Journal of Cosmetic Dermatology, 13, 232--235

Onychomycosis: 1064-nm Nd:YAG q-switch laser treatment

Hector Ricardo Galvan Garcia, MD

Dermatology Hospital, Dermatosurgery, Guadalajara, Jalisco, Mexico

Summary Background Laser Treatment of onychomycosis is a quick and easy method without

complications.

Aim Laser therapy is efficient for the Treatment of onychomycosis.

Material & Methods One hundred and twenty patients with a KOH (+) confirmed

clinical diagnosis of onychomycosis were included in this study, all of the patients

were treated in a single sesi�on with a 1064-nm neodymium-doped yttrium-

aluminum garnet (Nd:YAG) q-switch laser.

Results There was a 100% clinical response rate within the 9 month follow-up period

with no side effects.

Conclusi�on This method is proposed as a novel and safe method for the treatment of

this ungual pathology.

Keywords: onychomycosis, Nd:YAG laser

Introduction

At present, laser treatment for onychomycosis is con-

sidered common practice because it is simple, quick

and presents no complications.3 Recently, alternatives

to the 1064-nm Nd:YAG laser treatment have been

proposed: q-switch laser, long-pulse laser,4 and the

combination of both of these methods (Alma Laser

Modules).1 Although all of these methods yield similar

results, there is a great difference in the number of ses-

sions, settings and the necessary time that the doctor

and the patient need to complete the treatment. The

objective of our study was to demonstrate the effective-

ness, speed, and the minimum number of sessions

needed to achieve the best results during laser treat-

ment of onychomycosis.

Material and methods

One hundred and twenty patients were included in the

study from April 2012 to December 2013. All of the

patients had a KOH (+)-confirmed diagnosis of clinical

onychodystrophy resulting from hand or foot ungual

onychomycosis of the distal, proximal, or lateral type.

Patients of all ages who had not previously received

any type of treatment were included. Each patient

signed a consent form and permitted clinical photo-

graphs of their nails to be taken before and after the

laser therapy.

Pregnant patients and patients with a subungual

hematoma were excluded. In addition, patients taking

photosensitive medication and patients with psoriasis,

lichen, or atopic dermatitis with nail involvement were

also excluded.

A direct microscopic test was performed with a mix

of KOH (25%) and glycerol (5%) (1 h at 51–54 °C) forlipid emulsification, and mycological structures were

identified under 4009 magnification. This test was per-

formed at the beginning and at the end of the study

for each patient.

Correspondence: Dermatology Hospital, Dermatosurgery, Lopez Cotilla

2261 Colonia Arcos Vallarta, C.P.44130. Guadalajara, Jalisco, Mexico.

E-mail: doctorricardogalvan@hotmail.com

Accepted for publication May 21, 2014

232 © 2014 Wiley Periodicals, Inc.

Journal Innovention

Laser therapy

Laser therapy was performed randomly with two

1064-nm Nd:YAG q-switch laser equipment. The first

laser was a Monalisa Laser, Sincoheren Co., Xizhimen

Beidajie, Beijing, China; the second laser was a Q-Clear

TM, Light Age, Inc., Somerset, NJ, USA. The lasers’ set-

tings were adjusted to yield a fluency of 600 mJ/cm2

over a 3-mm spot at a 3-Hz frequency in a single ses-

sion. Three applications were performed in a squared

form across the entire ungual plate for each case

(about 300 shots for nail). Immediate changes after

laser light application were observed (nail clearance).

Treatment questionnaires and clinical revisions were

scheduled at 3, 6 and 9 months after treatment.

Results

One hundred and twenty patients were included in the

clinical study, 98 women and 22 men. Patients were

between 6 and 79 years of age, including 118 adults

and 2 children (6- and 10-year old, both female). A

total of 733 nails were treated, 714 toenails and 19

fingernails. Four patients had both affected toenails

and affected fingernails affected. There was a 93% clin-

ical response rate within 3 months of the initial laser

treatment. There was a 100% clinical response rate at

6 months. At 9 months, there was a 100% clinical

and mycological response (KOH�) rate (Figs 1–4).There were no recorded side effects.

Discussion

The greatest advantages of laser treatment for onycho-

mycosis compared with traditional treatments such as

oral or topical medications are the ease of application,

negligible contraindications, and overall absence of side

effects.

In our study, we decided to test our patients only

with KOH and not to perform cultures because various

prior publications have shown that the KOH test shows

a higher specificity (60–80% vs. 30–60% for cul-

tures).5–8,10 Moreover, there was a high incidence ofFigure 1 Pretherapy laser.

Figure 2 Posttherapy laser six months after.

Figure 3 Pretherapy laser.

© 2014 Wiley Periodicals, Inc. 233

Onychomycosis, Nd:YAG laser . H R Galvan Garcia

Trichophyton rubrum in these studies as the main caus-

ative agent of onychomycosis.

In previous studies 2 and,9 the inhibition of T. rubrum

has been described in colonies exposed to 1064-nm Nd:

YAG q-switch laser radiation at 4 and 8 J/cm2. More-

over, Meral and Tasar 6 have reported a significant

in vitro reduction of Candida albicans growth using this

laser therapy.

During the laser therapy, we observed near-instanta-

neous clearance of the affected nails, particularly nails

that showed a brown-black or dark green pigmentation

(Figs 5 and 6). In addition, we observed the clearance

of the characteristic “cracking” sound in the fungus-

affected areas of the ungual plate and in the clinically

free zones where there was no sound after the treat-

ment. The Nd:YAG q-switch laser has been described

under this name because it generates high-energy

peaks with many repetitions. It does not warm the tis-

sue (it is painless); thus, it produces impact energy that

mechanically damages only the objective of interest

(fungi).

Based on the above-mentioned clinical findings, we

suggest that laser therapy acts via “selective photo-

thermolysis” that works according to the type of pig-

ment, type of light used, and pulse frequency

(light + heat + impact power).

Conclusions

The present study confirmed the efficacy of laser ther-

apy for the treatment of onychomycosis in all of its

clinical manifestations, including in the hands and feet

and in all age groups, without side effects. This therapy

was quick and effective, and only a single session with

a 1064-nm Nd:YAG q-switch laser was required. No

differences were found in the therapeutic responses

between the different lasers utilized.

References

1 Alma Laser Modules Operator’s Manual 2012; Ch. 25.

2 Gupta AK, Ahmad I, Burst I et al. Detection of xantho-

megnin in epidermal materials infected with Trichophyton

rubrum. J Invest Dermatol 2000; 115: 901–5.

Figure 4 Posttherapy laser one year after.

Figure 5 Pretherapy laser.

Figure 6 Posttherapy laser, near-instantaneous clearance.

234 © 2014 Wiley Periodicals, Inc.

Onychomycosis, Nd:YAG laser . H R Galvan Garcia

3 Kozarev J, Vizintin Z. Novel laser therapy in treatment of

onychomycosis. J Laser Health Acad 2010; 1: 1–9.4 Kozarev J. ClearSteps – Laser Onychomycosis Treatment:

Assessment of Efficacy 12 months After Treatment and

Beyond. 2012. Available at: http://www.laserandhealth-

academy.com/media/objave/academy/priponke/4.koza-

rev_clearsteps.pdf.

5 Meireles TEF, Rocha MFG, Brilhante RSN et al. Successive

mycological nail testing for onychomycosis: a strategy for

efficient diagnosis. Braz J Infect Dis 2008; 12: 333–7.6 Meral G, Tasar F, Kocagoz S. Factors affecting the anti-

bacterial effects of Nd:YAG laser in vivo. Lasers Surg Med

2003; 32: 197–202.7 Nazar JR, Gerosa PE, Diaz OA. Onicomicosis: Epidemiolo-

gia, Agentes Causales y Evaluacion de los Metodos Diag-

nosticos de Laboratorio [Onychomycoses: epidemiology,

causative agents and assessment of diagnostic laboratory

methods.]. Rev Argent Microbiol 2012; 44: 21–5.8 Shemer A, Trau H, Davidovici B et al. Nail sampling in

onychomycosis: comparative study of curettage from

three sites of the infected nail. J Dtsch Dermatol Ges 2007;

5: 1108–11.9 Smijs TG, Schuitmaker HJ. Photodynamic inactivation of

the dermatophyte Trichophyton rubrum. Photochem Photo-

biol 2003; 77: 556–60.10 Weinberg JM, Koestenblatt EK, Tutrone WD et al. Com-

parison of diagnostic methods in the evaluation of ony-

chomycosis. J Am Acad Dermatol 2003; 49: 193–7.

© 2014 Wiley Periodicals, Inc. 235

Onychomycosis, Nd:YAG laser . H R Galvan Garcia