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Laser treatment for nail fungus

Discussion in 'General Issues and Discussion Forum' started by Cameron, Jan 4, 2009.

  1. Paul Bowles

    Paul Bowles Well-Known Member

    I'm just going to keep bringing the clinical results Martin. Good. Bad. Indifferent.

    Some people will think I have an agenda and hate my guts no matter what. Some people will ignore me. The rest of us can just get on with the job of discussing how this can benefit our patients, how it really works and if it actually has a place at the top of the food chain with oral terbinafine or other "gold standard" practices.

    I don't really have much interest in anything else.

    :morning:
     
  2. Ian Drakard

    Ian Drakard Active Member

    Hi Paul

    Not sure if I missed it earlier in the thread but have you reached a stage where you can audit outcome figures yet?

    Many thanks
    Ian
     
  3. Paul Bowles

    Paul Bowles Well-Known Member

    Hi Ian - yes we have lots of records and photos now and have enough data I think to analyze it. We think we have a way to analyze the photos to produce some tangible outcomes that we can use and make some recommendations from. Just need to get my rear end into gear and start doing it all. Too much on my plate at the moment!
     
  4. blinda

    blinda MVP

    :good:

    You`re not on my `ignore` list ;)
     
  5. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
  6. Paul Bowles

    Paul Bowles Well-Known Member


    Would have preferred a simple clinical trial be published showing laser versus placebo first! I wonder who is doing the trial (ill have to go look) and search for more info - interesting choice that they are comparing it to terbinafine, which I assume is the "safety" part in that title.......shame really because instantaneously that skews any possible result in my opinion as it is unfair to compare the "safety" of multiple treatments when one of those treatments is an orally ingested drug with known side effects..... Which one do you think will be tainted as "safer"? I'll reserve my final judgement until the results are released and the methodology clear but its disappointing I believe from the title alone!

    We have submitted our data for independent analysis. I haven't seen all the data but from reviewing my patients I have already started making some broad evaluations about when we should use 1064nm laser and when we shouldn't in our clinic. I think the management pathways are slowly getting a little clearer now in my opinion for the use of 1064nm laser.
     
  7. RiverRider

    RiverRider Member

    http://www.clinicaltrials.gov/ct2/show/NCT01920178

    From the text -

     
  8. Paul Bowles

    Paul Bowles Well-Known Member

    RiverRider whats your point? Photographs would be standard in any case, topical anti fungals around skin is a prophylactic measure which I believe has very little evidence for sub ungual OM prevention (maybe Blinda can give her opinion here) as is regular nail debridement. THe efficacy thing im happy with in the title, the safety thing - doesn't make sense in context.
     
  9. blinda

    blinda MVP

    RiverRider, I`m not too sure what you`re getting at, either. Could you please expand on your post?

    Paul, I am not aware of any firm evidence that topical anti-fungals used prophylactically are effective for prevention of subungual OM, although they are often used for prevention of recurring cutaneous infection;

    Antifungal Prophylaxis: An Ounce of Prevention Is Worth Three Grams of Amphotericin B
    Recurrent tinea pedis: a double blind study on the prophylactic use of fenticonazole powder.

    I tend to advise pts with recurring dermatophyte infection to use topical terbinafine regularly as a prophylactic measure.

    With regard to the paper, I see would consider the use of topical anti-fungals around the skin as reasonable also. That said, I agree with your thoughts on the `safety` aspect. I would like to see a placebo trial with the Pinpointe.
     
  10. admin

    admin Administrator Staff Member

    I think they were just linking to a newly registered clinical trial on this topic that we had missed!
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Antifungal efficacy of lasers against dermatophytes and yeasts in vitro
    Uwe Paasch, Andrea Mock, Sonja Grunewald, Marc O. Bodendorf, Michael Kendler, Anna-Theresa Seitz, Jan C. Simon, & Pietro Nenoff
    September 2013, Vol. 29, No. 6 , Pages 544-550 (doi:10.3109/02656736.2013.823672)
     
  12. Paul Bowles

    Paul Bowles Well-Known Member

    That is one element I can attest to - it gets really hot! Easily at or over 50 degrees in clinical use. Thanks for the link!
     
  13. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Laser treatment of onychomycosis: an in vitro pilot study.
    Hees H, Raulin C, Bäumler W.
    J Dtsch Dermatol Ges. 2012 Dec;10(12):913-8.
     
  14. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    So it fails to work in a test tube but they still think it should work clinically .... go figure!
     
  15. Paul Bowles

    Paul Bowles Well-Known Member

    I can attest clinically it works in certain cases - the key is to identify in which cases and why! There will be more to this than we think I believe.
     
  16. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    I don't deny that; its just that the experiment reported in the study found no effect in vitro .... yet they somehow can conclude from that it will work in vivo......
     
  17. TPeterson

    TPeterson Welcome New Poster

    "...there might be an effectiveness in vivo..."

    That's hardly a conclusion that "it will work in vivo"!

    I have to agree that the result is not at all encouraging. However, there are lots of possible mechanisms in vivo that are absent in a petri dish--including the placebo effect. ;)
     
  18. Philip Mann

    Philip Mann Member

    I have been following this post with interest for some time. I have had a Omega laser with a 820nm probe and a cluster probe with 10x 660nm 10x 950nm 10x 940nm and 10x 890nm. When I first got the machine about 9 years back I used it for mainly sports injuries and wound healing to very good effect. I the last six months with advice from the good folks at Omega I have started using it on fungal nails and have been impressed with the results. There is no doubt that it works most of the time.
    I have a few points to make.

    Laser is not bringing cells back to life! it is killing fungus, how? I am not sure we know exactly yet.

    Laser is not, in my opinion is not heating the nail to kill fungus. This is Low Level Laser (LLL)or "cold " laser, OK my gets a little warm towards the end of a long treatment but no warmer than a hot bath or laying in the sun and they sure don't to work for Onycomycosis.

    Pinpoint have kind of set them selves up to be knocked a bit, it seems to me that they made some big claims and have not been forthcoming with their data, but of course they don't want the likes of me using a much less expensive device to do the same thing when they are trying to re-coupe their investment and risk.

    What we do know is LLL is a safe treatment if used correctly and it's effects are at a cellular level, immuno stimulation vasodilation etc. So why not use it if it is doing no harm and is helping many. Lets face it we all prescribe orthotics!
     
  19. Mart

    Mart Well-Known Member

    Hi Philip

    Not sure if something got lost in translation here.

    I don't understand your reasoning:

    Non of the theoretical ideas regarding effective use of LLL you mentioned seem relevant to treating onychomycosis so how do you justify using LLL on this basis?

    What evidence do you have (even anecdotal) that LLL "helps many" with onychomycosis?

    Whats this got to do with prescribing orthotics?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  20. Suzannethefoot

    Suzannethefoot Active Member

    I had a low level laser which I found useless for onychomycosis and verrucae. Good for pain relief though, but as I bought it as a treatment for verrucae, I got rid. I am now in the process of buying a fotona laser, having spoken to many people who use one for onyco and verrucae, as well as cosmetic proceedures, so will report my findings here when I get some results.
     
  21. Philip Mann

    Philip Mann Member

    Hi Martin,

    sorry if I did not make myself clear, I will try to answer in reverse order to clarify a bit.
    What's it got to do with prescribing orthotics? all I was trying to say is that we all prescribe orthotics, we know they work but some of the evedence is anecdotal, it's not all evidence based based practice but we still prescribe them.
    How do I justify using LLL on onycomycosis well in my experience most of my patient's get better using LLL on onycomycosis, and I am unlikely to do any harm. I usually take a picture at first treatment then compare at six weeks so I can see improvement. I will have a look and see if I have any after pics.
    I am not trying to sell lasers for OM, Pinpoint are and they are not convincing a lot of people at present.
    There seems to be some practitioners who believe that heat is how laser is working on OM I do not. I think from what we do know about lasers it is more likely to be by vasodilation and imuno-stimulation

    Cheers

    Philip
     
  22. Paul Bowles

    Paul Bowles Well-Known Member

    If that was true I should be able to do it with nitro patches to the toe, lignocaine or even warm water. I'm not sure I would buy that theory without any hard data to support it, and im not sure how one would go about getting that hard data for the imuno stimulation side of things.
     
  23. blinda

    blinda MVP

    Indeed. On both counts. An in vivo study on cytokine activity in relation to a cell-mediated response would be very, very interesting, but unlikely to be performed by a Pod.

    Anyone read Japanese?
    http://www.ncbi.nlm.nih.gov/pubmed/19654447
     
  24. Ian Drakard

    Ian Drakard Active Member

    IMHO the main action of most lasers being marketed for this is likely to be heat, but they are acting at much higher power levels than LLLT.

    Could LLLT have an effect as well? maybe. Seeing as dermatophytes are feeding on the nail- not noted for either it's vascular or immune activity I can't see vasodilation and imuno-stimulation being methods of action.

    When I was last looking at LLLT in detail (several years ago now), there was very little in the literature on the effects on fungal cultures. There was a lot on the effects on mitochondria and gene expression on both human cells and bacteria. Mitochondria are being explored as potential targets for antifungal drug therapy so possibly a more subtle mechanism like this is at play if it works- beyond my expertise!
     
  25. Mart

    Mart Well-Known Member

    Hi

    I am curious about what you regard as good result for om and vp treatment measure?

    cheers Martin

    Sent from my Iphone
     
  26. Mart

    Mart Well-Known Member

    Please explain how you think that vasodilation and immune stimulation might work as a useful mechanism for onychomycosis

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  27. Mart

    Mart Well-Known Member

    If we use foot orthoses (responsibly) there should be some plausible reasoning why a particular foot orthoses design might be helpful for a specific individual presentation. Currently there is likely insufficient scientific evidence because the studies needed to explore this idea have not be sufficiently rigorous and are limited by the confounding nature of multifactoral cause and effect.

    Currently we have no strong plausible evidence of any mechanism which might come from laser to help with onychomycosis but reasonable suspicion of heat in absence of better ideas.

    Also existing studies for onychomycosis and laser effect are not convincing from a clinical perspective because they do not report useful outcome if you define that as cure. What is the point of regarding an improvement, even if it meets p< 0.05 for reduction in measured visible area of colour change in nail plate as a clinically useful outcome?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  28. blinda

    blinda MVP

    I suppose if enough epidermal antimicrobial peptides in the stratum corneum (subungually) are `stimulated`, then you may induce an immune response to dermatophyte infection. Taken from the above Japanese paper;
     
  29. Mart

    Mart Well-Known Member

    This idea seems plausible in normal skin where the desquamation rate is fast and tissue thickness compared to nail is thin. With tinea pedis there is typically an acute cell mediated response to metabolic products of the dermatophytes which reach the non cornified epidermis. Part of the host response is typically vesicular which likely accelerates the desquamation of the infected epidermis.

    Consider resistant chronic tinea in hyperkeratotic skin lesions such as the plantar calcaneal area where the desquamation rate is slowed and the skin thickness increased (creating a model somewhat akin to nail); oral rather than topical anti fungal delivery then may be indicated.

    I have not looked at what has been studied but the dynamics of onychomycosis seem likely to be a continual migration of dermatophytes at rate faster than nail growth within full thickness nail colonization. It this is true then it seems unlikely that antimicrobial peptides would be stable and concentrated sufficiently to the survive several months after departing the proximal nail fold before meeting fungal elements and then communicate usefully to establish an effective cell mediated response with an extremely distant blood supply. If the onychomycosis was localized to a thin band of nail adjacent to skin a cell mediated response would then seem plausible to me, I have never seen a presentation like this.

    Can anyone comment regarding their understanding of the evidence of infection dynamics of onychomycosis?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  30. blinda

    blinda MVP

  31. Mart

    Mart Well-Known Member

    Thanks ...... I speed read this paper and "The effect of dermatophytes on cytokine production by human keratinocytes" ( I assume the Japanese paper other have mentioned).

    I cant see how this is relevant to onychomycosis; the dematophyes only cause an inflammatory response when their metabolic products are presented to the immune system, this doesn't have any potential to clear onychomycosis.

    Someone please explain how things could be otherwise.

    The idea that laser can cause therapeutic altered gene expression to modulate an immune response within keratinocytes to treat onychomycosis seems moot even if true.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  32. Mart

    Mart Well-Known Member

    Br J Dermatol. 2013 Aug 19. doi: 10.1111/bjd.12594. [Epub ahead of print]
    A Second Look at Efficacy Criteria for Onychomycosis: Clinical and Mycological Cure.
    Ghannoum M, Isham N, Catalano V.
    Source
    Center for Medical Mycology, Department of Dermatology, University Hospitals Case Medical Center, Cleveland, OH

    although this paper is aimed towards drug intervention the difficulties it raises about useful clinical endpoint are relevant to laser studies too.
     
  33. blinda

    blinda MVP

    You`re right, as the nail unit is virtually secluded from the body`s cell-mediated immunity, there are little, or no, antigens presented in comparison to the epidermis. However, there does appear to be some evidence that the nail does contain a strong innate immunity. See abstracts here;

    http://www.ncbi.nlm.nih.gov/pubmed/14988673 - Innate immune defense of the nail unit by antimicrobial peptides.(I`m hoping to obtain the full article tomorrow)

    http://www.karger.com/Article/Pdf/131412 - Immune Privilege and the Skin

    This is a pretty good read (full article);

    http://www.ijdvl.com/article.asp?is...=78;issue=3;spage=263;epage=270;aulast=Grover

    Taken from the above;
    So, maybe those AMPs could be induced by inflammation?
     
  34. Mart

    Mart Well-Known Member

    That looks like an interesting avenue, I'll see if I can track this down too :drinks

    Cheers

    Martin
     
  35. Mart

    Mart Well-Known Member

    I speed read the papers from your citations + a couple of others. Essentially my understanding is that, as you mentioned, demonstration of antimicrobial activity from APMs isolated from nail so far is limited to Pseudomonas aeruginosa and Candida albicans.

    I agree this is interesting but it remains a long stretch to speculate that the activity might extend to most common dermatophytes associated with OM - even greater to think that laser therapy might up-regulate AMP production favorably to have therapeutic effect.

    For time being at least there seems no evidence to support view that innate immune response can be therapeutically manipulated to treat OM.

    I can email you papers if you have trouble sourcing them

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  36. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Lasers promising for onychomycosis treatment
    Full story
     
  37. blinda

    blinda MVP

    Thanks Martin,

    I agree, my posts were pure speculation as you asked how inflammation could play a role.

    It would be interesting to see the effect of the AMP Cathelicidin LL-37 on dermatophyte infection, not just bacterium and yeasts. So many questions....
     
  38. Suzannethefoot

    Suzannethefoot Active Member

    Without going into technicalities ,I would say a good result is if they are cured.
     
  39. blinda

    blinda MVP

  40. Suzannethefoot

    Suzannethefoot Active Member

    Both, but, as has been discussed previously in this thread, the nail does not always look totally 'normal' after resolution of the infection.

    Most of the potential patients I have discussed the procedure with are happy to accept a nail with some thickening or distortion, as long as the appearance is greatly improved. I have also explained that it is a team effort, and that they have to be vigilant in keeping athletes foot at bay, and spraying shoes, washing hosiery at a higher temperature, etc. to stop re-infection.
     
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