laser therapy to treat nail fungus
TRANSCRIPT
Marco Ucciferri,DPM, FACFAS
Laser Treatment of Nail Fungus
• 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):497-5192. Rich P et al. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S5-83. Pariser D. Semin Cutan Med Surg. 2013;32(2 Suppl 1):S1
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T. rubrum Is the Most Common Cause
1. http://phil.cdc.gov/phil ID#11009; ID#145882. 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 causativeorganisms2:
• Other Trichophyton spp
• Microsporum canis
• Epidermophyton floccosum
• Acremonium spp
• Fusarium spp
• Scopulariopsis spp
• Scytalidium spp
• Aspergillus spp
• Candida spp
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• 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: 263–2742. 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
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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
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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):S5-82. Westerberg DP, Voyack MJ.et al. Am Fam Physician. 2013;88(11):762-70
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Predisposing Factors
• Gender (male)
• Age
• Smoking
1. Thomas j et al. J Clin Pharm Ther. 2010;35(5):497-5192. 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
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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
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• 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):S12. Thomas J et al. J Clin Pharm Ther. 2010;35(5):497-519
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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
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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
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• Application to site of infection
• No known drug interactions at therapeutic concentrations
• No liver monitoring needed
Characteristics of Topical Antifungal Therapy
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Laser Therapy
• Q-clear
• Procedure
• Time to improve
• Cost
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
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