Background 1/29/2018. Lasers and Lights for Onychomycosis KEYVAN NOURI, MD. Keyvan Nouri, M.D. White superficial. onychomycosis

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Endowed Chair in Dermatology Richard Helfman rmatologic Surgery Vice-Chairman of the University of Miami Medical Group

bed Not just a disorder of the elderly incidence in children under 18 was found to be 0.

1 Lasers and Lights for Onychomycosis KEYVAN NOURI, MD Keyvan Nouri, M.D. Professor of Dermatology, Ophthalmology, Otolaryngology & Surgery Louis C. Skinner, Jr., M.D. Endowed Chair in Dermatology Richard Helfman Professor of Dermatologic Surgery Vice-Chairman of the University of Miami Medical Group Director of Mohs, Dermatologic & Laser Surgery Director of Surgical Training Department of Dermatology & Cutaneous Surgery University of Miami Leonard M. Miller School of Medicine Background White superficial Onychomycosis occurs when there is an overgrowth of fungus in the nail bed Not just a disorder of the elderly incidence in children under 18 was found to be 0.44% In older and diabetic populations, however, can be more troubling serving as a nidus for infection resulting in more serious complications. Notoriously difficult to treat Topical agents are ineffective in penetrating nail plate and reaching nail bed Oral antifungals have potential to cause adverse systemic side effects, which is more important given population where oncyhomycosis is most prevalent Distal lateral associated with T. rubrum Piraccini B, Tosti A White Superficial OnychomycosisEpidemiological, Clinical, and Pathological Study of 79 Patients Distal subungual Ghannoum MA et al A large-scale North American study of fungal isolates from nails: the frequency of, fungal distribution, and antifungal susceptibility patterns. Gupta AK et al Onychomycosis in children: prevalence and treatment strategies. Total dystrophic 1

Currently, lasers are only FDA approved for the temporary increase in clear nail growth in patients with NOT supposed to be advertised as a cure Some currently FDA-approved systems for this

(2012) Laser and Light therapy for Onychomycosis: A Systematic Review. Lasers in Medical Science.

penetration of topical antifungals 2 studies found efficacy: Apfelberg et al. (1984): 6/9 patients had clearance of organism with just one treatment.

2 Currently, lasers are only FDA approved for the temporary increase in clear nail growth in patients with NOT supposed to be advertised as a cure Some currently FDA-approved systems for this indication: Mechanism of Action Unclear Direct inactivation of fungus by heat Creation of ROS Selective photothermolysis exact chromophore not known Ledon JA, Savas J, Franca K, Chacon A, Nouri K (2012) Laser and Light therapy for Onychomycosis: A Systematic Review. Lasers in Medical Science epub CO2 Laser Oldest of the laser therapies studied for CO2 laser is ablative in nature, usually causing tissue destruction This can either destroy the fungus directly, or allow for better penetration of topical antifungals 2 studies found efficacy: Apfelberg et al. (1984): 6/9 patients had clearance of organism with just one treatment. Study parameters not clearly defined Borovoy et al. (1992): Nail plate fenestration with CO2 laser allows for better penetration of topical antifungals. One laser session mo. of topicals. Complete clearance in 75% at 3yr follow-up (n=200) Newer, less invasive laser options are currently available Apfelberg DB et al. (1984) Preliminary report on use of carbon dioxide laser in podiatry Borovoy M, Tracy M (1992) Noninvasive CO 2 laser fenestration improves treatment of. 2

3 UV light PDT UV light is germicidal to bacteria and fungi Also damaging to human tissue (known mutagen), limiting its role. UV blockers may be of benefit Potential role of UV light (UVC) alone for One ex vivo study. Found 100% inactivation of T. rubrum in nail fragments without resistance Effect of UVA light in PDT UVA light + synthetic photosensitizers were fungicidal to T. rubrum on stratum corneum independent of fungal growth stage Most studied light modality for Photosensitizing agent can be 5-ALA or other synthetic agents. [Experimental synthetic agents include light-activated porphyrins Sylsens B and Duteroporphyrin monomethylester (DP mme)] Idea: fungi and yeast convert 5-ALA to protoporphyrin IX Protophorphyrin IX possesses a peak wavelength absorption between nm, making it easily targeted by red light. Dai T et al. (2008) Ultraviolet C inactivation of dermatophytes: implications for treatment of Smijs TG et al. (2009) Preclinical studies with 5,10,15-Tris(4-methylpyridinium)-20-phenyl-[21H,23H]-porphine trichloride for the photodynamic treatment of superficial mycoses caused by Trichophyton rubrum Clinical trial 870/930 nm Only clinical trial was following nail avulsion: 30 patients Removal of the nail after urea for 10 nights 20% 5-ALA (3hr) + red light x 3 sessions 43.3% mycological cure at 1yr follow-up Found to be fungicidal and bactericidal in vitro, spawning clinical evaluation 4 sessions: 870/930 nm laser nm laser alone. Clear nail growth seen in 4/7 patients at 2 month follow-up. Nail cultures negative for all at 60 days. RCT: same settings as above. 44 patients underwent treatment in the experimental group and 15 patients were in the control group (exposed to sham light). 39% of nails had at least 3mm clear nail growth 4 months after last treatment. Improvement in 77% of cases noted by independent panel. No adverse events reported. 39% maintained negative cultures at 9 months follow-up Sotiriou E et al. (2010) Photodynamic therapy for distal and lateral subungual toenail caused by Trichophyton rubrum: Preliminary results of a single-centre open trial Landsman AS, et al (2010) Treatment of mild, moderate, and severe using 870- and 930-nm light exposure Landsman AS, Robbins AH (2012) Treatment of mild, moderate, and severe using 870- and 930-nm light exposure: some followup observations at 270 days 3

4 1064 nm and 1444 nm Nd:YAG Longer wavelength -- more deeply penetrate tissue and efficiently target fungal overgrowth in the nail bed Unfortunately, in vitro effects of Nd: YAG laser systems on T. rubrum growth have produced conflicting results 2 studies, same settings (Q-switched 1064 nm, 4 and 8J/cm2, 2 mm spot size) One study showed setting were effective in inhibiting T. rubrum colony growth 1. Second study found no inhibitory, fungicidal or fungistatic effects 2 Clinically, more promising results with 1064 nm Hochman 2011: 223 J/cm2, 0.65 ms pulse, 2 mm spot size, 2 passes. 2-3 sessions/ 3 weeks. 87.5% had negative cultures immediately after final treatment Kimura 2012: 14J/cm2, 0.30 ms pulse, 5 mm spot size, 2 passes. 2-3 sessions/ 4 or 8 weeks. 51% had negative cultures at 6 months Similar peak powers (13.7 J/ms & 11.6 J/ms) 1. Vural E et al.(2008) The effects of laser irradiation on Trichophyton rubrum growth 2. Hees H et al. (2012) Laser treatment of : an in vitro pilot study Hochman LG (2011) Laser treatment of using a novel 0.65-millisecond pulsed Nd:YAG 1064-nm laser. Kimura U et al.(2012) Treating onychomycoses of the toenail: clinical efficacy of the sub-millisecond 1,064 nm Nd: YAG laser using a 5 mm spot diameter Choi et al. proposed that due to the higher absorption by fat and water, the 1444 nm Nd:YAG may be better suited for targeting fungal organisms than the % - 85% reduction in colonies obtained from toenails diagnosed with Scanning Electron Microscopy (SEM) showed ventral surface maintained signs of infection, suggesting pretreatment debridement is warranted Future directions: Femtosecond IR Titanium Sapphire Laser (800 nm) Femtosecond lasers are lasers that maintain a pulse duration of seconds They break down transparent or semi-transparent biological tissues due to nonlinear absorption of laser energy with minimal thermal and mechanical effects Manevitch and colleagues found that a sufficient therapeutic window exists where in vitro fungal growth can be completely inhibited without affecting the structure of the nail plate Elimination of the fungus confirmed with SEM In vivo, clinical studies needed Choi MJ et al.(2012) Antifungal Effects of A 1,444-nm Neodymium:Yttrium-Aluminium-Garnet Laser on Onychomycosis: A Pilot Study Manevitch Z et al. (2010) Direct antifungal effect of femtosecond laser on Trichophyton rubrum 4

5 Indications & Contraindications Pre and Post-Op Care Clinically and mycologically confirmed by: Direct microscopy Fungal culture Culture + PAS = most sensitive (94%) 1 but may take long time Cannot tolerate, do not want other procedures Able to maintain adequate hygiene between sessions Unable to tolerate light therapy Seizure disorder LE Gold therapy Certain medications Caution with peripheral neuropathy Rule out other causes of dystrophic nails Obtain cultures for identification of species, if possible Discuss expectations with patients Clear nail growth is not guaranteed and may take many sessions. Re-infection is possible No wound care necessary Patients encouraged to keep feet dry and rotate shoes and socks (+/- powder) Topical antifungals between sessions may help to prevent recurrence May need urea pretreatment 1. Lawry et al (2000) Methods for diagnosing a comparative study and review of literature Complications and Safety Measures Our Experience Reported incidence is low Pain, heat or tingling during procedure Temporary darkening under the nail possible Temperature probe for patients with peripheral neuropathy 980 nm diode laser 7 patients Each session, treat until patient reports feeling warmth. Treatment stopped if too hot for comfort. sessions varying between 2 and 6 sessions +/- topical antifungal cream in between sessions 5

6 5 month f/u 6 month f/u * 3 rd and 6 th sessions *2 nd and 5 th sessions 3 month f/u Summary Role of lasers and PDT are being explored in the treatment of Mechanism of action is not fully understood Further studies are warranted to clarify lasers and lights for the treatment of * 2 nd and 3 rd sessions 6

7 Thank You 7

Laser Treatment of Onychomycosis. Description

Subject: Laser Treatment of Onychomycosis Page: 1 of 8 Last Review Status/Date: September 2014 Laser Treatment of Onychomycosis Description Onychomycosis is a common fungal infection of the nail. Currently