Laser Therapy To Treat Nail Fungus
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Summit Medical Group now offers an FDA-approved, outstanding new laser therapy to effectively treat and cure nail fungus. Join us for a lecture to learn more about the painless solution for eliminating unsightly thickened, yellow nails that will get you ready to break out the sandals.
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Laser Therapy To Treat Nail Fungus
- 1. Marco Ucciferri,DPM, FACFAS Laser Treatment of Nail Fungus
- 2. • Fungal infection of the nail unit: nail plate, nail bed, and periungual tissue1,2 – Causes discoloration, thickening, and separation from nail bed2 – May lead to permanent damage of nail plate and attachments3 • May be associated with significant clinical issues3 • Progressive condition that warrants intervention3 Toenail Onychomycosis 1. Thomas J et al. J Clin Pharm Ther. 2010;35(5):497-519 2. Rich P et al. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S5-8 3. Pariser D. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S1 For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 3. T. rubrum Is the Most Common Cause 1. http://phil.cdc.gov/phil ID#11009; ID#14588 2. Scher RK et al. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S2-4 T. rubrum is responsible for 90% of onychomycosis2 Trichophyton rubrum1 Less common causative organisms2: • Other Trichophyton spp • Microsporum canis • Epidermophyton floccosum • Acremonium spp • Fusarium spp • Scopulariopsis spp • Scytalidium spp • Aspergillus spp • Candida spp For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 4. • ZAIAS Classification – Distal (lateral) subungual onychomycosis (DSO/DLSO) – White superficial onychomycosis (WSO) – Proximal subungual onychomycosis (PSO) – Candida onychomycosis Clinical Presentation & Classification 1. Zaias, N. Onychomycosis. Arch Dermatol. 1972; 105: 263–274 2. Hay RJ, Baran R. JAAD. 2011; 65(6): 1219–1227 1972 – Totally dystrophic onychomycosis (TDO)1981 – Endonyx onychomycosis1999 – Mixed pattern onychomycosis (MPO) – Secondary onychomycosis 2011 For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 5. Diagnosis Onychomycosis? Psoriasis! Looks like onychomycosis with distal thickening of the nail with some onycholysis, but the patient has psoriasis AND history of nail trauma which might have koebnerized the nail. Courtesy of B. Elewski, Professor of Dermatology, UAB For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 6. Diagnosis Differential diagnosis (adults):1 • Psoriasis • Nail trauma • Exogenous substances (eg. Nail polish, medications) • Lichen Planus • Neoplasms • Infection (bacterial) • Aging Clinical Diagnosis:1 • Physical examination • Concomitant tinea pedis • Family history • Age Lab confirmation:1 • KOH, culture, PAS, PCR1,2 1. Rich P et al. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S5-8 2. Westerberg DP, Voyack MJ.et al. Am Fam Physician. 2013;88(11):762-70 For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 7. Predisposing Factors • Gender (male) • Age • Smoking 1. Thomas j et al. J Clin Pharm Ther. 2010;35(5):497-519 2. Scher RK et al. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S2-S4 • Occlusive shoes • Public sports facilities/gyms • Nail salons • Poor foot hygiene • Concurrent fungal infection (eg. Tinea pedis) • Diabetes/Peripheral vascular disease • Nail trauma • Immune deficiency • Genetics • Humid and warm Demographics1,2 Lifestyle/ hygiene1,2 Medical Condition1,2 Climatic Conditions1,2 For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 8. Demographics of Those Seeking Rx Treatment* 1. NDTI data, September 2013 63% of patients are less than 55 years old1 0% 5% 10% 15% 20% 25% < 20 20-24 25-34 35-44 45-54 55-64 ≥65 MALE PATIENTS 49.1% FEMALE PATIENTS 50.9% 50% of patients female/male1 Treatment seekers* are balanced male vs. female, and across diverse age groups * Data refers to Lamisil users For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 9. • It is an infection…a fungal infection • Progressive condition1 • Permanent damage to nail plate and attachments1 • Transmission to other body parts and/or other people1,2 Toenail Onychomycosis: Importance of Treatment 1. Pariser D. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S1 2. Thomas J et al. J Clin Pharm Ther. 2010;35(5):497-519 For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 10. Toenail Onychomycosis: Goals of Treatment Eliminate causative agent1* Elewski B et al. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S9-12 Restore appearance of toenail(s)1* Pharmacological: Physiological (Nail growth): * Results may vary For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 11. Oral Rx Products • Itraconazole capsules and tablets • Terbinafine tablets Topical Rx Products • Efinaconazole topical solution • Tavaborole topical solution • Ciclopirox topical solution OTC Products Homeopathic Products Laser Treatment Toenail Onychomycosis: Current “Treatment” Options For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 12. • Application to site of infection • No known drug interactions at therapeutic concentrations • No liver monitoring needed Characteristics of Topical Antifungal Therapy For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
- 13. Laser Therapy • Q-clear • Procedure • Time to improve • Cost
- 14. Summary • T. rubrum is the most common cause, responsible for 90% of cases • A frequent and increasing problem • Both females and males, and patients of all ages seek treatment • A significant clinical burden – warrants treatment • Treatment goals: elimination of fungus & improved toenail(s) appearance • Effective topical therapy may be appropriate for treatment of toenail onychomycosis For Presentation Purposes Only. Not To Be Copied Or Left With Health Care Professionals.
Editor's Notes
- Onychomycosis is defined as a fungal infection of the nail unit, including the nail plate, nail bed, and periungual tissue This fungal infection causes discoloration, thickening, and separation from the nail bed Untreated, onychomycosis may lead to permanent damage of the nail plate and its attachments, and it may be associated with significant clinical issues For the reasons stated here, and considering onychomycosis is usually a progressive condition, it warrants intervention References: Thomas J, Jacobson GA, Narkowicz CK, Peterson GM, Burnet H, Sharpe C. J Clin Pharm Ther. 2010;35(5):497-519 Rich P, Elewski B, Scher RK, Pariser D. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S5-8 Pariser D. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S1
- The most common organisms found in onychomycosis are Trichophyton rubrum, which is responsible for an estimated 90% of infections, and Trichophyton mentagrophytes, which is implicated most commonly in the remainder of cases. Microsporum spp and Epidermophyton floccosum are unusual causes of onychomycosis in the United States. A number of other organisms also may be involved in fungal nail infections, [upon CLICK] including some nondermatophyte molds, such as Fusarium and some yeasts—[upon CLICK] especially Candida spp. References: Scher RK, Rich P, Pariser D, Elewski B. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S2-4
- The first classification of onychomycosis was proposed by Zaias (1972), and is based on the clinical appearance and pattern of nail plate invasion. He described four clinical types: distal (lateral) subungual onychomycosis (DSO/DLSO): where invasion originates from the distal and lateral undersurface of the plate white superficial onychomycosis (WSO): where invasion originates from the upper surface proximal subungual onychomycosis (PSO): where the attack starts from the undersurface of the proximal nailfold Candida spp. onychomycosis In 1981, Baran et al. introduced the concept of totally dystrophic onychomycosis (TDO) to explain the fact that, in some patients, the nail plate and, often, surrounding periungual tissue may be involved by the infection In 1999, Tosti et al. introduced the concept of endonyx onychomycosis to describe the condition where the nail plate is attacked from the distal end of the nail plate causing deeper penetration of fungal hyphae In 2011, Baran et al. proposed a further expansion of the classification of onychomychosis to include Mixed pattern onychomycosis (MPO): whereby multiple forms can exist on the same nail Secondary onychomycosis: whereby the fungal infection arises secondary to other conditions such as psoriasis or keratoderma The authors proposed, although it can be associated with chronic mucocutaneous candidosis, candida may not be a true primary nail pathogen. References: Zaias, N. Onychomycosis. Arch Dermatol. 1972; 105: 263–274 Hay RJ, Baran R. JAAD. 2011; 65(6): 1219–1227
- Differential diagnosis of onychomycosis needs to be established. Other diseases have clinical presentations that may be confused for onychomycosis. Does this patient have onychomycosis? No. This patient has psoriasis. Looks like onychomycosis with distal thickening of the nail with some onycholysis, but the patient has psoriasis AND history of nail trauma which might have koebnerized the nail. References: Patient case and diagnosis provided by Boni Elewski, Professor of Dermatology, UAB
- Onychomycosis can mimic many other clinical conditions that affect the nail, such as: Psoriasis Trauma Exogenous substances (eg. Nail polish, medications) Lichen planus Neoplasms Other nail infection (bacterial) Aging The diagnosis of onychomycosis is suggested by the clinical presentation as well as the family history and patient age. Concomitant tinea pedis infection is extremely common in patients with toenail onychomycosis. The diagnosis of onychomycosis should be confirmed prior to the initiation of therapy using an office/laboratory test including: Potassium hydroxide (KOH) preparation Fungal culture Periodic-acis Schiff (PAS) staining Polymerase Chain Reaction (PCR) KOH of subungual debris and periodic-acid Schiff (PAS) staining of nail plate samples provide confirmation of organisms but do not identify or ascertain the viability of organisms present. Culture is slower and less sensitive but currently is the standard method for identifying the causative organism. Polymerase chain reaction may become a useful method but is not yet widely available. The gold standard of diagnosis for onychomycosis remains the fungal culture. Culturing is the only method that is widely available at this time that provides definitive identification of a specific organism. References: Rich P et al. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S5-8 Westerberg DP, Voyack MJ.et al. Am Fam Physician. 2013;88(11):762-70
- Onychomycosis is reported to be more prevalent in the elderly and appears to occur more frequently in males, as well as among smokers Onchomycosis is a topic of concern among several patient populations, including those with poor peripheral circulation, those with diabetes, and those with compromised immune function Recent studies also suggest a genetic factor in susceptibility to onychomycosis, meaning family history may influence susceptibility to onychomycosis Other factors are known to increase the risk for developing onychomycosis, including Heavy perspiration Humid and moist environments Occlusive footwear A history of nail trauma Walking barefoot in public places such as pools or gyms where moisture is prevalent Frequenting nail salons References: Thomas J, Jacobson GA, Narkowicz CK, Peterson GM, Burnet H, Sharpe C. J Clin Pharm Ther. 2010;35(5):497-519 Scher RK, Rich P, Pariser D, Elewski B. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S2-4
- Although male gender and increasing age are predisposing factors for increased incidence of onychomycosis, according to NDTI data on patients who went on to use Lamisil: 63% of patients who went on to use Lamisil were less than 55 years old Equal proportion of men and women References: NDTI data, September 2013
- Onychomycosis is an infectious disease of significant importance, and few providers would consider the infection too trivial to treat, even if the initial presentation appears mainly cosmetic - onychomycosis is often a progressive condition that warrants intervention Consequences of untreated onychomycosis include permanent damage to the nail plate and its attachments, local spread of the infection or spread to other parts of the body, transmission of the infection to others, and other clinical issues References: Pariser D. Semin Cutan Med Surg. 2013 ;32(2 Suppl 1):S1 Thomas J, Jacobson GA, Narkowicz CK, Peterson GM, Burnet H, Sharpe C. J Clin Pharm Ther. 2010;35(5):497-519
- The goal of treatment of onychomycosis of the toenails is to eliminate the causative organism Elimination of the fungus sets the stage to restore the appearance of the toenail(s) However, it is important to note that treatment outcomes for onychomycosis are a product of two factors: the pharmacology of the drug prescribed – that is it’s ability to eliminate the causative agent (ie. fungus), and physiology - the body’s ability to restore the appearance of the infected toenail(s) via growth of the nail(s) Patients should not expect to see improvement in toenail(s) appearance until after the fungi are eliminated and until the damaged nail has grown out—a process that, for toenails, may take 12 to 18 months or longer. Individual results may vary. References: Elewski B, Pariser D, Rich P, Scher RK. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S9-12
- “Treatment” options for toenail onychomycosis include: Prescription oral antifungals: include itraconazole capsules (eg. Sporanox) and terbinafine tablets (eg. Lamisil) Prescription topical antifungals: include efinaconazole topical solution (eg. Jublia); tavaborole topical solution (eg. Kerydyin); ciclopirox topical solution (eg. Penlac) OTC products: anecdotally, some patients may be trying OTC products, there are no OTC products approved by the FDA for the treatment of onychomycosis Homeopathic products: anecdotally, some patients may be trying homeopathic products, these are not approved by the FDA for the treatment of onychomycosis, and little if any clinical data is available to support the safety and efficacy of these agents for the treatment of onychomycosis Devices: – which include lasers. Several lasers have been granted FDA marketing approval for the temporary improvement in the appearance of the nail. It is important to note that regulatory clearance of device systems are made on the basis of "substantial equivalence" to the technical specifications of pre-existing devices approved for marketing for onychomycosis, not on the basis of clinical trials data, so these systems cannot be directly compared to pharmacologic therapies1. References: Gupta AK, Simpson F. Skin Therapy Letter 2012; 17(9): 4-9
- The characteristics of topical antifungal therapy include Application to site of infection No known drug interactions at therapeutic concentrations No liver monitoring needed
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