What is Onychomycosis?

Onychomycosis is a fungal infection of the toenails or fingernails. Dermatophytes are the fungi most commonly responsible for onychomycosis. It is a very common condition and is estimated to impact 26% of the population with older people in 80% of cases. You may suffer from onychomycosis if you have one or more of the following symptoms:

• Thickening nail
• Crumbly or brittle nail
• Nail distorted in shape or separated
• Nail with no luster or shine
• A white, yellow, orange or brown coloured nail
• Debris build-up under the nail
• Persistent athletes foot or tinea pedis

Fungal Nail Treatment Options

• Fungal infections are often ignored. Many people will paint with nail varnish or gel to disguise them. In many cases, it is considered part of the ageing process. If there is no fungal skin infection and the nails are not too deformed, many patients choose to have the nails cut and shaped thin and flat by a Podiatrist on a regular basis without addressing the underlying infection.
• Topical treatments such as Curanail (Amorolofine) are licensed for mild infection affecting but are unable to penetrate well under the nail. The nail should be filed and thinned regularly by a Podiatrist to ensure optimal penetration of the drug. Treatment is around 30% effective.
• More extensive infections require a stronger approach requiring tablets such as terbinafine (Lamisil) or Sporanox (itraconazole) which are taken for 3-6 months. Cure rates with tablets are around 80%. We can take nail samples for the GP to analyse before treatment and a liver function blood test is often taken to check that the medication is within safe limits.
• The nail can be removed under local anaesthetic and once healed (after a week or so) amorolofine can be applied to the nail or the Lunula laser applied for 4-6 sessions
• Lunula laser treatment has been used since 2012 to treat fungal infections in a non invasive way. Two beams of Laser light are applied to the end of the foot and disrupt the growth of fungus. After a series of 4-10 treatments the fungal activity is reduced enough to permit the nail to grow out. Treatment is around 60% effective
• Reinfection is a consideration and good foot hygiene, being vigilant for fungal skin infection (athletes foot/tinea pedis) and keeping the shoes fungal free are essential. One study suggested that 35% of patients treated with terbinafine tablets reinfected within a year. Like any infection if you pick up the germs you could become infected.

Prospective patients with fungal nail infection are often looking at the laser treatment we provide and more information is provided below. We have tried to provide as much general information as possible but we advise you have a face to face consultation with the podiatrist if you fulfil the basic criteria for lunula laser treatment and are aware of these requirements of treatment :

1. Lunula laser treatment requires a treatment every week as a minimum for 4-6 weeks at the start. We often advise twice a week for the first 2-3 weeks if able to kickstart the process. You should live locally, or your job should allow this frequent visiting.
2. The treatment takes 12 minutes per foot – 24 mins for both feet.
3. The nails grow 0.5-1 millimetre a month so progress is slow. Normally results can be seen after 2-3 months as the nails grow.
4. There may be damage to the nail if its particularly thick or curled which may affect the result.
5. In some patients we do advise topical treatment with podiatric debridement (thinning) of the nail or oral medication. If this is advisable we can discuss this. In other cases, removal of the nail prior to laser treatment is beneficial.
6. Our treatment cost covers more than this minimum 4-6 treatments mentioned above and we provide the opportunity for treatment for the first 3 months or so. We encourage patients to come in weekly when possible until the nail growth is evident.

Laser Solutions for Nail Fungus

Laser therapy uses light at particular wavelengths to interact with fungus without affecting the healthy skin or body being targeted to specific features of the nail and fungus.

A&A Podiatrists can use two different lasers to achieve optimum results for this persistent infection: The Lunula and The PinPointe FootLaser.

In the former, two beams of light (blue and red) are produced by the Lunula laser which are rotated over the foot and nails that cause the fungal cells to react and produce hydrogen peroxide within their cells. This in most cases is cumulative over a few weeks when repeated and reduces the amount of viable fungus within and below the nail.

The second laser – the PinPointe FootLaser uses a targeted YAG laser to heat the fungus within and around the nail. This heats the fungal cells rapidly causing fungal damage. This laser produces some heat within the nail but it is stopped once it becomes uncomfortable. This laser is less effective so is our back up treatment if needed.

The Process

This begins with an assessment of the foot and nails and takes a holistic approach. Identifying causative factors, sources of fungus as well as considering the duration of infection and damage to the nails caused by the fungus, trauma or footwear. Overall general health and hygiene factors are discussed and methods of reducing cross infection or reinfection.

A&A Podiatrists take a thorough and long term approach to treatment with laser. Our treatment plan lasts three months when using the Lunula laser to ensure we monitor the progress of the nail growth and continue treatment until the nail is well on its way to becoming clear.

The Lunula laser takes 12 minutes per foot. In some cases (where the nail is very thick and fibrous) we have removed the nail surgically to remove all the infected nail before using the laser and allowing the nail to grow back.

The PinPointe laser we found to le less effective than the Lunula but we use it as a plan B as needed. This would usually be after 4-6 months from the start of Lunula treatment. Lunula stimulates the fungal cells to release toxic hydrogen peroxide within the fungal cell, PinPointe aims to over heat the cell causing destruction.

Fungal Nail Treatment Plan

As above, treatment commences with a consultation and discussion of causative and preventative methods. Anti-fungal cream is prescribed and baseline photographs taken. The thickened and fungal areas of the nail are thinned with a water file to remove as much loose fungus and nail as possible.

A typical regime consists of two phases.

• An initial 3 month treatment phase whereby we aim to use the Lunula laser 1-2 times a week for much of this time (minimum 6 sessions, aim for 10+).
• This is followed by a monitoring period for 3 more months where we allow the nail to continue to grow. After this period or sooner if the nails have grown fast we will see you back for a review and to file the nails. In most cases the nails will be clearly growing out fungal free at the base but if more treatment is needed this can be discussed.

Cost

The cost of treatment is typically broken down into a per foot charge. This fee will cover treatment for the entire 3 months of treatment with the Lunula laser. The initial appointment and the review appointment are charged separately.

The initial appointment costs £60 and appointments to check and file the nails are £30. These are not included in the Lunula cost. They are taken into account in the charging structure.

The one foot (or one hand) cost is £270 for a 3 month plan – and £540 for both feet (or both hands). Both big toes cost £450

If the PinPointe laser is used then this is charged at £45 per treatment usually after 6 months after the commencement of Lunula treatment. Two treatments are often applied a month apart. Additional lunula treatments are £20 per foot.

Prices are subject to change without notice and Payment is due in full at the start of treatment.

Effectiveness

The effectiveness of all treatments varies. We would expect 50-78% to be more reflective of the typical success rates. The degree of infection, nail damage and duration of infection can cause variable results and would be discussed on a case by case basis when this is the case.

In some cases the amount of trauma to the nail is so great the nail will never grow back normally, in others it will.

Cosmetic Alternatives

It is also possible to cover the nail with a specific acrylester gel for the toes that can be moulded and bonded over the ‘stump’ of fungal nail. This is called a Pedique and more information can be located on this link. This, once covered with nail will look normal and will do so until it grows out over time (typically 3-6 months). It is not appropriate to do this within the treatment phase of laser therapy but can be used after whilst it is growing out. For some this is a cosmetic alternative to laser treatment or where the nail is damaged and there is no fungus.