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03/11/2013    David Zuckerman, DPM

Efficacy of Lasers for Onychomycosis (Adam Landsman, DPM)

It’s important to first acknowledge that any
type of laser treatment for fungus toenails is
not a miracle cure. We need to continue to
develop the research investigating laser
treatments in order to determine the exact
mechanisms of action, how we can improve
outcomes, what the biomechanical and structural
role of the foot is, and how it affects
outcomes, as well as to examine the systemic
implications of laser treatments, i.e., auto-
immune disease, diabetes, etc.

I was surprised that Dr. Landsman believes that
heat plays the primary role in destroying
fungus, especially given his research with the
laser company Normir in photo-inactivation along
with ROS mechanism. Heat very well may be one of
the mechanisms of action in the destruction of
fungus, but I have not seen any IN-VIVO studies
suggesting that heat is the only mechanism of
action. Perhaps, I misunderstood what Dr.
Landsman was implying, but it seems as though he
is suggesting that 80 degrees C, or 176 degrees
F, would be an effective temperature to use for
the laser nail treatment. At 176 degrees F,
though, you can say goodbye not only to the
toenail, but to the entire toe as well.

Additionally, I have never seen any written
evidence suggesting that wavelength determines
power. Wavelength determines penetration along
with other factors such as peak power. Without
the proper wavelength, you can have all the
power in the world but you must have penetration
along with peak power to achieve the proper
therapeutic dose.

Dr. Landsman also commented that diode lasers do
not have sufficient power. I cannot speak for
other laser companies, but we at Clearly
Beautiful Nail Solution have high-powered lasers
that go as high as 60 watts. The range is 10,
15, 30 and 60 watts. We have tested our lasers
demonstrating up to 25 centimeters of
penetration and, in some cases, more.

There have been multiple 1064, 980 lasers that
have undergone FDA clearance for fungus toenail
treatment with the submission of clinical
studies. However, FDA clearance only shows that
the company that submitted a study is similar or
predicated to another laser company that already
demonstrated a similar laser device. However,
none of the companies have submitted double-
blind, randomized, placebo-controlled and multi-
center studies to the FDA.

In conclusion, there is a lot of work to be done
in examining the effectiveness of laser
treatment of fungus toenails. I believe that
lasers make toenails look better than other
forms of treatment, which helps contribute to
the very high patient satisfaction. But laser
treatment for fungus toenails should be
considered and treated as a cosmetic procedure,
not a procedure that will consistently kill any
type of dermaphyte. While I do believe that heat
is a factor in the destruction of fungus, photo-
inactivation and bio-stimulation are equally
important mechanisms of action.

As Dr. Landsman alluded to, proper technique is
important. Many doctors get varying results,
even when using the same lasers. Nail selection
might be a factor. It’s also possible that we
are forgetting to educate patients about the
goals and limitations of laser treatments. But
in any case, it is of vital importance that we
continue to conduct more studies.

David Zuckerman, DPM,
CEO Clearly Beautiful Laser Solution
Cherry Hill, NJ,

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