Revisiting Laser Treatment: Does It Have A Viable Role In Onychomycosis Treatment?

While doctors have been using lasers to treat onychomycosis for more than 10 years, there has been some controversy as to whether this is a viable option for patient care. There is limited supporting documentation and research that can quantify outcomes with lasers. I have not published any of my data but what I do have is 15 years of experience with the use of a 1064 nm Nd:YAG class IV laser.

I will first start by saying that not all lasers have equal power. Unless you have a class IV Nd:YAG laser, Q switch or other laser that can produce enough energy to penetrate the nail tissue with selective thermophotolysis, the outcomes may not be comparable.

At the first consultation, I quickly categorize the nails as mild, moderate or severe. Mild cases present with superficial white onychomycosis, minimal lysis and discoloration that occupies less than 25 percent of the nail. Nails that have moderate involvement have discoloration that occupies up to 60 percent of the nail and there is visible lysis and mild thickening. Severe onychomycosis includes lysis approximately 75 percent in the proximal portion of the nail, discoloration affecting more than 60 percent of the nail, subungual debris and thickening.

I find the best outcomes with laser treatment are for patients with mild and moderate involvement. In severe cases, I honestly tell the patient to either live with the condition or I recommend a medical pedicure to keep the thickening under control. We can treat the nail with severe onychomycosis with lasers but it will take extreme diligence with a possible recommendation of a nail avulsion and treating the nail with combination therapy as it grows out.

In all cases, I do recommend a home regimen to include a home antifungal sweep of the shower, carpets and any open sandals. I also recommend the patient file the nail on the top and the tip with subsequent soaking. Patients do this twice a week.

Our office also provides medical pedicures. There is a significant difference in clinical outcomes in the patients who commit to having medical pedicures and patients who do not. A medical pedicure provides an in-depth cleaning of the skin and the nails including debridement, evacuation of any subungual debris and treatment with a topical antifungal. I also address the use of digital offloading with spacers and orthotics for nails that are at higher risk for microtrauma in shoes, which can lead to an increased incidence of fungus. 

Combination therapy is required to be successful with the treatment of nail fungus. I place patients on a treatment program with specific protocols and adherence to that program is imperative for positive outcomes.

With mild cases of onychomycosis, I recommend a topical antifungal medication and at least three laser treatments spaced every two weeks apart. After the laser treatments are complete, I recommend continuation of the topical medication for at least six months.

For moderate cases of onychomycosis, I will include antifungal treatments spaced three weeks apart, topical medication and medical pedicures. I typically jump-start the program with a short course of oral medication.

I address severe onychomycosis with oral medication, lasers, topical medication and medical pedicures. Again, it may be prudent to start with a nail avulsion and provide treatments as the nail grows in.

I also recommend advising the patient on a maintenance program and that nail fungus is often a recurrent issue.

My conclusion on laser treatment for nail fungus is that outcomes can be very rewarding if you offer the treatment to the appropriate patients. Combination therapy with topical medication and medical pedicures for debridement are imperative as is providing treatments with a strong laser.

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