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Laser treatment of fungal nails-question

Discussion in 'General Issues and Discussion Forum' started by Kym, Oct 25, 2012.

  1. Kym

    Kym Active Member

    Members do not see these Ads. Sign Up.
    :D Hi,

    I am wondering if anyone has up to date info or experience with laser treatment for fungal nails here in Australia. I would be interested to learn about the costs involved to patients and the length of treatment and how good (or not so good) the outcomes are. Where these machines are available etc. Any info appreciated!

    Kym :pigs:
  2. Paul Bowles

    Paul Bowles Well-Known Member

    Hi Kym, we are currently running two studies on them in our clinic. We are about 1/2 way through data collection on study one. About to start study two in the next 4 weeks. We are currently using the Fox Arc branded laser. It is distributed in Australia by MD solutions. If you PM me I can get you their details if you require. I have personally used Cutera and PinPointe in the past as well. Am happy to discuss via PM further as needed. Our studies are independant and not funded by any laser company.
  3. Admin2

    Admin2 Administrator Staff Member

  4. fishpod

    fishpod Well-Known Member

    costs high results low prescribe lamisil tablets doh
  5. David Widdowson

    David Widdowson Active Member

    Did see an advert in Sunday Mag with a fab offer of £150 off first treatment. Wow, must be bargin of the month!
  6. Paul Bowles

    Paul Bowles Well-Known Member

    I don't believe this is an entirely accurate statement nor it is particularly evidence based. The cost of treatment via laser really doesn't have to be excessively expensive and on examination of costs involved in the correct prescription and follow through with oral terbinafine I would argue (in Australia anyhow) the costs is comparable or less for laser application/management. As for results - I think the evidence is lacking somewhat in terms of the amount of literature out there. We are working to try and fill that void somewhat with two really good studies investigating results further.

    As I have said in some posts before, from the data I have seen thus far in our studies I have seen some really good results in patients with less severe infections (partial nails) who by the way appear to be very satisfied according to their clinical responses. In severe infections from our cohort (full nail) I think the jury may still be out, but then again we have only reviewed them within a 6 month time frame so far - so I would imagine on my previous clinical experience with nail growth a minimum of 12 months would be normal for full nail turnover. So we shall have further information at that point early next year I would think.

    I believe our second study is amazingly well designed and although it will be a small sample size we believe it should show a very statistically significant difference (if there is in fact is one to be shown) pre and post treatment regimes using laser for onycomycoses in toenails.

    I don't really understand the people who continually troll these forums giving their obviously misinformed opinions about something they have probably never used. The statement above by fishpod could be broadly generalized to many medical interventions on the planet - including expensive customized foot orthoses. But I bet it doesn't stop you prescribing them for a living does it? Funny that!

    Some patients cannot be prescribed oral terbinafine - where does that leave them? Stuck in the realm of topically applied agents which I would suggest looking at the evidence don't really work that well either for a miriad of reasons?

    Lets get serious people - want to help the community make educated and evidenced based decisions about treatment regimes? Less comment more research!

  7. fishpod

    fishpod Well-Known Member

    dear paul . i am not ill informed and not atroll oral terbinafine is the medical 1st line treatment for fungal nails . the pt presents we take a sample the lab analyses we prescribe oral terbinafine this costs the NHS 4.50 for a months supply x this by say 6months cost 30 quid if the pt pays for script 3 months for under 8 quid. so please tell me how the cost of oral terbinafine is similiar to the cost of laser treatment DOH. next oh we want to help patients maybee. perhaps people who buy lasers costing 20 to 40 grand need to get their money back plus fill thier wallets call me a cynic i know. next if the treatment is so bloody good why dont the NHS use them because heaven knows they have enough patients i see 1000 a year alone with fungal infections 'why do private medical insurance companies not cover the cost of this treatment do they know something you dont maybee. lamisil is off patent worldwide so i suspect its now cheap even in australia.

    if lamisil does not work i can refer my patients privately but then have to tell them its 567 hundred quid a pop guess what that cuts the number of interested parties down to about 6 . this treatment modality is about making money lets not beat around the bush any private practitioner who can afford 40 grand for a.laser will have to be first a salesman second a podiatrist. just aview from a troll.

    there is more research and more evidence on the use of terbinafine than there will ever be on lasers as the pharmaceutical industry is a multibillion dollar i industry the medical laser industry is not. when dermatologists use them in hospitals and their efficacy is proved i will cease to be a ludite and buy one
  8. fishpod

    fishpod Well-Known Member

    just athought have you bought your laser or have the company loaned it to u for free or a subsidised lease . pray tell
  9. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi Paul, thanks for your input. Hope you and yours are well. apologies for not reading all posts. Surely you will have to review in 12 -> 18 -> 24 months to get true results. As an infectious "disease" and further spores are likely to inhabit the local environment? There can be no guarantees for the long term????? Can there? If the nail is a secondary infection and the dermis is not treated...... is the nail not likely to be reinfected???

    Thanks all.

    Warm regards

  10. Paul Bowles

    Paul Bowles Well-Known Member

    Of course - we will continue to review but we obviously have to report the results of the study within a specific time frame. 12 months was the first hurdle we decided to jump. Of course we have been reviewing within that time frame as well. Will we continue to follow with interest after? Of course....but you know as well as I do - if patients get better, or don't improve - you may loose them to follow up longitudinally.

    Of course. After a course of antibiotics for a throat infection does that mean you won't get another? Same principal. By that definition oral terbinifine is in the same boat. Whats to say after taking a course of that you wont re-infect either? There is no guarantees. There is always a chance of re-infection.

    So lets look at the proper course of action which should be taken for the prescription for oral terbinafine. Nail samples and pathology + prescription + LFT prior to drug starting and LFT at 6 weeks...lots of hurdles to jump just to get on a drug which is even on PBS is still expensive. There is a chance of minor or major side effects (as with any medication) including liver function issues. It has a good success rate - but chance of re-infection is of course possible. If a patient re-infects you do it all over again and expose again to liver function issues? How many times could you do this in a persons life-time? Its a reasonable question which I don't think anyone has asked.

    Apply the same principals again to topical 1064nm laser - we have to ask all the same questions.

    Looking at advice on prevention and other aspects is highly important - did we ever believe or say it wasn't? We aren't of course looking at that at this point in time - we are basically looking at the simple hypothesis does 1064nm laser topically improve onycomycoses?
  11. Paul Bowles

    Paul Bowles Well-Known Member

    Well I don't know - with the limited jump in and jump out comments like you published above one can only assume. The data currently on 1064nm laser is in its infancy, so unless you are currently actively involved in research with it I also assume your knowledge is limited to what is currently out there OR your own personal experience. If your information was based on current published research I don't think you can conclusively say what you did above based on that evidence. If you have used the laser personally I also don't see how you could make the statement you did above. See my dilemma?

    Just because YOU have been using terbinafine for years and YOU have had great success and YOU think other methods have low success rates and are expensive doesn't mean YOU are right. I'll let the evidence guide me - not personal opinion.

    In Australia the cost of terbinafine OFF the parmaceutical benefits scheme is around $149 AUD. With pathology the government subsidize it to around $99 ON PBS. In Australia we do not have the luxury of having general Podiatry in the public health system, even so the costs you refer to above blatantly neglect the clinical cost to the NHS.

    If you follow safe clinical protocols in clinical practice a patient would have (making assumptions on the conservative side below):

    a) Initial consultation - nail clippings taken for microscopy Approx: $90AUD
    b) Pathology request - Approx: $70+AUD(Hopefully medicare funded still doesn't stop the fact that someone has to pay for it)

    ** Assuming a positive result is obtained considering the nature of a high false positive chance with this type of lab test a re-test may be required adding more cost **

    c) Further appointment with Podiatrist to discuss results and referral to GP - Approx $50+AUD
    d) GP visit discuss results, referal/approval for oral terbinafine and LFT referal - Approx $35 AUD(Hopefully medicare funded still doesn't stop the fact that someone has to pay for it)
    e) LFT prior - $60+ (Hopefully medicare funded still doesn't stop the fact that someone has to pay for it)
    f) Two courses over 3 months for of drug: $99
    g) Second LFT at 6 weeks - - $60+ (Hopefully medicare funded still doesn't stop the fact that someone has to pay for it)

    Total: $464 assuming these basic assumptions and low predictions are correct (they may in fact be higher)

    There are clinics in Sydney performing laser for $200+AUD? Sure there may be some charging much more but thats just like any service. I just don't get your argument?

    That is generally the desired outcome yes - so how does denying them an option for treatment help them? Do you give them the option? How have you clinically contributed to the community regarding further research on the effects of 1064nm laser for nail fungus to prove its worth or worthlessness?

    No they would simply look at your statements as aggressive and ill informed. You call them names, why wont they call you names? You shout your proof from the rooftops which as I have pointed out above makes no sense, yet you expect them to conform to it? I'm not sure - are the people who own 1064nm lasers all driving sports cars because of it? I doubt it. Do you place apply the same cynical view you have of 1064nm laser to expensive customized foot orthoses? Or extra corporeal shock wave therapy? Or autologous blood injections? Or vac wound dressings? Or versa jet ulcer debridement? Or corticosteroid for plantar fasciosis? Or recurrent continued expensive palliative toenail cutting for non high risk elderly patients? I could go on....

    Im not sure - you are the one who works in the NHS why don't you know or ask the question? You should know - or you should be asking the question. Maybe the real truth here is you are failing in your due diligence to step out of the safety zone of your office and ask the hard questions anywhere but an anonymous forum on the internet?

    I am pretty sure the NHS doesn't have some super secret access to a cohort of research we don't.

    Maybe its the exact same reason the NHS spends millions of pounds a year on homeopathic medicine - have you raised this with them as well? Then again they may have access to some super secret top quality research that says spending millions a year on homeopathic medicine actually does something!

    Nope - oral terbinafine in Australia isn't all that cheap.

    As stated above there are clinics in Sydney charging less than the cost of oral terbinafine - brings your argument to a grinding holt. Your gripe seems to be about how people make money off Podiatry? Why are you picking on 1064nm laser? Surely the bulk of your anger should be directed at other way more expensive and less researched things Podiatrists do to make money? Then again maybe you should leave the NHS and go into private practice!!!!!

    I think we have successfully proven that in this post. :) But remember argueing on the internet (especially when you are hiding behind anonymity) is like THIS (<----------CLICK THE LINK)

    You just don't get it do you? Until there is enough evidence to show this I don't think any of us can make an informed decision - so how about you become part of the solution in investigating better options for your patients instead of sitting on the wall throwing rocks at people who do!

    I'm sure your unit could get a "loan" laser from one of the medical laser companies for research purposes. I am sure you could scrounge up a few of your 1000 patients and a quick literature review to design a study. I am sure you could also submit your study to your hospital/university ethics Board for approval and I am very sure you could collect data and publish your results.

    I am not sure if you could bothered to get off your ass and do something constructive though! Prove me wrong.....

    My PM is always open and I am happy to further discuss on the phone/skype if you want to assist in any way I can to facilitate any interests you may have in furthering the knowledge base on 1064nm laser (or anything for that fact) - whether the outcomes of that research be good or bad! It all adds to the pool.
  12. Paul Bowles

    Paul Bowles Well-Known Member

    The laser I am using was purchased by the clinic I work for. We have only 1 unit.

    I have had over the past 3 years multiple offers from laser companies to trial their units - so I am sure you wont find it hard to "borrow" one if you need.

    I am using a Fox Arc laser base model valued at $30,000 AUD. Which is actually quite cheap compared to the others. Its a small unit, desktop, emits very little ambient heat off the unit and takes up almost no space in my office. The clinic purchased it for several reasons but the final decision by the practice manager came down to a viable business plan which paid the laser off and offered cheap treatments to patients who wanted it as a treatment choice. Primarily the clinic has used it on a large population of patients who are unsuitable for oral terbinafine and who have been using topicals such as Loceryl 5% with no success for many years. Before you ask our clinic charges under $150AUD for it. All the patients in the research I am doing have not paid to be a part of it. We do collect data on all patients who have 1064nm laser including photos and patient responses.

    I just get the added benefit of using it for research and data collection. I personally have no vested interest in the laser as the funds didn't come out of my pocket directly. If our research turns out some positive results I am sure the clinic will be happy to purchase more units and place them in all the clinical rooms. If our research yields poor results then so be it.

    At this stage we haven't analyzed the data/pictures/results but I have been lucky enough to see the pictures collecting on a folder in my desktop. One cant help but have a quiet look on a friday afternoon. Without in depth analysis and only a quick glance I can say the pictures from many patients from week one, week 12 weeks and week 24 reviews appear very different. The control nails look the same (surprise surprise!!!)

    A second study we have designed which will hopefully be approved by ethics soon is interesting and although I can't discuss it yet it should give a clear picture of how the 1064nm laser has its effect and over what time frame it does so.

    We are also using it in other research at the moment including skin lesions such as verrucae and a study is currently being looked at and ethics prepared for possible uses in partial nail avulsion.

    Want to jump onboard? I could use someone in the UK collecting data for me on the 1000 strong patient load you say you have!!!!
  13. Kym

    Kym Active Member

    As the original posser of the question that started all this debating....I wish to THANK YOU all for the information on both sides of the argument that occurred and I will now take this all on board!! I believe research is really important and time will tell...

    Many Thanks again!
  14. fishpod

    fishpod Well-Known Member

    thanks for the interesting info paul look forward to your results being positive u may have a convert in the uk. the differences betweem uk and aus very interesting. ps i am a private practitioner doing nhs work so in a slightly different position to most pods in uk as have access to diagnostic tests nhs records etc. i see 5000 contacts per year about 1/5 have fungal nails. my lungs should be full of all that horrible stuff after 30 years . hope it does not kill me .
    anybody out there wanting to loan us a laser we will happily treat our pts for freeand collect data
  15. Warts

    Warts Member

    Hi Paul
    I was just wondering, I referred a patient to you for laser therapy for his toenails- the cost was $1500. He was seen again in 6 months time-charged $750. The results for him were lacking and he did not continue treatment, but looked at other alternatives. What laser were you using when you charged this amount?.

    I will await the conclusion on your study that will hopefully answer my question that the present cheaper laser you are using (obviously my patient did not get the results he was wanting) is proven effective and will get positive results.
  16. fishpod

    fishpod Well-Known Member

    interesting information warts perhaps a zero was left off the the bill 150 dollars to 1500 dollars. 2250 dollars for 2 treatments chicken feed i would like to help my patients at those prices.
  17. Paul Bowles

    Paul Bowles Well-Known Member

    I can assure you that I have never seen a patient of yours and charged them over $2000 for laser. As I dont know your real name I cant confirm I even know you or if you have ever referred any patients to me. I can assure you though since the day we started we have never charged a patient over $149 for laser. We have only had our laser for just under 6 months.

    Maybe you could retract your statements/insinuation and apologise, as quite obviously your statemments are defamatory to me personally and I don't think our practice manager will take too kindly to your anonymous defamation of a fellow Podiatrist - as I am sure that wasnt your intention.
  18. Paul Bowles

    Paul Bowles Well-Known Member

    Be careful what you believe on the interwebs - as stated above the poster has never refered a patient to my office for treatments which they describe. Just goes to show how anonymity can allow anyone to have a pot shot at anyone else on these forums - as I think I have stated before, if you aren't part of the solution, you must be part of the problem! Publicly defaming or belittling people on the internet serves no purpose to further the cause here.

    I'll await "WARTS" public apology and whilst I do, I am going to read their whopping 4 posts (one of which was defaming me) which have obviously contributed so much to this community.
  19. Warts

    Warts Member

    Sorry Paul, I did get you mixed up, I apologise most felt heartedly
  20. Paul Bowles

    Paul Bowles Well-Known Member

    Yes - I am sure you do......whoever you are!

    The good news is you have doubled your postings on Podiatry arena just in this one thread, simply by posting dribble! Well done - felt heartedly!
  21. Yeah, Paul, I'm getting to the point now of believing that all these people who hide behind pseudonyms should be barred from posting here on Podiatry Arena, unless they are willing to give us their real names. This type of defamation would never happen here on Podiatry Arena if we knew who was making these comments!

    What a bunch of cowards!:mad::bang::butcher:
  22. Paul Bowles

    Paul Bowles Well-Known Member

    You know my thoughts Kevin - we are on the same path!
  23. Warts

    Warts Member

    I do sincerely apologised to you, I did not mean my comments to offend.

    I am interested in to see if a cheaper laser can achieve favourable outcome for fungal nails. How much does the laser you are using cost?
    What you charge for a treatment is so cheap?

    I was wondering why there is such a big difference in cost of treatment/ hence what laser was being used ($30 000)
  24. Paul Bowles

    Paul Bowles Well-Known Member

    I'm pretty sure ive outlined all of the specifics above - if you require more info please feel to PM me at anytime.

    They are all 1064nm lasers. The cost of the laser has nothing to do with treatment outcomes. Nor should the brand necessarily. My treatments costs are up to our practice manager - I can ask her to call you if you would like an in depth explanation or business plan? Feel free to PM me your name and number. Personally I see no need in charging extortive amounts of money for simple treatments. There is no point having expensive patient management options if 90% of the population has the issue and only 5% of the population can afford it? Wouldn't you agree? I could also ask why you charge what you do for orthoses as well and make a massive huff and puff about that - but I shall spare you the time since its Friday afternoon! ;)
  25. Paul:

    I wouldn't answer "Warts", especially after she/he accused you of overcharging patients in the previous post, until they gave you their real name. It's time we just quit responding to these supposed medical professionals who want to be anonymous and say anything they want to us on this forum with no responsibility for their actions.
  26. Paul Bowles

    Paul Bowles Well-Known Member

    I don't disagree with your sentiments Kevin - but I do respect (not agree) with peoples choices to remain anonymous on these forums. This thread and WARTS comments merely highlight the potential damage someone could do here by posting anonymously.

    If you are serious about a discussion and your opinion you should be serious enough to put your name to it! All other comments are potentially just "trolling".

    Now lets move on and let past mistakes be exactly that!:drinks
  27. What if someone called you on the phone, refused to tell you their real name and then started asking you questions? Would you respect that person and take the time to answer their questions even though they wanted to remain anonymous? I wouldn't.

    My time is too valuable to waste giving advice to people who don't have the courtesy to provide me with their real names here on Podiatry Arena, over the telephone or in person.

    If anonymous posters want to remain anonymous, then that is their right. However, anonymous posters will never get the respect from me or the amount of time from me when compared to those who are courteous enough to provide us with their real names. That is just the facts of life in an academic forum that demands expert opinion from other very busy medical professionals that are basically, giving away their expert opinions for free on a public forum.

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