Treatment of onychomycosis using a 1064-nm diode laser with or without topical antifungal therapy: a single-center, retrospective analysis in 56 patients

Abstract

BackgroundCurrently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects. Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. Against this background, we performed a systematic retrospective analysis of our clinical experience of 4 years of onychomycosis treatment applying a long-pulsed 1.064-nm diode laser.MethodsWe retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1.064-nm diode laser (FOX, A.C.R. Laser GmbH, Nuremberg) during the time period of July 2013–December 2016 with or without concomitant topical antifungals. Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3.9 laser treatments at 2–6-week intervals. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy.ResultsClinical improvement was achieved in 56% of patients treated with laser only after a mean of 4.5 treatments and in 69% of patients treated with laser in combination with topical antifungals after a mean of 3.6 treatments. Cultural healing was detected in 63% of patients treated with laser only after a mean of 5.4 treatments, vs. 86% of patients treated with laser and concomitant topical antifungals after a mean of 4.8 treatments. Microscopic healing (complete healing) with the absence of fungal pathogens was achieved in 11% of patients after a mean of 4.7 treatments with laser only, vs. 21% of patients treated with laser and concomitant topical antifungals after a mean of 4 treatments. No relevant adverse effects were observed.ConclusionsThe 1.064-nm diode laser is an effective and safe option for the treatment of onychomycosis. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach. Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments.

Combined laser and ozone therapy for onychomycosis in an in vitro and ex vivo model

“…One of the advantages of laser therapies is their ability to concentrate the energy beam on the affected tissue, thus reducing possible side effects, such as those that exist with oral treatments. All lasers currently approved by the FDA for the treatment of onychomycosis are based on neodymium-itrium-aluminum (Nd:YAG 1064 nm), CO 2 , and femtosecond infrared titanium-sapphire [ 26 , 27 ]. These photodynamic therapies are based on the specific absorption of the laser energy by fungal chromophores which are not present in the human tissues, therefore causing a photothermic and photochemical effect, destroying the fungal hyphae, depending in main parameters such as wavelength, pulse duration, frequency, irradiation area, and the number and timing of the treatments.…”

S2k guideline: Laser therapy of the skin

“…Laser monotherapy is inappropriate for onychomycosis, but a combination of laser and topical medications is more effective than monotherapy with topical medications [31].…”

S2k‐Leitlinie: Lasertherapie der Haut

“…Laser als Monotherapie sind zur Therapie der Onychomykosen nicht geeignet, aber in Kombination mit Topika wirksamer als im Vergleich zur Topika‐Monotherapie [31].…”