other than rash very seldomly, and you will need to see me every 2-3 months to monitor your progress. Compared to the PinPointe laser, which has no published studies on its effectiveness, Penlac Nail Lacquer has been used for over a decade and various published studies show that it is fairly effective. My experience with treating about 100 patients, including myself, with this therapy is that it provides significant improvement in nail appearance in 75% of patients after about 10 months of treatment.

If you are very concerned about your nail fungus, then there is also an oral medicine, called Lamisil, that you can take daily for 90 days along with the Penlac, which seems to increase the likelihood of successfully treating these fungal toenails of yours. However, Lamisil, comes with a risk of liver disease, temporary changes in your taste sensation, diarrhea, rash and blood disorders, but otherwise seems to be very safe for most individuals. If you decide to take Lamisil, we will need to perform blood and liver tests throughout your course of treatment.

Personally, I would advise using the Penlac nail lacquer only because it is relatively inexpensive, it has no major side effects, and seems to work for the vast majority of people for a problem which is, in your case, a cosmetic issue. If you would rather spend over a thousand dollars to see if the laser will work as well as the doctors on the radio and in the newspaper say that it does, then that is your choice, since it is your money to spend. Maybe if there were some good scientific studies that actually showed how well it worked, then I could recommend laser fungal toenail treatment. Until that time, I recommend that you save your hard-earned money for something else that is more important and more predictable."

Please, Hamish, continue to send us before treatment and after treatment photos of your patients since this is of great interest to many of us. Until then, good for you for sticking to your guns in a treatment you seem to honestly believe in. I wish you, and your patients, the best of luck.

By the way, everyone following along, this thread, "Laser Treatment for Nail Fungus" has now become the most popular thread ever in the history of Podiatry Arena....33,000+ views.....and growing every day! I am amazed at the interest in this subject!

 

I will agree with Kevin regards to the treatment of Onychomychosis with Laser. Podiatry seems to be increasingly pre-occupied with machines that go ping and generate $$rather than results. I disagree that Penlac is as effective as Kevin ascertains. I can not vouch for Kevin's results. As far as I am aware the "clinical studies" indicate that it is effective 40% of the time in mild to moderate cases. Whoopde doo! At least Kevin isn't charging $1,200.00 to cover his TV and Radio Adds.

Podiatrists can make a good living treating folks ethically. They can make a killing treating!

Whatever you are comfortable with. I don't give a ****!

regards

Good luck to you all!

 

One more thing.

We all think each other is an asshole! But that's what debate is all about. We know we are. we agree with each other! At the end of the day we actually respect each other. ( I hope)The difference to those who think they are academically contributing to Podiatry rather than contributing to their own pitifully pompus ego is that they don't recognize that they are assholes.

But that's just one asshole talking to another.

 

One more thing.

We all think each other is an asshole! But that's what debate is all about. We know we are. we agree with each other! At the end of the day we actually respect each other. ( I hope)The difference to those who think they are academically contributing to Podiatry rather than contributing to their own pitifully pompus ego is that they don't recognize that they are assholes.

But that's just one asshole talking to another.

Lights out!

 

Graham was it really worth pointing out twice what an ass-hole I am? Jeez I get that enough at home!



Hamish thanks for putting those photos up, like Kevin I would love to see more. I would hardly worry about people advising you that you are wasting your time on these forums. To me that suggests that they would only be doing this for some type of gain - I only post here in the hope that if I need help someone might be kind enough to offer me advice. I don;t post here for financial reward or gain - you may suggest to those giving you a hard time about posting her that you do it because you love it and you believe in what you are doing!

Also I do know Paul Bours really really well - he is indeed the man I speak of in my previous posts. I thought when I last spoke to him he stated he had already purchased it and was waiting for it???? We had a long discussion (as I have here) about the evidence behind it. He seemed convinced after a recent trip to the US.

Anyhow Hamish, hope you stick around - fungus thread or not I like chatting with you. I do agree however that unless someone can show some clinical evidence (because we don't have any peer reviewed stuff yet) then there is not much else to talk about.

Kevin - its been a slow month - that's why 33,000 people are interested in fungus!!!

 

Hi all,

I like George have no financial interest in the pin point laser or the Dow clinic. I have met Hamish and I only work in Private practice in the UK.

I believe that we Brits have almost nothing in common with our Colonial cousins. My daughter is married to an American and lives there. I find it easier to operate in Spain, and I speak very little Spanish than the US where even buying bread is difficult. The UK health system is completely different to anywhere else and the route by which patients approach a PP Pod is almost never via NHS referral. Our education system is also far different from the US, our BSc is a valued qualification, the US is more akin to our A levels. It is only at PhD level they equate and even then the route is very different. Even out professional titles differ.

The point I am trying to make is we are different, and many of the non UK posts on this thread reflect that difference. It seems people are ascribing their national attributes rather than trusting that Hamish is not using this forum as an advertising platform but trying to share his ‘experience’ with what he thought was an ‘interested audience’.

So to specifics.

Paul as far as I can tell the $AUD is about half the value of the British £. Hamish charges £650 therefore £1300 AUD not $13350 AUD (ten times more, no wonder you are appalled.) With respect the rest of your contributions seem just as inaccurate.

Kevin, again with respect your screed on OM is your choice. I found it incredibly biased towards your treatment of choice, certainly any Brit would see through it (difference again?).

At the end of the day what are you offering ‘a significant improvement in nail appearance’. Not a cure and you do not explain if this applies to all OM cases irrespective of the extent of the infection.

75%, it appears you outperform any published data. Finally what do you do with the 25% failures, do you refund their treatment costs?

Graham, I found your first post quite confusing, you agree with Kevin’s assessment of Laser therapy, although he has no experience of the treatment, then point out the 40% cure rate for his treatment of choice and the 40% you point out is ‘clinical trials’ not the RBCs the big boys are baying for.

Crazy.

The UK do not run TV and Radio ads and to imply Hamish is unethical is unfair.

If I could understand it I may agree with your double posted Asshole post, there is a delete option. Is it true Canadians and Americans do not get on, is it because of a humour gap?

Finally Paul.

Yes Hamish is ‘nice to chat to’. He is always prepared to be lengthy in his postings and in the main is very thorough in his ‘research’.

So taking a theme from Roberts last post can we all agree that in the main Podiatry is all smoke and mirrors, it’s theory is heavily based in practice not research, and yes it does need to move forward. However unless forward thinking Pods are allowed to extrapolate from other discipline’s research and then try it out we will stagnate.

Last point I studied 15 years ago when force plates were very new and primitive and computers had almost no memory. Now they abound, but I do not see the RBCs to support their use in foot orthotic design.

Correct me if I am wrong but I assume they all use an algorithm that is proprietary to the manufacturer. I had a spinal bend following an algorithm. I became sceptical.

Hamish’s work is still early days, we really need to be looking at cure rates as defined by no reoccurrence after what 1, 2 years? He and his clients are taking the commercial risk. I’m sure if it fails Hamish is big enough to come and tell us the truth.

Bob

 

Maybe I didn't make myself clear when I stated that I tell my patients "My experience with treating about 100 patients, including myself, with this therapy is that it provides significant improvement in nail appearance in 75% of patients after about 10 months of treatment."

I don't even suggest topical Penlac solution treatment for those patients with the worst mycotic infections and my 75% does not indicate a cure, it only represents a significant improvement in nail appearance in the approximately 100 patients I have treated with Penlac Nail Lacquer (daily application). Maybe when PinPointe Laser finally publishes a study in a peer-reviewed journal on what their "cure rate" is, then we can finally see how it compares to the ciclopirox nail lacquer treatment which has now, for about a decade, had literature published in peer-reviewed journals on its "cure rate".

 

Kevin,

You are trying to confuse me with clever words.

The product you refer to is not available in the UK.

Please remember we are different.

The only American I have discussed OM with, a relative by marriage who lives in Virginia, was well disillusioned with her Foot doctor and his OM treatment, and fees.

I also examined my daughters mother in laws 'plantar fasciitis' on a visit , resolved when we treated it as 'policeman's heel'.

Funny old world is it not?

Bob

 

Bob:

Not trying to confuse...honest.:drinks

Speaking of being confused.....what does OM mean?

In addition, why is ciclopirox not available in the UK? It is very popular here and seems quite safe. Is it available in other countries???

 

Onychomycosis.

I'll be in the UK in April. Will check and see if there is anything comparable available. When I left many moons ago there was a topical terbinafine solution which showed some potential.

 

Online information:

Unsure if this sheds much light although does appear Ciclopirox is not available in the United Kingdom.

Regards,

Mandy.

 

Apologies an obvious typo - was meant to be $1335 (I used an online conversion tool to do it and cut and past leaving the zero in).

Please point out my other inaccuracies and I would be happy to talk you through them. It would appear that your post is simply inflammatory in nature and not getting to the real point of the issue "peer reviewed evidenced based medicine". I personally don't agree with your assumption that Podiatry is mainly "smoke and mirrors" and not evidenced based. I am sure most people on these boards would disagree strongly. Is there more research to be done? Absolutely.

REG does it strike you as odd that the least researched practices seem the most expensive?

Anyways REG lets let by-gones be by-gones, as I have stated previously nothing will come out of this thread until the peer reviewed, independent, double blind, randomized evidence is presented.

 

You missed a P in you last sentance, which is the same word as cheese in Swedish .

Just trying to lighten the mood a little !!

Edit and you just fixed up you post got to be quick around here !!

 

Michael:

....and you missed the second "e" in "sentence"......:drinks