I have been treating fungal nail infections since 2011 using laser light therapies. Previous to then all I could recommend to my patients was proprietary treatments or a course of prescription tablets. From anecdotal experience the paint on treatments were only effective on low grade infections effecting just the free edge of the nail, and I was not happy to recommend taking tablets, due to potential unwanted systemic side effects, but the options were limited. As a podiatrist in many ways I felt I was ‘fobbing off’ patients, which would lay uncomfortable on my conscience.
As a professional clinician it is always important to keep updated on relevant medical practices which led me to investigate laser treatments for fungal nails. In 2011, I invested in the Fotona long wave Nd:YAG 1064nm laser. Lasers are increasingly being integrated into medicine having many clinically proven effects on the body for treating a multitude of conditions. The infrared 1064 nm wavelength was found to effectively heat up an infected nail plate above 40 degrees to trigger a process of cell death in a fungal dermaphyte. All treatments for treating onychomycosis (nail fungus) work on the basis of weakening the fungus until it cannot replicate and is deactivated. No one treatment can effectively do the job in one go. Treatments can be protracted and slow, not helped by the simple fact nails grow very slowly. The growth of an infected nail is retarded as the fungus is synthesizing all it can nutritionally out of the keratin. One good bit of news is in healthier younger individuals nail fungus will grow slower than it will in older less healthy people, as there is better circulation, initiating some immune response.
The thermal treatment is time consuming and uncomfortable despite using a cooler. When I first started using a thermal laser the protocol advised just 4 treatment sessions, but I found this was not proving to be enough for more deep seated infections. Protocol also advised review patients at two months, but I would question the efficacy of this? How would I be able to know if an infection was cleared, the parasitic fungi had died off? My reason for questioning was I knew how tenacious dermaphytes are. It does not take long for fungal activity to become strong again, thus often reviews would be about trying to handle a patient’s disappointment. I needed to be able to determine if the laser had been successful after a course of laser, hence I brought in specific dermaphytes sensitive culture testing.
Cultures revolutionised my clinical practice, and proved 4 treatments were not enough to get what I regard as a ‘clinical’ cure; 6-8 treatments are required to successfully treat infections. A ‘clinical cure’ is when at the point a culture is taken there is no fungal activity in the nail to result in a negative culture which exhibits no growth or colour change.
A ‘treatment cure’ is when after 6 to 12 months the infected nail has completely grown out clear. This can be difficult to achieve. A damaged infected nail has compromised integrity, it is weak and vulnerable to becoming re-infected, which can occur due to a variety of factors. The patient gets another athlete foot infection, puts on an infected shoe harbouring fungal spores. A squamous skin cell harbouring spores can thrive for up to 20 months to re-infect when the conditions become right e.g. moisture, warmth and dark. Often our patients regardless of us sanitising their footwear, giving them instructions on post care become re-infected.
In an ideal world the nails need to grow out superfast. The thermal laser does not promote quick nail growth, but could the advent of the ‘new’ Lunula ‘cold’ laser be the answer? The Lunula uses low level laser technology, utilising 2 proven therapeutic wavelengths to actually work with the body, whilst the thermal lasers action only caused a process of destruction and resulting repair process. The Lunula’s wavelengths stimulate photochemical, biochemical cell responses. One is fungicidal and the other boosts the immune system to fight back and attack weakened dermaphytes. Effectively a ‘healing process’ is initiated , increased vascularity and nutrition which in turn speeds up the new nail growth. It is clinically proven Lunula treatments increase nail growth.
I switched to the Lunula January 2013, and have not looked back. Infected nails do appear to grow out quicker minimising chances of re infection. Patients still require between 4 to 8 treatments to get a’ clinical cure ‘ but virtually all my patients would achieve a ‘clinical cure’, a clear culture . The culture results could not be argued against. I did not do anything else different, except swop laser wavelengths. My results were definitely better. The Lunula is more successful in achieving a cleared infection than the thermal. The other great bonus was treatment practice was easier, quicker and totally painless for the client.
Brilliant, I now feel I am successful and effective as a clinician to treat even the most deep seated infections, but I could not rest at this point. I wanted to give my patients some security to further minimize re-infection issues which led me to the Clearanail Micro Penetration Drill. I found this innovative device in its prototype form at the 2012 Society of Chiropodist and Podiatry Conference.
A micro pressure drill designed to painlessly introduce minute holes into the infected nail plate to increase the absorbency of liquid Terbinafine Hydrochloride to reach the source of infection.
A simple concept which could benefit my practice and patients. I had one of the first in the country as it was yet to go into production.
My rationale for buying one was to offer clients after a successful ‘treatment cure’, a preventative measure. By drilling lots of small holes at the edge of the treated fungal infection, a build-up of Terbinafine would act as ‘fire wall’, in essence as a barrier to inhibit, prevent any chances of a relapse to allow the nail to safely grow out.
It worked, it really does help to minimize risk re-infection, that I have often been asked why not just use the Clearanail instead of the more expensive laser? In the April 2015 Podiatry Now journal, the drill has been endorsed as an effective treatment for Onychomycosis, but it has not undergone any proper clinical trials. Any proof it works is anecdotal, and yes it does work, but on lower grade, more recent infections. I find on deep seated higher grade infections it is not as effective as the Lunula laser, and I certainly would not recommend it as a treatment option for these patients. It cannot reach into the infected nail folds, it cannot speed up nail growth or boost an immune response. It does not help to break the skin to nail infection cycle which the Lunula will. The laser will treat the predisposing Athlete Foot skin infection whilst the drill does not. Its practice therefor can be limiting.
The Clearanail’s place in my fungal clinic is as a treatment option for singular low grade infections, and as a laser post care preventative measure. A Clearanail treatment is subject to the all the later re-infecting variables. Patients generally require several ‘drilling’ sessions, so cost can add up, it is not totally painless in application, skill is required, and applying Terbinafine twice daily has compliance issues.
Successfully treating onychomycosis regardless of what treatment modality a podiatrist chooses to use is difficult. It requires developing a good working relationship with your patient, primarily managing their expectations, and getting them to be compliant with home care e.g. get rid of old favourite shoes and get infected partners, loved ones treated to prevent cross infection. The results are well worth it in the end. I get real job satisfaction with a happy delighted patient who no longer feels ashamed in showing off their nails.
Nice article its very helpfull thanks for sharing