Thoughts on laser for onychomycosis

[Creflo]

It's been a while since this was discussed on sdn, thoughts from anyone who actually has tried it?

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[Pronation]

T

 

[Feli]

I just tell them laser is similarly effective to terbinafine but much more costly...
It uses heat/photo energy insured of chemical to damage the fungus...
And neither has much success - especially long term - if the nail attachment is compromised (which it nearly always is).

...if you think orthotics customer service issues are lame, try people who spent 2-3x that or more on nail laser (plus "touch ups") for many visits and nothingburger results despite the time and $$$. Yes, i was once unfortunate to work a few years at an office that used laser and know many others that do.

I do debride,
generic $1.25 (sell for $3) AF cream + debride,
total avulsion to restart the nail + AF cream after (avulsion only if it's painful and/or pt wants to try everything),
PO terbinafine + cream + debride +/- total avulsion,
matrixectomy if it's painful and recurrent onycho and a lost cause.
Path of clippings is very rare (usually when the pt is bent on tabs and i think it's a risk or its just dystrophy and not onycho).

I guess one could say I don't max 'practice management' on onycho, but we all know it's mainly nonsense (fungi nail, toecylen, formula 7, "biopsy," laser, karyflex, etc etc). We are better than that scammy junk without EBM.

 

[Adam Smasher]

I refer laser pts to Groupon, many deals to be had in my area, ~$200

 

[Shiyuan]

Never used, never will.






I’ll stick to my Dremel 🤩

 

[air bud]

I tell them if they have the cash to burn then sure you can try it but personally I think it's a waste of money and would never offer it to patients.

 

[JustAPedicurist]

I plan on doing it. Need to pay the bills

 

[Retrograde_Nail]

Never used. Never will.

 

[PeaJay]

Onychomycosis causes onychodystrophy… killing the fungus is not necessarily going to help. Not that any laser actually helps. Remove the nail and let regrow per above or toss some terbinafine at it and see where the dust settles.

 

[Pronation]

F

 

[Adam Smasher]

I see a pattern emerging but I won't spoil it...

 

[JustAPedicurist]

P

 

[heybrother]

This is sort of humorous, but to the best of my knowledge there are no podiatrists in my town offering this service. Meanwhile, there's a hospital employed family medicine doctor who charges people cash for it. The cash doesn't go to her hospital - she sees them for something else and then the patient pays her the cash... That seems different.

 

[JustAPedicurist]

Why not offer it? If people want it give them what they want, and maybe you’ll pay off your loans in a decade

 

[Shiyuan]

Why not offer it? If people want it give them what they want, and maybe you’ll pay off your loans in a decade

With an MGMA job you’ll pay off your loans in 5-8 years if you do your finances right 👍🏻

 

[JustAPedicurist]

With an MGMA job you’ll pay off your loans in 5-8 years if you do your finances right 👍🏻

My goal is to get a MGMA job… I have been contacting relentlessly with no luck

 

[Pronation]

With an MGMA job you’ll pay off your loans in 5-8 years if you do your finances right 👍🏻

Well yes, that’s what happens when you’re paid like a doctor and don’t even have to peddle lotions and potions. Also it’s fairly common for hospital employed positions to offer complete loan repayment after ~10 years of employment.

 

[HardRoadPaved]

Remove the nail and let regrow per above

doesnt that cause trauma to the nail bed that we are desperately trying to protect?

 

[Feli]

Why not offer it? If people want it give them what they want, and maybe you’ll pay off your loans in a decade

You can make plenty of $ selling insoles and pads and disp DME and things they actually need and that will help them.

With an MGMA job you’ll pay off your loans in 5-8 years if you do your finances right 👍🏻

Yes, and nearly 20% of DPMs have such a job... most of then not being new grads

 

[Hybrocure]

I’m interested to see people’s experiences with it and more studies done.

Part of me wonders how much topical companies/pharma/reps rally in the criticism against it too, I do think there is likely an element of bias in the criticism against it.

 

[Feli]

Onychomycosis causes onychodystrophy… killing the fungus is not necessarily going to help...

Yeah, it's tough since dystrophy (lysis) causes the opening for the pathogens, and then the pathogens cause the thick/loose nail. Chicken or the egg.

I tell them the total avulsion re-start might help, might not (if dystrophy is permanent from matrix/bed damages from shoes/inj/etc).

I like my usual, "so look, this is a tough problem. I could be treating the president's wife and be offered a boatload of money, and I can't guarantee any improvement unfortunately. Nobody can. It's a very difficult problem without an easy fix, and anyone who says otherwise is probably selling you something."

 

[Feli]

I’m interested to see people’s experiences with it and more studies done.

Part of me wonders how much topical companies/pharma/reps rally in the criticism against it too, I do think there is likely an element of bias in the criticism against it.

Laser for toenails has been out quite awhile. There is a good amount on pubmed and elsewhere.

Some of them do nothing. Some have reported results about as good as terbinafine PO (roughly 80% see some improve, roughly 50% see near or total clearing). Again, those are always short/intermed term results. If you follow them awhile (laser or terbinafine), if the nail attach is not good, they will get thick/brown/yellowed again. Studies know this and will present 1yr or less f/u outcomes.

Many of the studies are by the makers, though (similar to wound "grafts" and most things podiatry love).

 

[DYK343]

Laser doesnt work. It simply doesnt. And its $$$.
Im not souring my reputation for that
Terbinafine has good results in my experience and the whole liver thing is WAY over blown.

 

[heybrother]

(a) These lasers cost thousands to tens of thousands of dollars. Someone on IPED posted they bought a hyperblue for like $30K.

(b) Anything that isn't covered by insurance has to be sold. It can feel distasteful selling things, especially things that don't work. Patients often respond negatively to expensive things that are pushed on them vigorously and then fail.

(c) When you buy something - you feel inclined to sell it / talk about it. A long time ago I clerked with a very pitiful doctor who tried to tell every patient they needed custom orthotics. No one got them. He could have seen another patient or 3 with all the time he wasted talking about things the patients weren't going to do. I bought a used shockwave. The MA I trained was super excited about it and wants to create TikTok videos about it. I would like to make my investment back and then some but I don't want to be that guy above going on about a cash pay option on a 1st visit when what the patient really needs is a shot.

(d) You need to ask yourself what sort of practice you want to have. Some people would say - I'm going to have onychomycosis visits regardless of what I do so I want to have more services to offer them. Cash pay services protect me from the ever decreasing reimbursement of insurance companies.

(e) Other people would say - I want the core of my business, my focus to be - surgery, reconstructive, wounds, sports, whatever etc. Creating reasons for people to come to me for a line of business that I don't want distracts from my core purpose.

(f) I'm mostly of the opinion that if laser worked - every family medicine and dermatology office would offer it.