Overview of Onychomycosis (toenail fungus) and the role of laser therapy in new treatment options
Onychomycosis (nail fungus) affects about 10% of the US adult population. Although not associated with morbidity and mortality, it can be painful and often associated with psychosocial problems due to thick, discolored, and/or disfigured nails. Treatment has been limited to oral anti-fungal medications with a significant propensity for side effects and re-occurrence. Recently, the use laser energy show promising signs of safely and effectively treating this difficult condition. This blog describes the causes, risk factors, differential diagnoses, and treatments for onychomycosis.
Onychomycosis or “Tinea unguium” is a common nail disease usually caused by a dermatophyte (skin fungi). Other causes include Candida species (yeast) and non-dermatophyte molds. The most common pathogen in onychomycosis is Trychophyton Rubrum, which accounts for about 80% of all cases. This fungus, which can cause athlete’s foot (Tinea pedis), also causes onychomycosis; hence both must be treated simultaneously.
Other causative dermatophytes include Epidermophyton floccosum and Trichophyton mentagrophytes. These fungi thrive in warm, humid environments, therefore, are difficult to eradicate once embedded in and under the nail plate. These fungi also secrete enzymes that breakdown nail keratin, resulting in “subungual hyperkeratosis” or excess keratinous matter under the nail. Infected nails appear thick, porous, discolored (usually yellow, brown, or white), flakey, cloudy and/or crumbly.
Nail plates can become infected as a result of blunt trauma (sudden) or micro trauma (gradual). In either case, the protective peripheral barrier around the nail is damaged, thereby allowing the entry of pathogenic organisms. However, onychomycosis can occur spontaneously without symptoms, known trauma, or concurrent athlete’s foot. Onychomycosis is also a common cause of nail dystrophy and onycholysis. Nail dystrophy is defined as “misshapen or partially destroyed nail plates”. Onycholysis , or “separation of the nail from the nail bed” is a commonly associated with dystrophic nails.
Risk factors for onychomycosis include: Increasing age, male gender, diabetes, nail trauma,
hyperhidrosis (excess perspiration), peripheral vascular disease, poor hygiene, Tinea pedis, or immunodeficiency. Onychomycosis affects approximately 50% of men over the age of 40 and is rarely seen in children and adolescents.
Fungal infections only account for about 50% of nail dystrophy (destroyed or damaged nail plate). Differential diagnoses include: Psoriasis, lichen planus, contact dermatitis, traumatic onychodystrophies, congenital pachyonychia, bacterial infection, yellow nail syndrome, idiopathic ohycholysis, or onychogryphosis.
Historically, onychomycosis has been difficult to treat due to the time required for nail growth, the inability to penetrate the hard nail with effective medicinal treatment, and the overall virulence of the causative pathogen.
For decades, griseofulvin was the only oral antifungal available. However, its effect was limited due to a weak antifungal spectrum and poor pharmacokinetic profile. Cure rates were low and reoccurrence was common. The newer generation oral antifungal agents, terbinafine and itraconozole, have improved antifungal activity and more favorable pharmacokinetics. Both agents are absorbed into the nail matrix following recommended courses of oral administration. However, both are associated with liver toxicity (hepatotoxicity) and cannot be administered with other medications metabolized by the same liver enzymatic system. Consequently, liver function tests are usually recommended every 4-6 weeks. Itraconazole is also contraindicated for patients with congestive heart failure. In studies, these therapies yielded marginal clinical cure rates of 30-50%. Clinical relapse is also common as medication concentrations in the nail bed drop below the minimum concentration required to eliminate residual dermatophyte spores. Only one viable spore can re-germinate and lead to clinical relapse.
Most topical antifungals are simply ineffective against onychomycosis. Most lack a keratin soluble (oil or lipid based) carrier required to actually penetrate the nail plate and reach the site of infection. Also, many topical antifungals have limited activity against a potentially broad spectrum of causative pathogens. Over-the-counter (OTC) antifungals at best, may control fungus on nail plate surfaces and adjacent soft tissues.
FFN-Rx is an innovative topical antifungal developed in early 2011. FFN-Rx contains a blend of three potent antifungals (6% terbinafine, 6% ciclopirox, and 2% fluconazole), which act synergistically. FFN-Rx features a patented, nail penetrating carrier system, a proprietary blend of botanicals which allow the suspended medications to be carried deep into the nail matrix.
Other topical antifungals include Penlac (8% ciclopirox solution) and Formula 3 (1% tolnaftate solution). Both antifungals have the disadvantage of a single medication. Prescription Penlac must be used for several months and has about 10% efficacy. Formula 3 also features a nail penetrating base, however, contains a very low concentration of active drug.
Laser Onychomycosis Treatment and combination therapy:
Onychomycosis can be safely and effectively treated by combining multiple modes of action at the site of infection, requiring no systemic (oral) medications. The method used by the author (Laser Treatment Associates) involves “continuous combination therapy”. As the infected nail grows out, it is treated by both laser energy and a topical medication which is applied by the patient. The concomitant use of a topical is standard protocol for laser nail fungus treatment. The objective is to exhibit a pharmacologic effect on potentially viable fungal elements remaining in the nail plate, as well as to sterilize the entire nail plate and surrounding soft tissue over time.
Many practitioners use lasers such as the CoolTouch 1320nm ND:YAG which is ideal for nail fungus treatment. The 1320nm wavelength is absorbed by water, the prime target when treating a living organism (the fungal hyphae and spores), infecting a non-living tissue (the nail). If a patient’s nails have thickened due to the infection, a nail debridement and or lateral thinning of the nail is recommended to reduce the fungal load, stimulate clear, healthy nail growth, and facilitate the absorption of the laser and topical treatments.
Our best advice to the reader:
Do your research and ask questions.
All nail fungus treatments are not equivalent, substitutable, or interchangeable. Seeking treatment from a specialist is ideal, as nail fungus is inherently difficult to treat and prevent from re-occurring. Treatments done by a high overhead Physician or Podiatry office may clinically inadequate (i.e., not enough treatments), very expensive, and generally profit (vs. clinically) oriented. MD’s, DPM’s (podiatrists) and other “western” medicine providers are taught to treat onychomycosis by prescribing oral medications (usually terbinafine 250mg QD for 90 days) and conduct monthly liver functions tests. This antiquated process of repeated office & pharmacy visits is inefficient and relatively ineffective.
Don’t wait too long.
Once nail fungus sets it, it will continue to proliferate and with no blood supply to deliver an immune response, it will not spontaneously resolve. In fact, it will usually worsen as the entire nail plate is becomes completely inundated. The best time to begin treatment is now, as there is no downtime with most viable treatment options.
Be consistent and patient.
It can take a toenail anywhere from 7 to 15 months to completely grow out and replace itself. Thick nails must be laterally thinned. . Athletes foot fungus = nail fungus. If you have athlete’s foot- treat it. If you don’t, avoid it by not walking barefoot in communal/public showers or any public area. Avoid nail trauma and always let your nails grow past the nail bed (i.e. don’t cut them too short).
This laser nail fungus treatment is provided exclusively by:
Laser Treatment Associates, LLC
8719 E. Dry Creek Rd.
Centennial, CO 80112
Daniel Ashkar (owner & blog author) Bio:
BA Biochemistry/Chemistry, 1995 MBA Health Administration, 2000
Hospital Sales (Infectious Disease specialist) Johnson & Johnson, 1997-2005
Pharmacology CMR (Certified Medical Representative)
Certified Laser Specialist (Rocky Mountain Laser College, 2010)
CoolTouch Certified operator CT3 PZ 1320nm ND:YAG laser, 2010
Founder of Laser Treatment Associates 2010