05/06/2019    Keith Gurnick, DPM

Laser Treatment Reported Ineffective for Onychomycosis Related to Diabetes (Allen Jacobs, DPM)

I have rarely seen any patients who have come to
me after having a laser toenail treatment or
multiple repeat laser toenail treatments
for "fungal appearing" toenails, tell me they are
satisfied with the results. These patients had
laser treatments done by either a podiatrist or a
dermatologist, or at a cosmetic or aesthetic
clinic setting. They tell the same story, they
either refused or were not offered oral or topical
conventional medications, and the laser
treatment(s) were presented as a "cure" or
solution to the problem, that if it works their
toenails will come back to looking normal.

One day, maybe someone will present to my office
with the same "after" results that are often
pictured on podiatry websites, but I just have not
seen that patient yet. He or she may be out there
somewhere, if you are, come see me.

I feel, that those who promote and use lasers to
treat "confirmed" onychomycotic toenails should be
honest in their approach to dealing with the
patient. It should be discussed that it is only a
treatment, and not a cure. Also, those doctors who
have been quoting a 88% cure rate, should stop
misrepresentation the results of initial studies,
funded by the company that made the lasers, and
done by podiatrists with a vested interested in
the product and modality.

The study involved only a very small groups of
patients (13 to be exact) that included only
short term results and visual improvements without
any long=term clinical or mycologic
follow-up testing results showing anything even
close to a 88% cure rates.

Those of us who have been treating onychomycosis
over long periods of time are well aware that for
many patients, we can effectively treat nail
fungus, and we can control fungus, and we can
improve toenail cosmetic appearance and shape and
structure, but we are are rarely achieving
permanent cures for toenail fungus.

Patients should be told that the laser is one of
many treatment options, but that often combination
therapy is indicated and necessary for this very
tenacious condition. I suspect that many of these
patients eventually fail to return to the "laser
doctor" and thus the doctor is not really aware of
the long-term results nor the lack of efficacy of
their laser treatments.

In my practice, I do not use any lasers for
onychomycosis, and I have found that oral
terbinifine works best, but I have also had
excellent results with topical Jublia
for non-lunular involvement, some patients needing
to continue using it longer than the drug company
specified instructions and indications. Also, I
often prescribe Jublia as an after treatment
modality for most patients after they complete
their 12 week regimen of orals, for prevention or
relapse. No one treatment works for everyone
and each patient should be evaluated as an
individual.

Disclosure: I have no financial relationship with
the Jublia or terbinifine manufacturers.

Keith Gurnick, DPM, Los Angeles, CA

Other messages in this thread:

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05/03/2019    Adam Landsman, DPM, PhD

Laser Treatment Reported Ineffective for Onychomycosis Related to Diabetes (Allen Jacobs, DPM)

As soon as I saw Dr. Levy's post, I knew it was
just a matter of time until somebody came forward
to declare that based on this one study, lasers
don't work for treatment of onychomycosis. It
only took one day. As doctors, we should look at
some facts (not sound bites) before deciding what
is best for our patients.

FDA: correct that FDA cleared lasers for cosmetic
improvement of nails, however this was not due to
the fact that laser can't kill fungus, but rather
because, they also deemed that onychomycosis is
incurable.

Nijenhauis Study: 64 enrollees separated into 2
groups, so 32 subjects per group--this is clearly
an underpowered study. In addition, they found
improvement in 41.9% of their sham treatment
group. How did that happen? Other issues
include the grinding of nails throughout the
study, treatment of nails with extensive
infection, and exclusion of patients with darker
pigmentation (lasers work by interaction with
tissues of a specific color). Although not
statistically significant, they did find that 7
patients improved significantly in the treatment
group, compared to 3 in the sham group.

No one disagrees that laser treatment for
onychomycosis can be inconsistent for a variety
of reasons, including level of detachment from
the nail bed, extent and duration of infection,
circulation to the toes, pigmentation of both the
nail and the skin, and of course, physician
technique. This is just one of many studies, and
many points of view.

I agree that special care must be taken with
populations at risk, such as our diabetics with
peripheral neuropathy. However, the implication
that our profession has been sold a bill of goods
by corporate marketers is quite a leap from
discussing the science at hand. Keep in mind
that most CME presentations cite data that was
previously published in peer-reviewed journals.
My patients who have failed topical therapy (i.e.
7% cure rate with ciclopirox), refuse terbinafine
(55% cure rate), and are intolerant of
debridement still enjoy relief from laser
therapy. Laser therapy is not embraced by
everyone, but is still a good option for some.

Adam Landsman, DPM, PhD, Cambridge, MA

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05/03/2019    David Zuckerman, DPM

Laser Treatment Reported Ineffective for Onychomycosis Related to Diabetes (Allen Jacobs, DPM)

I appreciate Dr. Jacobs pointing out that lasers
shouldn’t be used for the treatment of mycotic
toenails where there is PVD and lack of sensation.
I have taught hundreds of doctors over the past 15
years and always pointed out that a detailed
physical and history need to do done, as last time
I looked we are well trained podiatric physicians.

There is a role for lasers in the treatment of
mycotic toenails. Lasers work by the mechanism of
photo-biostimulation with heat playing little to
no role in the mechanism of action.

Cure for mycotic toenail? There is little to no
long term cure with lasers, topicals, or oral
antifungal as well as micro drilling. First do no
harm is a good guild line to use when deciding on
your single or multiple treatments and
approaches, whether we ae treating diabetic or the
young girl in her 20s looking for a better-looking
toenail

The use of therapy lasers, as well as treatment of
diabetic ulceration, is some something Dr. Jacobs
should look further into.? OCPM did a research
project showing the effectiveness of therapy
lasers in the treatment of diabetic, venous as
well as arterial ulcerations.
,
I agree 100% with the opinion that our seminar
needs to be free of commercialism as much as
possible. I am amazed at the treatments for
diabetic ulcerations that have little evidence
especially level one and with an outrageous cost
associated with treatment. I am happy to provide
evidence that therapy lasers can be effective as
well as cost effective. Our schools needs to step
up to the plate and do more research on treatments
that works and aren’t so expensive. Happy to
provide the OCPM research paper done years ago
about lasers and ulceration treatment. Please see
the attached study

As a podiatrist, we need to do more evidence-based
research as well as cost-effective treatments We
need to treat mycotic toenail infections to help
reduce the pressure and potential ulceration which
has and can lead to loss of limb.

Disclosure. I own ZFT and the Remy Laser

David Zuckerman, DPM, Cherry Hill, NJ