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Diode Laser Treatment of Onychomycosis A New Horizon in Management

Abstract

. Objective: To investigate if Diode laser-808 nm treatment has the potential to eradicate onychomycosis.
Patients and Methods: Forty patients with a total of 102 mycotic toenails were randomized to the treatment group (808-nm Diode laser) or control group (no laser treatment). We conducted four laser treatments at 4 to 6 week intervals. In both groups, a local antimycotic agent was applied to the sole of the foot, the area between the toes and the skin directly surrounding the nails. The primary endpoint was complete remission of the onychomycosis after 12
months (fungal culture and histology); secondary endpoints included clinical improvement (Onychomycosis Severity Index, OSI) and the occurrence of pain or other adverse events.

. Results: A comparison of both groups' OSI scores showed no significant differences at baseline (P > 0.05). In both groups, toenails had solely a Trichophyton rubrum infection. The primary endpoint of mycological remission (i.e. no evidence of infection in fungal culture and PAS stain), while the secondary endpoint is improvement of clinical appearance of the nails using the Onychomycosis Severity Index (OSI). In the OSI scores, there were no statistically confirmed differences between the two groups. No adverse effects were observed in either the laser or the control group.

. Conclusion: The Diode laser 808-nm shows a long-term efficacy as a monotherapy. Its role as an adjuvant therapy should be investigated in upcoming trials.

. Keywords: Diode laser 808 nm; Onychomycosis

 

Introduction
In more than 99% of patients, onychomycosis is caused by a dermatophyte infection. The most common causative pathogen is Trichophyton rubrum and the second most common is Trichophyton mentagrophytes [1,2]. Only rarely are molds and candidal species the cause [1,3]. Onychomycosis is the most widespread nail disorder occurring in adults [4,5]. The reported prevalence ranges between 2 and 13%. The risk of infection increases significantly with increasing age. About 30% of patients between the ages of 60 and 70 years of age have infection and among 70-year-olds about 50% [2,6]. The incidence appears to be rising in all age groups [5]. The treatment of onychomycosis remains challenging. Both topical and systemic antifungal agents are associated with treatment failures, need for long-term therapy, high rates of recurrence, and significant costs[7-11]. The commonly used ciclopirox or amorolfine (Loceryl®,Galderma) nail lacquer take a long time to eradicate the infection and rarely completely cures severe onychomycosis [9]. Also, most patients have concomitant fungal infection of the foot which goes untreated. Systemic treatment is usually with terbinafine, itraconazole, or fluconazole. The list of adverse effects and possible drug interactions is long [12,13]. At present there is no cost-effective, safe, effective, and easy-to-use alternative. Along with photodynamic treatment [14], in recent years [15] there have been increasing reports on the successful use of laser treatment for onychomycosis. Still, very few data are available. So far, only three clinical studies have examined the positive effect of treatment with Diode laser (808 nm) [16,17] and diode laser with wavelengths of 870/930 nm [18]. There are also a few publications on in vitro results of laser therapy. Kozarev and colleagues treated Trichophyton rubrum in vitro once with longpulsed Nd: YAG laser (wavelength: 1064 nm, fluence: 40 J/cm2, spot size: 4 mm, pulse duration: 35 ms) and reported a significant, visible regression of the fungus after three days [16]. The biological and physical effects of laser treatment on dermatophytes are still uncertain and have been variously discussed in published studies. The advantages of laser treatment of onychomycosis are self-evident. In the present study, we conducted our own tests using the protocols for treatment of Trichophyton rubrum in vitro which have been reportedly successful...