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Laser treatment for toenail fungus

Discussion in 'Podiatric Residents & Physicians' started by 215353, 05.27.10.

  1. 215353

    215353

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    The DPM I used to shadow is now offering laser treatment for toenail fungus. He is doing a trial experiment and is giving the laser treatment for free to some of his patients with toenail fungus. If the results are promising he is going to add the laser device to his practice.

    If he does add this service to his practice he is planning on charging $800. This will most likely be out of pocket for the patient since this won't be covered by insurance.

    He is having a laser tech guy come in and assist him during the trial experiments. Will he always need this laser tech to give the treatment?

    Does this treatment fall under cosmetic podiatry since it's elective?

    I'm guessing plastic surgeons would be the only other doctors who would offer this service as well correct?

    Do current residents or attendings think this treatment is just a fad or is it a new legitimate service that could become a new staple within podiatric practices?
  2. Podfather

    Podfather

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    Our practice was offered this when it first came out. We were to have exclusivity for our area and the sales pitch was more about how many new cash paying patients this would add to our offices rather than science. It is not a covered service and we were to receive about $1,000.00 per patient. Prior to agreeing I asked for studies demonstrating that it worked and contacted a few DPMs who were using it. Well the only study they had at the time was extremely flawed and in fact the laser had not been approved by the FDA for onychomycosis only dental work. I also thought it was strange that this was being pushed by DPMs with very few dermatologists (even though there were some on the company's board) running with the ball. The DPMs using it at the time were all about the patients they were getting and while most said it worked the longest patient was out only 6 months. After I looked in the mirror and fought temptation, I declined. We have several individuals who have the laser in town now and I see all of the ads weekly.

    IMO the jury is still out and when true peer reviewed studies demonstrate a cure, low recurrence, and no complications then I will revisit it. If the science proves it works then everyone will have one and like Lasik we will see the price and profit drop. If the science shows it doesn't work or if all of a sudden it makes nails look worse then imagine the refund requests or lawsuits that will emerge.

    Remember the old adage: If it sounds too good to be true................
    Last edited: 05.28.10
  3. birdieDPM

    birdieDPM Junior Member

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  4. 215353

    215353

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    Thanks for chiming in you SPAM-Bot. This is an academic forum, it's not a place to peddle your creams.
    Last edited by a moderator: 05.22.12
  5. PADPM

    PADPM

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    Wow, is this post a load of B.S. or what??? If you believe that any of the above treatments will actually clear fungal nails........I've got some land I'd like to sell you. By the way, you forgot to mention that Vick's VapoRub also cures fungual nails.

    I guess it's just a slight coincidence that this free advertisement you've linked us to also happens to be your first post! Amazing coincidence.

    Most of the lasers that I've researched have reported success rates of approximately 60-80%. However, all of the lasers are FDA "cleared" but NONE of the lasers are FDA "approved" for use on fungal nails at this time.

    The treatment is safe and somewhat effective. I know a doctor who actually own a company manufacturing a laser, and he says that realistically, he is recommending at least two treatments, and some patients are requiring three.

    Even IF there is clearing, patients must remember that onychomycosis is an infection. Therefore, as with any infection, there is ALWAYS the possibility of re-infection (aka)/recurrence in the future despite any successful treatment.

    The advantage of the laser is no oral medication or potential side effects, no required labs and relatively quick treatment. The downside is no long term studies and no insurance coverage, with significant out of pocket costs.

    However, in my area, there are already doctors low-balling one another fighting for business. The price has already reduced drastically.

    I have no problem utilizing this modality, as long as a fungal culture/PAS has been performed, and as long as the patient has a full and honest understanding of the realistic expectations and possibility of recurrence, and that the patient is not expecting a miracle cure.
    Last edited by a moderator: 05.22.12
  6. Feli

    Feli ACFAS Member

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    I would totally agree. I did a ppt on this for residency academics. I half jokingly picked the topic since my program is mostly surgical, but I reviewed the lit and learned from making it. I was gonna post it, but it's too large of a file.

    Shockwave for fasciitis was supposedly DPM's Lasik... now laser for onycho toenails is. We'll see. Like shockwave or Topaz, here's very little EBM for the onycho lasers, and most of it's polluted by industry sponsorship. The way I see it, terbinafine is now $10 for 90 day supply, and it's safer than most think (contra with SSRI, B-blockers, or MAOI) yet seems to suffer from the bad hepatotoxicity rap of older oral antifungals - even though it uses different enzymes to get metabolized. I think terbinafine's definitely a fair and economical option for patients who have multiple nails involved, pain or quality of life decrease from their onycho, few/no meds with no contra Rx to terbinafine, and don't drink.

    Total nail avulsion and then applying antifungal cream to the nail bed as the nail regrows is also an option, but most patients won't accept that unless it's significantly painful (which is why we should be doing the treatments to begin with... not just for cosmesis). That is probably what I'd do for myself if I had the condition and it made the nail thick and painful.

    As was mentioned above, a lot of people (and docs) just don't address the underlying cause... fungal infection of the nail bed keratin. Whether it's laser, terbinafine, nail avulsion, or any other modality that "cures" it, it comes right back if the causes (hyperhidrosis, tinea of the skin, onycholysis, etc) aren't addressed. The different lasers theoretically thermally burn (Nd:YAG aka PinPointe) or have the right wavelength (near IR aka Noveon) to ablate the fungi in the nail and its bed, and that makes it interesting, but we'll have to see real results in good literature that's not polluted... derm journals, pod journal, etc studies which aren't just industry sponsored.
  7. dyk343

    dyk343

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    The attendings I have been talking to all say this treatment has low efficacy/high recurrence rates.
  8. PADPM

    PADPM

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    I've gained some experience since my last post on this subject. Our office wasn't quick to jump on the bandwagon, and we sat back and watched for a while. The only problem is that we were constantly getting calls from patients AND primary care docs to see if we offered laser treatment.

    Due to our size and reputation, it was almost "expected" that we would offer this new technology, even though the jury was still out.

    A laser company was certainly interested in obtaining our business, so we worked a deal with them to make it VERY affordable to our patients.

    We are/were very upfront with our patients regarding the studies and the controversy. Additionally, we will not perform the procedure on any patient unless there is a positive PAS. We also will not perform the procedure on anyone with grossly thickened mycotic nails. The nails must have a mild to moderate involvement. We also let them know that even if there is success, there is the possibility of recurrence since this IS an infection. We paint a very realistic picture.

    We have many patients who can not or will not take oral terbinafine, despite the fact a month supply can be purchased at WalMart for 10 bucks.

    At this point we have seen fairly promising results and significant patient satisfaction. As long as you have performed a PAS and receive a positive result and you are honest and upfront with your patients AND you perform the procedure on mild to moderately infected nails, you have a great chance of having satisfied patients.

    We offer our patients everything from palliative care to oral medication to topical meds (for very mild cases) to laser treatment. We simply got tired of telling patients "no, we don't do laser", so we thought we would give it a try at a very affordable price, and as a result we've been pretty happy with the results at this time.

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