To determine proposed outcomes of a comprehensive integrative approach to treatment of onychomycosis.
Efficacy of conventional treatments
Subungual distal onychomycosis or toenail fungus can be a frustrating condition to treat. It is extremely rare that it presents with life-threatening morbidity however for those who are afflicted with chronic infection is common and the deformity of the nail can lead to orthopaedic issues of the foot. Before the advent of laser technology, toenail fungus was conventionally treated with only topical and oral anti-fungal medication with mixed results.
Topical medications may have been helpful in partial cure rates of up to 56% of subjects according to some studies (1,2) and is usually reserved for mild to moderate infections. With the addition of laser technology to topical treatment, cure rates ranged from 50-92% with considerable patient satisfaction to the outcomes of nail growth, colour, and shape (3,4,5). Systemic oral therapy such as terbinafine and azole group antifungals are reserved for moderate to severe cases, and even then cases must be carefully evaluated due to a narrow therapeutic index and adverse effects of these agents.
Two common factors that affect the efficacy of the combined treatment are nail thickness (5) and the type of organism that causes the infection (6). Debridement or mechanical reduction of thicker toenails can increase efficacy rates up to 16% (7) on nails that are treated with topical therapy alone, although more studies are needed to determine how mechanical debridement would affect laser treatment.
The most common causes of onychomycotic infections are dermatophytes, candida (yeasts), non-dermatophytic molds, or a combination of the mentioned organisms. Risk factors for chronic toenail fungal infections include genetics, repetitive trauma, age, blood circulation issues, exposure to infective agents, and other environmental factors. Effective management of as much of these aspects would be beneficial to improve outcomes however there have yet been any experiments that have been published which combine treatment to target causative and risk factors together.
Given the clinical evidence of current treatments for onychyomycosis, it can be surmised that the combination of topical, laser, debridement, and oral therapy can help improve overall outcomes. Furthermore, for difficult and severe cases, other factors such as dietary, structural, and environmental may play important roles in the management of subungual distal onychomycosis.
Toenail fungal infections are normally managed by conventional medical doctors and podiatrists who are responsible for discovering and providing the most effective singular or dual combination treatments that have been researched. A naturopathic approach not only applies conventional methods, however, may include addressing other factors which improve outcomes and provide a collateral benefit to the patient. These factors may include structural, circulatory, gastrointestinal, immunologic, dermatologic, or other social conditions that perpetuate infections. Orthopaedic adjustments, dietary interventions, nutritional supplements, ozone therapy (8) and stress management are just a few other tools that are helpful in therapeutic management.
An initial appointment includes a taking a comprehensive history of pathology and comorbidities, visual inspection, and clipping samples of affected nails for laboratory testing of infective agents. Therapy involves at least four treatments of nail debridement, if needed, 1064nm diode laser therapy, a prescribed fumigation kit, and a prescribed topical triple antifungal medication. Patient education for at home care of nails is an essential part of lasting prevention of re-infection and is provided by the doctor. Follow up visits range between 3-6 weeks. Improved nail growth, colour, shape, and reduced infection can be seen in as early as 3 months however typical results are likely to occur at 6-12 month follow up appointments.
Treatment is usually well tolerated with the most common adverse effect is experiencing heat on the nail bed during laser treatment and occasional friction heat with debridement. Relative contraindications include peripheral neuropathy. Caution is used on patients on light-sensitive medications. Outcomes vary depending on adherence to treatment, infection severity, and comorbidities.
Literary evidence supports the use of laser treatments alone or in combination with topical agents for the treatment of subungual distal onychomycosis. The use of an integrative and comprehensive approach when treating subungual distal onychomycosis can be effective in improving outcomes versus conventional treatment. More evidence is needed to determine accurate results and future studies will be required.
About the Author:
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