Journal of Clinical and Aesthetic Dermatology

AUG 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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58 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY august 2017 • Volume 10 • number 8 O r i g i n a l r e s e a r c h currently, the studies conducted have employed different types of lasers (cr ystals, g ases, and semiconductors) with regard to wavelengths and varied pulse duration (milliseconds, microseconds, and nanoseconds). each published study evaluated one brand of laser with its proper ties; therefore, there is no standardized method of treatment defined for the use of laser in epilation or for vascular lesions. in general, few studies on laser therapy for the treatment of onychomycosis validate this alternative as monotherapy. this is due to the small number of patients evaluated, the scarcity of randomized trials, 5 –7 and the variable periods used for the clinical and laborator y monitoring of patients who received laser therapy. in this study, onychomycosis was more prevalent in women, who repor ted aesthetic discomfor t on the appearance of the nails during the laser sessions. the majority of patients were between 40 and 60 years of age, with a mean age of 53.2 years. in 2000, ghannoum 8 described a similar adult population. the same author repor ted a higher prevalence of onychomycosis in patients with per fusion alterations such as diabetes, hyper tension, and ar teriosclerosis. the data obtained in the present study were in agreement, as 50 percent of the patients had hyper tension, 14.3 percent had diabetes mellitus, and 7.1 percent had hypercholesterolemia. in relation to work activities, the majority of published studies make no mention of this variable with the exception of one study carried out in india by gupta et al 9 in 2007, in which the authors related the predominance of clinical presentation of onychomycosis to rural workers. this can be associated with the poor hygiene habits of these individuals and with greater contact with the soil. in the group of patients assessed in the present study, 23.3 percent were housewives/husbands and an additional 30.1 percent were retired people ( 16.7%), cooks (6.7%), and janitors (6.7%). this group of workers has regular activities that entail the use of water and cleaning products, as repor ted by elewski et al. 10 the distal subungual clinical form of onychomycosis was more frequent in the group evaluated in this study, which is in agreement with other published studies. this form occurs due to the easier access of the fungus to the free edge of the nail plate. it was also obser ved that the dystrophic form showed no case of cure with laser treatment. the dystrophic form presents a thickening of the nail plate. the presence of dermatophytoses is ver y common in this form, representing the aggregation of fungal agents and conferring the worse form of prognosis with traditional treatments. 11 the dermatophyte T. rubrum is the most frequent causative agent in onychomycosis in toenails, 4,12 having also been the most isolated fungus in the group of patients assessed in this study, followed by T. mentagrophytes and Fusarium spp. some authors consider that the production of xanthomegnin by the dermatophyte fungi 13 would act as a target for the laser, 14 in accordance with the theor y of selective photothermolysis. 15 the choice of toes as the anatomic site assessed in this study and others rather than fingernails was made by taking into account the fact that yeast can be isolated in the fingers and can represent only contaminant agents. in a total of 15 published studies (table 1), different authors investigated the use of the 1064nm laser (nd:yag) either as a single inter vention, as a combination of 1064nm/532nm, or in comparison with another laser. in all of these studies, the authors stated that only the toenails were evaluated, exactly as per formed in this study. Only one repor t used an 870/930nm laser and another used a cO 2 laser as a strategy for penetration of topical antifungal in nail plates. this series of studies was c ompiled in a ver y well documented review by Bristow 16 in 2014. in general, the review included both case studies and comparative studies, but there was a randomized study landsman et al 1 7 that included 36 patients with proven onychomycosis. in addition, hollmig et al 5 also conducted a randomized study, which evaluated 27 patients and 125 nail plates. li et al 6 in 2014 compared the use of the 1064nm nd:yag laser with itraconazole and obser ved better results at Weeks 8 and 16 in the group using itraconazole. however, equal results were obser ved at the 24th week of follow-up. notably, in the last five years, only three randomized studies were conducted. 6 ,18,19 in 2014, garcia 18 in mexico evaluated a group of 100 patients, including three children, with onychomycosis, and clinical and mycological cure was obser ved in 100 percent of cases. more recently, helou et al 19 showed clinical and mycological cure in 20 of 30 patients treated with shor t pulse nd:yag laser. in general, all studies repor ted in the last five years have included a ver y limited number of patients, ranging in number from 8 to 131. among the diagnostic criteria used, the fungal culture tests and direct mycological tests were more common, followed by periodic acid-schiff (Pas) stain and culture polymerase chain reaction. Weinberg et al 20 evaluated 94 samples of the nail plate and suggested the following technique sensitivities: KOh (80%), Pas stain (92%), and culture (59%). as a methodological strategy, the number of patients included in this study (n=30) was within the average adopted by different researchers. in the 15 studies published in the last five years, Weinberg et al 20 placed seventh in total number of study subjects, surpassed by Zhang et al 21 (n=33), Kimura et al 22 (n=31), Kalokasidis et al 23 (n=131),

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