Overview of Onychomycosis (Nail Fungus) and New Laser Treatment Options
Causes:
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:
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.
Differential Diagnoses:
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. A detailed description of these diagnoses is beyond the scope of this article. Therefore, readers are encouraged to consult their health care provider and/or research as needed.
Traditional Treatments:
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 oral 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 may (at best) treat fungus on nail plate surfaces and adjacent soft tissues.
FFN-ctf is an innovative topical antifungal developed in 2011. FFN-ctf contains a blend of three potent antifungals (6% Ciclopirox, 6% Terbinafine, and 2% Fluconazole), which act synergistically. FFN-ctf 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. FFN-ctf is used exclusively by Laser Treatment Associates in Centennial, CO (see author's bio).
Other topical antifungals include Penlac (8% ciclopirox) and Formula 3 (1% tolnaftate). 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 low concentration of active drug.
Alternative (Laser) Treatments:
Recently, the clinical use of laser energy has attracted increasing attention. There are currently several technologies and treatment plans being promoted as safe and effective alternatives to oral and topical medications. These lasers emit various wavelengths with corresponding mechanisms of fungal de-activation. Here are some examples:
The "CoolTouch CT3+" ND:YAG 1320nm by New Star Lasers is a mid infrared, gold-standard skin laser. The CT3+ has inherent advantages for nail fungus treatment, as nails are simply modified skin. 1320nm energy is absorbed entirely by water, resulting in thermal necrosis (killing by heat) of fungal infections in the nail matrix (water vaporization is vital in laser nail fungus treatment). The laser spot size is variable from 3mm-10mm, which allows precise and uniform treatments by controlling beam width and depth of penetration according to nail size. The thermal sensor allows the operator to monitor and optimize the treatment temperature in real-time. The cryogen feature manually or automatically cools the treatment surface with a compressed gas for patient comfort and thermal shock effect. The CoolTouch laser allows superior control of key treatment parameters. The CoolTouch CT3+ is FDA cleared for use in general podiatry and dermatology, and currently under investigation for onychomycosis. The CoolTouch CT3+ laser is used exclusively by Laser Treatment Associates in Centennial, CO (see author's bio).
The "Pinpointe" ND:YAG 1064nm is a modified mid-infrared dental laser. 1064nm is a versatile wavelength used for dark hair removal, dark ink tattoo removal, collagen remodeling, and enlarged pore reduction. 1064nm energy is absorbed by melanin (skin pigment), hemoglobin (protein in red blood cells) and water. The Pinpointe is simple to operate and widely marketed. However, it lacks a thermal sensor; thus treatment temperatures cannot be monitored. It also has a 1.5mm fixed spot size and no cooling function. The Pinpointe is FDA "cleared for temporary increase in clear nail", an indication which has NO bearing on safety and efficacy. See end of article for more information on FDA "clearance" vs. "approval". Reference: http://www.fda.gov/AboutFDA/Transparency/Basics/ucm194460.htm
The "Noveon" laser by Nomir Medical is a near-infrared diode laser which delivers dual wavelengths (870nm and 930nm) exerting a "photo-inactivation" mechanism of action against fungal pathogens. The Noveon features electronic probes attached to infected toes. The automated process does not require a laser operator to administer the procedure. The Noveon is FDA cleared for general podiatry and dermatology and also under investigation for onychomycosis.
Conclusion:
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.
Laser energy shows great potential for safe and effective treatment of onychomycosis. Medical aesthetic laser energy is non-ionizing, non-mutating, and allows targeted treatment at the site of infection. It is important to note that nail fungus can re-occur even with the most diligent treatment plan. If you are committed to seeking the most cost-effective treatment, it is important to ask the right questions when researching options:
Does the clinic specialize in laser nail fungus treatment?
How many separate treatments are performed and in what intervals?
How many passes are done on each nail and how are treatment endpoints determined?
What concomitant topical medications are used, if any? (Combining a strong topical with a robust laser treatment is an inexpensive and safe "added measure" for optimal onychomycosis treatment outcomes)
What are the treatment costs? (Beware of "fixed price, single treatment" plans which are clinically and economically unfavorable)
What is the wavelength of the laser and what is the energy absorbed by? (water, hemoglobin, melanin, etc)
Most importantly, ask the laser clinic or medical office for PHOTOS of their treatments and patient testimonials. For more information on this topic, please call, visit our website, or come in for a free consultation. Full contact information located in author's bio.
Bear in mind:
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 higher 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" medical 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.
Important note on FDA "approval vs. clearance" of medical devices:
If a laser is promoted as "FDA approved", validate by requesting documentation, specifically the FDA definition of "approval" vs. "clearance". Many clinics falsely advertise their laser as "approved" for nail fungus, while the device may only be "cleared for temporary increase in clear nail".
FDA clearance only requires "substantial equivalence" to existing devices legally marketed for the same use. FDA approved devices are evaluated based on safety and efficacy. Refer to http://www.fda.gov/AboutFDA/Transparency/Basics/ucm194460.htm for more information.
Article Source: http://www.articlesbase.com
About the Author
Daniel Ashkar, MBA, CLS
Laser Treatment Associates
8719 E. Dry Creek Rd.
Centennial CO 80112
(303) 224-3545
info@lasertreatmentco.com
www.lasertreatmentco.com
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
