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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60 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 Kosarev and Vizintin 2 4 (n=72), li et al 6 (n=76), and garcia 18 (n=120). s urprisingly, the results repor ted by Kalokasidis et al 23 showed a high cure rate (95.4%), corroborated by the negative results of the direct mycological tests and culture for fungi. this cure rate was far superior to the rates repor ted in other studies. the laser used was the Q-switched nd yag 1064nm/532nm, with patients undergoing two treatments with an inter val of 30 days. the results obtained suggest that the distal subungual and white super ficial onychomycosis types are more susceptible to this modality, while the dystrophic clinical type is less susceptible. in our study, there was a predominance of the distal subungual clinical form (53 of a total of 72 nail plates evaluated). however, the use of the 1340nm laser did not present a high cure rate, considering the 30 patients cured. in general, there is no consensus on the efficacy of laser therapy for the treatment of onychomycosis, despite the methodological differences obser ved in the studies published on the subject. this lack of consensus can be justified by the lack of standardization regarding the types of studies, the numbers of patients evaluated, the number of nail plates included, and the types of fungi isolated. the majority of the research suggests that the elderly have the highest prevalence of onychomycosis. the visual appearance of the nail plates, reflecting a clinical improvement in some studies published in the last five years as well as in our study, was based on the levels of satisfaction of the patients assessed. however, the frequent use of the Onychomycosis severity index (Osi), which is an instrument that grades the sur face of affected nails, has been obser ved in the literature. it is impor tant to emphasize that an actual "cure" requires some skepticism on the par t of the physician, even if a clinical improvement of onychomycosis is obser ved. in general, when taking into account the duration of the studies carried out, from 12 w eeks up to 36 weeks, it is impor tant to stress that the growth rate of the nail plate is approximately 1mm/month. however, in the elderly, the growth rate decreases by 0.5 percent. recently, an exception regarding the study duration was verified in the study published by hollmig et al 5 in 2014, because this group of researchers held laborator y clinical follow-up of the patients evaluated for 12 months. this is the longest recorded period in the literature regarding the use of laser therapy for the treatment of onychomycosis. the information published by yan et al 2 5 in 2004 regarding the slower growth of the nail plate infected by dermatophytes should be highlighted. T. rubrum was the most isolated fungus in this study, and the period of patient follow-up (3 months) can be considered relatively narrow for the growth of the nail plate. thus, a longer clinical and laborator y follow-up may be useful to assess the effectiveness of laser therapy in onychomycosis. in this context, findings published by hollmig et al 5 in 2014 show that although there was an improvement in the appearance of the nail plates of the group assessed in the study at three months, this improvement was not confirmed in a longer period (12 months), suggesting temporar y clinical improvement. With these obser vations in mind, one must recall the possibility of relapses, which are ver y frequent in onychomycosis. relapses are defined as the recurrence of fungal infections on the nail plate with insufficient clearing. in contrast, reinfections are attributed to new infections, which can appear in the nail plates that were previously cleared of infections. 16 the type of onychomycosis is an impor tant factor that can contribute to the success of the chosen treatment. 26 thus, the types classifiable as distal lateral subungual and proximal white subungual are those w ith better response to the laser treatments. some published studies do not mention the clinical classification of onychomycosis, as opposed to this study. 5,21,27 CONCLUSION Due to the use of different methods and types of lasers used in the published literature, it is not yet possible to conclude that laser therapy is effective as a monotherapy for treatment of onychomycosis. fur ther studies should be conducted, including classification of the type of onychomycosis, clinical and laborator y follow-up over longer periods, and comparison of the groups treated with conventional therapy. randomized and comparative studies may provide more reliable results. taking into account the current state of the ar t and the relevant literature published to date, the clinical presentation of onychomycosis remains a major challenge in terms of the treatment and eradication of the fungal agent involved. REFERENCES 1. anane s, chtourou O, chedi a, et al. Onychomycosis in the elderly. Ann Dermatol Venerereol. 2007;39:746–753. 2. scher rK, tavakkol a, sigurgeirsson B, et al. Onychomychosis: diagnosis and definition of cure. J Am Acad Dermatol. 2007;56:939–944. 3. Debruyne D, coquetel a. Pharmacokinetics of antifungal agents in onychomycoses. Clin Pharmacokinet. 2001;40(6):441–472. 4. gupta aK, simpson fc. medical devices for the treatment of onychomychosis. Dermatologic Therapy. 2012;25:574–581. 5. hollmig st, rahman Z, henderson mt, et al. lack of efficacy with 1064-nm neodymium:yttrium-aluminum-garnet

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