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Laser treatment for nail fungus

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

  1. Lilypad

    Lilypad Member

    Hello, thanks for the information posted here. An interesting topic and good to see some open debate.
     
  2. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Laser and light therapy for onychomycosis: a systematic review.
    Ledon JA, Savas J, Franca K, Chacon A, Nouri K.
    Lasers Med Sci. 2012 Nov 20. [Epub ahead of print]
     
  3. zsuzsanna

    zsuzsanna Active Member

    I have had a patient who paid something like £200 for a course of laser treatments. It did not work, they even gave her extra treatments, still no improvement. She had given up complaining to the "doctor" who assured her that it would work.
     
  4. Paul Bowles

    Paul Bowles Well-Known Member

    I've had patients who tell me they have also had oral terbinafine and was assured "it would work". I have had patients tell me they have had orthotics and were assured "it would work" and they didnt. I have had patients who had antibiotics for a sore throat and they also didnt work.

    Heck my mechanic told me replacing my exhaust manifold would stop my car making the dreadful noise it does - that also didnt work.....

    Whats your point?

    We all simply do the best we can for our patients. Sometimes things dont always work. Nothing medical has a 100% certainty attached to it.
     
  5. zsuzsanna

    zsuzsanna Active Member

     
  6. Paul Bowles

    Paul Bowles Well-Known Member

     
  7. Mart

    Mart Well-Known Member

     
  8. Paul Bowles

    Paul Bowles Well-Known Member

     
  9. Mart

    Mart Well-Known Member

     
  10. Paul Bowles

    Paul Bowles Well-Known Member

     
  11. Sam4drite231

    Sam4drite231 Welcome New Poster

    There is a need for further research on the efficacy of laser treatment for toenail fungus. A couple of these treatments, as far as I know, has been cleared by the FDA to be used specifically for toenail fungus and the rest are for "off-label" use.
     
  12. Mart

    Mart Well-Known Member

    FDA seems more concerned with evidence of safety than efficacy for this; within the marketing of "laser tx" for onychomycosis the FDA approval is sometimes used to imply efficacy - this seems either disingenuous or ignorant.

    thats my rant for the day :morning:

    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
     
  13. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    That is my gripe from earlier in this thread. All the FDA have done is clear it as being safe. Those touting this approach have used this FDA clearance on safety in their marketing to imply that the FDA said that it is efficacious, when that is NOT what the FDA ruled.
     
  14. Paul Bowles

    Paul Bowles Well-Known Member

    Ok - so I have an interesting excercise - as people know we have been collecting data on the 1064nm laser for almost 6 months now. We have patients who have had no intervention, oral terbinafine and laser 1064nm. I will randomly grab one case, and select an initial photo and then a photo from a 3 month follow up. I will get the initial case notes and post them but wont look at which intervention group they were allocated too. Lets have some discussion based on any changes and people can give us their clinical thoughts on the possible changes or lack there of and why that may be (positive or negative) and how they would have managed this case. It think it will be an interesting excercise - anyone want to play? Should be fun none the less!!!

    Then we can reveal what treatment group they were allocated to and what gthe treatment was (time, dose, null).
     
  15. Mart

    Mart Well-Known Member


    Sounds like fun to me :santa:

    Cheers

    Martin
     
  16. blinda

    blinda MVP

    Me, me! Can I play, even if I`m a girl?
     
  17. Paul Bowles

    Paul Bowles Well-Known Member

    Pt AX2013-B

    History: right hallux longitudinal discoloration present for 7+ years. Stated that they thinks it is getting worse slowly. No infection on any other digits however wife also has the same problem and she wants to seek treatment as well.

    Medical History: Overweight male 56 years old. Generally well, no reported medical history of note.

    Medications: Currently none. Has previously tried topical tea tree oil with no success as well as topical Loceryl 5% for 12+ months applied twice weekly with no real success. History of nail sample for pathology from general practitioner shows positive onycomycoses.

    Treatment: Patient AX2013-B - nail cut and shortened on initial visit, podospray drill with tungston tip burr used to lower nail height. Pt AX2013-B allocated to treatment group (could have been no treatment, oral terbinafine group or 1064nm laser group).

    [​IMG]

    Picture A: Pre allocation to group

    The patient was reviewed at 12 weeks and the nail was again shortened and ground down using a tungston burr

    [​IMG]

    Picture B: Post 3 months

    So - lets see:

    Regardless of the treatment - do you think at 3 months the appearance is conducive to a good result for the patient?

    What treatment do you believe this patient might have had?

    Personally I do not know what treatment group they were allocated to - I can check though by matching the patient code to our database and then calling the patients electronic file.

    Lets have a civil discussion and try and get somewhere with this....
     
  18. Paul Bowles

    Paul Bowles Well-Known Member

    Blinda you are the resident and foremost expert on fungus here at the Arena - I would be upset if you didn't play and the community would also be at a loss!!!
     
  19. blinda

    blinda MVP

    I`m no expert, really I`m not. Just nerdy about skin :eek:

    OK, definately improved clinical outcome, as overall fungal load is reduced and the active part no longer appears to be in the matrix.

    Impossible to say which tx they had, so I`ll made a wild stab in the dark.....laser?

    Good game, good game. :drinks
     
  20. Mart

    Mart Well-Known Member

    Agreed good result so far but my money on oral terbinifine. If this is laser result that would be particularly impressive (and I will eat my santa suit) because, as Blinda mentioned, infection did appear to extend into proximal nail fold which would imply same of laser effect.

    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
     
    Last edited: Dec 19, 2012
  21. Paul Bowles

    Paul Bowles Well-Known Member

    Any more takers before I go to work and look this patient up in the database? Cmon people - all you people who have had quite alot to say about oral terbinafine, laser, topical applications - put your money where your mouth is and have a stab at this. Amazing how people seem to vanish into thin air when you ask for an opinion....even more amazing that the only people commenting on this actually are willing to put their names and reputations to it not hiding behind some thin veil of anonymity throwing red herrings!!!

    Heres your opportunity everyone who has posted in this thread - speak up now!

    Thanks Mart and Blinda for chiming in - it is a cool game. I'll refrain from giving my opinion at the moment suffice to say it is a very positive improvement and impressive regardless of the treatment - so I think I can safely say they are NOT in the null treatment group (i.e. they did receive some form of treatment).
     
  22. Mart

    Mart Well-Known Member

    Hi Paul did you unlock the code yet?


    Cheers

    Martin
     
  23. Paul Bowles

    Paul Bowles Well-Known Member

    I haven't looked yet - we have only had two of you play the game....where are all the people claiming "this that and the other" from this thread??? Looks like they are all too scared to put their money where their mouth is and take a punt on playing the "fungus game" with us Mart!!!

    I'll give it a few more days and look up the results file next week at the clinic and let you know what the results are. Maybe we could play it again with a different patient as well! I like this game - just wish more people would play!
     
  24. Mart

    Mart Well-Known Member

    I could sweeten the incentive by playing bookmaker and offering odds.

    I checked Ladbrooks - people will bet on anything in UK - the odds are already calculated. Currency is flying pigs.

    no treatment 100:pigs:- 1:pigs:
    laser 10:pigs:- 1 :pigs:

    oral terbinifine 2:pigs: -5 :pigs:



    send your pigs

    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
     
  25. Paul Bowles

    Paul Bowles Well-Known Member

    LOL - Gold Mart.....active betting currency you have established! I love it!
     
  26. Hmmm, betting on the appearance of toenails as to how they have been treated? Mart and Paul, think you would do better trying to get us to bet on something a little more interesting such as to looking at two shirts, one dirty and one clean, and asking us which laundry detergent was used to achieve these results.....:cool:
     
  27. Mart

    Mart Well-Known Member

    Hi Kevin

    You are witnessing a cultural difference in humor rather than a serious commentary about how to approach scientific thought - Aussies and Brits share a joy in irreverence which is relatively scarce in north America. You have to realize that as children we were were severly beaten for trivial misdemeanor and it did, contrary to what was said, harms us. To be clear ........ no offense intended :drinks

    Cheers. Martin
     
  28. blinda

    blinda MVP

    None taken.

    Hmmm...Not dissin` dermatology, surely? :boxing:

    We 3 are obviously on our own in this game. C`mon then Paul, which was it?
     
  29. Just questioning the way the "game" is being promoted. Why not just provide us with the data instead of making a "game" out of it? Considering the respone so far..I don't think most of us are too keen to guess on such matters.:cool:
     
  30. blinda

    blinda MVP

    Whilst I agree that i`d rather see the data (pronounced `dayta`, not `dahta`;)), Mart hit the head with the nail (Dinglish), in that we do enjoy a little irreverance and indulging in outlandish games of skill while `dressed in bizarre costumes` ... now `n then. Guess you had to be there;

    http://www.youtube.com/watch?v=L2bTwSfWtsE

    Who remembers `Its a knockout?`
     
  31. Paul Bowles

    Paul Bowles Well-Known Member

    Hi Guys,

    Mart and Belinda thanks for participating and more importantly having a laugh about it along the way. The main reason I haven't revealed what the treatment method was in this case is simply because I have been on leave from work (returning only this week) and I thought I would give people time to come back from Christmas and participate if they wanted to.

    I decided to do it this way so people on these forums who are constantly shooting their mouths off may put their money finally where that mouth actually is. Looks like no one actually wanted to do this besides Belinda and Mart whom I give credit to.

    See too often on these forums (even with the anonymity factor) people will chime in with their opinions based on no facts, no education, no information and just shoot their mouth off straight from the hip. This case study gave them the opportunity to do so, but it looks like no one besides Belinda and Mart wanted to put "themselves" out there? Sort of proves a point doesn't it - when push comes to shove the trolls don't want to get involved!

    I'm going to look up the results for you guys now and post below - but mark my words, watch the trolls and bottom feeders (regardless of the result) come in here and trash on about whatever is posted. I'm not 100% sure which treatment group this patient was in but I am 99% sure the trolls will have an opinion on it regardless once I reveal it. Remember prior to revealing the result TWO PEOPLE put themselves and their opinions on the line. Lets see how many have an opinion on it after?

    Thanks again to Belinda and Mart for being good sports - and to Kevin, it is all in the spirit of the humour mate, apologies you didn't quite get what Mart and I were bantering on about. Must stem back to ye olde cricket days where "banter" and "jovial behaviour" was the order of the day and if we didn't have that, then well it just wasn't cricket!!!!

    Results below in 10mins!
     
  32. Paul Bowles

    Paul Bowles Well-Known Member

    The patient below was actually in the group:

    1064nm laser

    The pictures below show before treatment (Pic A) then 3 months post one treatment (Pic B).

    The treatment was:

    Consult: Photo taken. Debride nail with clippers and burr, flush with saline thoroughly and apply 1064nm laser at 10.0W for 700J

    12 week review: Debride nail with clippers and burr, flush with saline thoroughly, photo taken and apply 1064nm laser at 10.0W for 700J

    According to my notes I am scheduled to review this patient again soon so will post next set of pictures at this point.

    Also I have been scanning the results file of pictures I have - this is not an isolated case (I am sure the trolls will jump on saying it must have been pure luck!). As we go through and collate more data I can post different pics if people want me to. I think we all know what the control group (i.e. no treatment) look like as we see it on a monthly basis in our clinics (i.e. they dont change).

    Let the trolling begin....

    :dizzy:

     
  33. Mart

    Mart Well-Known Member

    Thanks Paul . . . clearly not what I expected and extremely contrary to my own experience earlier this year. Now I am seriously curious about trying to understand that whereas before inclined to perhaps being overly skeptical. I have started cutting my Santa outfit into bite sized chunks.

    when you mention 10.0W for 700

    I assume that you mean 700 pulses each of 10W? if so what was pulse duration and was it dispersed along entire nail or focused at proximal nail fold?

    Is your study rigorous enough to publish?

    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
     
  34. Paul Bowles

    Paul Bowles Well-Known Member

    Thanks Mart,

    no it was set at 10.0W and delivered a total of 700J of energy to the nail. I have the pulse duration/interval results as well in the results folder which I can get if you need them. This touches on an important issue which I assume you are alluding to - we need to set standards for these settings. Thats one thing we were conscious of when doing this on patients - all patients who did receive the laser had the same intervention, same laser, same settings.

    I don't think from personal use there is much to understand - beyond all the physiological discussion that goes on I think its simply about heat. Also note this procedure is not painless in my experience. Patients squirm and find in uncomfortable for the duration on each nail which is about 2-3 mins.

    I think alot of people who have used 1064nm laser don't generate the required heat with it or "stop" when the patient says its uncomfortable. I talk my patients through it and let them know its perfectly normal what they are experiencing. I have never seen a thermal burn or other issue with the laser and my use of it.

    Sure its rigorous enough to publish.....we will write it up and see where we get with it - I just have to find the time! The second study we are looking at doing is taking patients with confirmed OM on pathology and on DAY 1 taking a nail sample "A" then using the laser and taking a second sample "B" and getting both analyzed by the lab. We think the results of that study may be more interesting.

    I have no doubt 1064nm laser works as a treatment modality - even the skeptic in me believes it works - I think the only questions we need to look at is how can we standardize treatments for patients? Why doesn't it work in some cases? (I have my own theories on that but there is definitely a small proportion of patients we have seen that have had little or no improvement visually with 1064nm laser) and how can we better lower costs of this treatment to make it broadly available?

    Speaking of costs, if we take this patient as an example who has had 2 treatments and apply normal clinical costs to them it would have seen them $290 out of pocket. This is before private insurance or any other form of rebate they may have been able to claim. Not a bad cost vs benefit outcome for the patient.
     
  35. Mart

    Mart Well-Known Member

    That is very interesting. Although we standardised the total exposure, we intentionally varied the rate of dosing to sub pain level in ALL cases - this may explain why our findings were so profoundly different from your example (we had NO visual improvement in 80 cases which were selected for complete nail thickness involvement as opposed to superficial onychomycosis) . Did you use Cutera Genesis machine?

    I'll check my records and post our dose values later.

    Good to see you thinking about costs too.

    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
     
  36. Paul Bowles

    Paul Bowles Well-Known Member

    Sounds like you have hit the nail on the head - varying the dosing may in fact cause issues especially if the variance doesn't allow the nail to heat up to sufficient levels.

    All nails I have done the procedure on get physically hot to touch and that is with me wearing gloves!

    The "stop it hurts" issue is something Podiatrists for some reason think they MUST adhere to and is a real issue. When you are giving someone a local anaesthetic and they may say "oh that hurts!" do you stop? No its perfectly normal to experience discomfort whilst doing that. The laser I see as no different. I have no doubt some people reporting poor results didn't apply enough energy to the nail to generate sufficient heat. Application of 1064nm laser is NOT a painless procedure - then again its not exactly childbirth either ;)

    We are using the Fox Arc diode based laser - but technically I don't know if laser brand will make any difference. They should all be doing the same clinical thing at the baseline level. Its the one thing that "urks" me - no technical standards across the industry.

    Costs are important - the machine is no use generally if its cost obtrusive to people. Fungus is non discriminatory - poor people get it as well!
     
  37. blinda

    blinda MVP

    Indeed. In the UK, where the majority don`t have private medical insurance, cost is a major factor.

    I would greatly appreciate contact details of any pods offering this in the South of England. The local skin clinic (where I have referred pts with resistance/allergy to terbinafine) has ceased offering this service.
     
  38. Mart

    Mart Well-Known Member

    Paul and Blinda

    Some thoughts regarding possible limitations to achieving a predicable efficacy in dose - any comments?

    If method for calibration of laser output power is not transparent or assumed to be function of power consumed then dose may not be standardizable across platforms

    The temperature gradient through the nail is likely extremely variable and immeasurable because of difference in thickness and energy absorption of photon coefficient.

    Possibility of using pain experience threshold or measuring surface temperature as an index of dose may be problematic also because of possible variance according to several factors including uniformity of exposure.

    To a certain extent the truth of heat being mechanism is predicated on the posssiity of dermatophytes being less tolerant of heat stress than basal epidermis - I wonder if this has been studied either directly or indirectly?

    The heat dose may modulate according to pulse width and variability of nail composition - I wonder if there is significant variance to local microscopic temperature according to amount of photon absorbable pigmention. In our study there was clearly vast difference in temperature within tissues because there were areas of pluming particlularly where there was post debridment bleeding and denuded nail bed exposure and/or application of Agno3 to cauterise leaking vessels.

    It will be interesting to find out what the efficacy of your study achieves since this will point to the importance of thinking about accuracy of and confounding factors which might limit proper evaluation of dose response

    Cheers Martin
     
    Last edited: Jan 14, 2013
  39. MDeSoto

    MDeSoto Member

    Paul, thank you for posting the details. I look forward to seeing future results.
     
  40. Mart

    Mart Well-Known Member

    couple of papers attached showing the relationship between skin and dermatophyte injury to both temperature and length of exposure. Interesting that human skin can tolerate such high temps for short periods and that dermatophyte intolerance is variable according to organism - at least at very long exposure times. Haven't found anything yet in the millisec exposure range but it seems certain that short exposure to temperatures well above 43 degree C will be necessary to kill dermatophytes.

    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
     

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