Case Studies In Laser Therapy

This author discusses the use of laser therapy and how it was beneficial in addressing nail deformities in patients with onychomycosis.

The use of lasers in podiatry is not new and physicians have used lasers to successfully treat many conditions other than onychomycosis. The criteria for Food and Drug Administration (FDA) approval of lasers for temporary clearing of nails and treatment of nail fungus is becoming better defined with the increased use of lasers. From a podiatrist’s perspective, we should consider lasers as part of the complement of treatment options available to patients.

   The patient’s expectations for the use of laser therapy for onychomycosis differ from those of the podiatrist. While laser treatment does not necessarily focus on eradicating an infection, it can make the nail’s appearance more aesthetically pleasing. If the nail bed has been damaged from trauma, it is unlikely that the nail plate will maintain a normal appearance. Laser therapy is not designed or expected to change the damaged nail bed. However, the nail plate that grows is subject to fungal infiltration and any modality that can reduce and prevent the further spread of fungal infiltration is a viable solution.

Case Study One: A Non-Painful Nail Deformity

A 75-year-old female presented with a complaint of deformity to the toenail on the right hallux. The patient reports trauma to the site that occurred more than five years ago. It is not painful. The toenail bothers her more because of the way it looks. An examination revealed lysis of the distal two-thirds of the toenail and evidence of a thickened, dystrophic nail plate at the base. There was evidence of subungual debris. A KOH test was positive for fungus and confirmed with a Periodic acid-Schiff (PAS) reaction.

   The patient had laser treatment to the toenail on May 4, 2012. This consisted of exposure to the right hallux nail plate of 85 pulses with 189 joules.

   On the August 8, 2012 follow-up visit, I noted an improved appearance of the patient’s right hallux toenail, including proximal clearing and evidence of decreased thickness and improved coloration at the right hallux nail plate. The patient was pleased with her progress.

Case Study Two: Discolored Nails And A Painful Digit

A 68-year-old female presented with a complaint of deformed and discolored toenails on her left great toe and second digit. She had been concerned with their darkening appearance and thickness. The second digit was painful with pressure. During the examination, I noted discoloration at the distal one-third of the hallux nail plate with associated lysis. Incurvation of the nail plate was present at the left second digit with discoloration and thickening at the distal aspect. There was evidence of subungual debris, which was KOH positive.

   The patient underwent laser treatment to the toenail on May 4, 2012. She received treatment to the left hallux nail plate of 262 pulses with 209 joules of energy and at the left second digit of 102 pulses with 81.3 joules.

   At the August 7, 2012 follow-up appointment, an examination revealed marked improvement at the second digit, which demonstrated a flatter nail plate without evidence of striations in the nail texture. The left hallux nail also showed improvement with no evidence of discoloration and an adhered nail plate. Superficial lysis was present at the distal hallux. The patient was pleased with progress but requested a second treatment to the left hallux. An additional treatment to the left hallux consisted of exposure of 176 pulses with 142 joules.

In Conclusion

The laser I used in these cases was an A.R.C. Fox Laser set at 4 watts at a 1,064 nm wavelength and a pulse length/interval of 200 ms.

   In both cases, the use of laser therapy for onychomycosis was effective. The initial treatment eradicated the mycotic infection and cleared the nail. Additionally, without the presence of subungual infection, the nail plate growth was able to restore itself to the underlying surface and provide a more aesthetically pleasing result.

   It is also imperative that one follow the proper steps for diagnosis of onychomycosis and avoid using this treatment for contraindicated conditions such as infection, melanoma, cellulitis, osteomyelitis, fracture, melanoma or other pathologies at risk for metastasis.

   Podiatrists should consider offering this treatment to patients with onychomycosis. It will not work for all patients and it is essential that you make that clear to patients before initiating treatment. It is also important to educate patients that treating onychomycosis is a process. Remind them that average nail growth is 3 mm/month and that preventing re-infection is as critical to achieving success as the laser treatment itself.

   Dr. Torres-Hodges is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, a Fellow of the American Professional Wound Care Association and a Podiatry Fellow with the Council on Nail Disorders. She is in private practice in Pensacola, Fla.