Toenail infection (or onychomycosis) is one of the most common fungal diseases that affects a significant percentage of the general population. Curing it with the use of oral drugs and topical anti-fungal lotions often turns out to be laborious and tricky with questionable results, while the infection frequently relapses after a period of time. As a consequence, a number of alternative physical treatments have emerged, slowly gaining popularity thanks to several in vitro studies already showing encouraging results. Three of these alternative solutions are photodynamic therapy, laser therapy and plasma therapy.
Photodynamic therapy works by employing photosensitive agents (such as methylene blue dye, methyl-aminolevulinate, aminolevulinic acid or rose bengal) applied directly to the targeted area and irradiated with a light of specific wavelength and oxygen to generate reactive oxygen species which ultimately eliminate the infected tissue. Employing this method, however, calls for the patient having to comply with lengthy treatment sessions that last well over a six-month period, thus inevitably rendering the treatment not convenient for every patient. In addition, this particular therapy frequently depends on pre-treatment of the affected area (usually with urea) so as to enable photosensitizing agents to reach the nail plate.
While the premise sounds promising and in vitro studies have confirmed the method’s potential, in vivo studies delving deeper into its effectiveness mainly involve, at least for the time being, scant case reports. In any case, a systematic review carried out in 2016 revealed interesting findings in terms of the therapeutic advantages of photodynamic therapy, while few mild side effects (moderate pain, swelling and redness) were reported before subsiding in the following days. Another, randomized clinical trial conducted in 2014 displayed impressive results, with eight out of ten participants (treated with methylene blue dye irradiated with non-coherent red light) having found to be relieved from onychomycosis, compared to the unsatisfactory results rendered by a group that only received anti-fungal oral medication (fluconazole). What’s more, anticipated advancements in permeability of photosensitizing agents and reduced pre-treatment as well as the fact that the method does not interfere with other drugs make a strong case for this solution. Regardless, more research should be done before one can be positive on the actual therapeutic benefits photodynamic therapy is capable of delivering.
Laser therapy offers a non-invasive and painless procedure that uses laser heat to trigger a relatively complicated photo-thermal process which ultimately weakens and eradicates the fungus responsible for the infection. A laser beam is adjusted at a certain wavelength and absorbed by the fungus, thus undermining its structure while leaving surrounding tissues intact. The types of lasers employed in dealing with nail fungus are Yttrium Aluminum Garnet (YAG – usually set to emit a 1064-nm wavelength), Q-switched or Potassium Titanyl Phosphate.
A clear testament to the method’s strengths is the fact that the Food and Drug Administration has already given approval to laser therapy for dealing with toenail infections. Still, this approval mostly revolves around cosmetic benefits, while solid results pertaining to mycological remedy are much harder to determine.
A major cause for concern is cost: laser treatments are steeply priced, with the total cost for a typical five-session package ranging from $2,000 to $5,000, rendering this method practically unaffordable for the bigger portion of patients. Results, however, are estimated to be noticeable a couple of months later, although a full year may be needed to fully evaluate the method’s effectiveness.
Once again, although the theory is sensible, laser power can’t exactly be totally trusted for curing onychomycosis. The biggest issue lies more on the limited data available so far as well as the insubstantial methodology employed – the actual results are actually fairly satisfactory. For example, studies conducted so far hadn’t incorporate control groups, which makes reliable assessment of the method real potential extremely precarious. Moreover, clinical terminology used is sometimes very diverge (resulting in pointless comparisons), whereas the sheer amount of data is not ample enough to provided conclusive evidence. Some studies have come up with results for patients encountering issues in one toenail, whereas others have gone for a several-nails-per-person approach, thus yielding conflicting evidence which rather shrouds than sheds light on the treatment’s effectiveness. With these in mind, a review taking place in 2017 showed that almost four out of ten patients’ toenail condition ameliorated while the percentage rose to 70% of affected nails; on the down side, the proportion of participants who achieved totally clear nail results was dramatically lower (less than 15%), suggesting onychomycosis would almost certainly recur in the future. As for the mycological effects, they were shown on 63% of nails but only on one out of ten patients. On the plus side, side effects, swelling or bleeding are not to be expected when employing this specific method. Nevertheless, although laser therapies seem to be able to enhance the appearance of nails, the data available for the time being is not equally favorable when it comes to actually remedying onychomycosis (at least in comparison with conventional topical and oral treatments currently available in the marker for a fraction of the cost). So, for now, the limited amount of information available coupled with ambiguous results suggest that laser treatments be further investigated before being able to be regarded as a truly trustworthy method for curing toenail fungus.
Rounding out the list is plasma therapy, which is carried out by administering ionized gases at low gas pressures (“cold” or non-thermal plasma) directly to the surface of infected nails in a painless procedure. Since non-thermal plasma has displayed great effectiveness in killing bacteria and anti-fungal properties in vitro, it appears to be a very promising solution for onychomycosis sufferers, since it is a non-invasive method which has the added bonus of not interacting with other drugs.
A study carried out in 2017 with 19 participants dealing with toenail fungus turned over a very healthy clinical cure percentage of almost 55% with mycological cure reaching 15%. Questionnaires at the end of the study ensured that patient satisfaction was also taken into account. In total, plasma therapy was shown to provide substantial relief and a salutary remedy for onychomycosis sufferers. Still, thorough research as well as a copious amounts of real-life data are necessary to confirm the true potential of this method.