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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
Other messages in this thread:
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
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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