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Open Access 31-10-2022 | Photodynamic Therapy | Original Paper

Urea versus fractional Er:YAG laser pretreatment of methylene blue photodynamic therapy in the treatment of moderate toenail onychomycosis: short- and medium-term effects

Authors: Enrique Alberdi, Clara Gómez

Published in: Archives of Dermatological Research | Issue 4/2023

Abstract

Keratolytic properties of urea 40% have long time used for the treatment of onychomycosis. Fractional ablative lasers enhance the delivery of topically applied photosensitizers improving photodynamic therapy (PDT) efficacy. The aim of this study was to compare the short- and medium-term efficacy of a pretreatment with urea 40% and fractional Er:YAG (Fr Er:YAG) laser radiation before PDT mediated by methylene blue (MB) for moderate toenail onychomycosis. Twenty-first-toe toenails were randomized to receive either urea 40% (Group I) or Fr Er:YAG laser (Group II) pretreatment and 9 sessions of MB/PDT over the course of 16 weeks. At baseline, 28- and 40-week follow-ups, clinical efficacy was assessed by digital photographs [allowing determination of the onychomycosis severity index (OSI)], whereas mycological efficacy was assessed by histological examination and fungal culture. Details of the side effects and patients’ satisfaction were also recorded. In both groups, a significant decrease in OSI values was observed at the 28-week follow-up and a slight rebound at the 40-week follow-up. The percentage of nail involvement decreased significantly in both groups at the 28-week follow-up, to continue declining gently in Group I at 40 weeks, in contrast to the rebound observed during this period in Group II. The mycological cure rate was 20% and 30% at 28-week follow-up and 70% and 40% at 40-week follow-up, in Group I and II, respectively. Patients reported being fairly satisfied, and no side effects were detected in any groups. Although both pretreatments favor the action of PDT for the treatment of onychomycosis, the use of urea at 40% is more effective in the medium term.

Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR (2004) Fractional photothermolysis a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 34(5):426–438. https://doi.org/10.1002/lsm.20048CrossRefPubMed

Tierney EP, Kouba DJ, Hanke CW (2009) Review of fractional photothermolysis: treatment indications and efficacy. Dermatol Surg 35(10):1445–1461. https://doi.org/10.1111/j.1524-4725.2009.01258.xCrossRefPubMed

Westerberg DP, Voyack MJ (2013) Onychomycosis: current trends in diagnosis and treatment. Am Fam Physician 88(11):762–770PubMed

Scher RK, Tavakkol A, Sigurgeirsson B et al (2007) Onychomycosis: diagnosis and definition of cure. J Am Acad Dermatol 56(6):939–944. https://doi.org/10.1016/j.jaad.2006.12.019CrossRefPubMed

Aggarwal R, Targhotra M, Kumar B, Sahoo PK, Chauhan MK (2020) Treatment and management strategies of onychomycosis. J Mycol Med 30(2):100949. https://doi.org/10.1016/j.mycmed.2020.100949CrossRefPubMed

Houang J, Perrone G, Mawad D, Boughton PC, Ruys AJ, Lauto A (2018) Light treatments of nail fungal infections. J Biophotonics 11:e201700350. https://doi.org/10.1002/jbio.201700350CrossRef

Kozarev J, Vizintin Z (2010) Novel laser therapy in treatment of onychomycosis. J Laser Health Academy 1:1–8

Giroldo LM, Felipe MP, de Oliveira MA, Munin E, Alves LP, Costa MS (2009) Photodynamic antimicrobial chemotherapy (PACT) with methylene blue increases membrane permeability in Candida albicans. Lasers Med Sci 24(1):109–112. https://doi.org/10.1007/s10103-007-0530-2CrossRefPubMed

Morton CA, Szeimies RM, Sidoroff A, Braathen LR (2013) European guidelines for topical photodynamic therapy part 2: emerging indications-field cancerization, photorejuvenation and inflammatory/infective dermatoses. J Eur Acad Dermatol Venereol 27(6):672–679. https://doi.org/10.1111/jdv.12026CrossRefPubMed

10.

Abdallah M, Abu-Ghali MM, El-Sayed MT, Soltan MY (2022) Fractional CO₂-assisted photodynamic therapy improves the clinical outcome and patient’s satisfaction in toenail onychomycosis treatment: an intra-patient comparative single-center study. J Dermatolog Treat 33(1):542–549. https://doi.org/10.1080/09546634.2020.1771252CrossRefPubMed

11.

de Oliveira GB, Antonio JR, Antonio CR, Tomé FA (2015) The association of fractional CO2 laser 10.600nm and photodynamic therapy in the treatment of onychomycosis. An Bras Dermatol 90(4):468–471. https://doi.org/10.1590/abd1806-4841.20153588CrossRefPubMedPubMedCentral

12.

Morais OO, Costa IMC, Gomes CM, Shinzato DH, Ayres GM, Cardoso RM (2013) The use of Er:YAG 2940nm laser associated to amorolfine lacquer in the treatment of onychomycosis. An Bras Dermatol 88(5):847–849. https://doi.org/10.1590/abd1806-4841.20131932CrossRefPubMedPubMedCentral

13.

Dars S, Banwell HA, Matricciani L (2019) The use of urea for the treatment of onychomycosis: a systematic review. J Foot Ankle Res 12:22. https://doi.org/10.1186/s13047-019-0332-3CrossRefPubMedPubMedCentral

14.

Alberdi E, Gómez C (2020) Methylene blue vs methyl aminolevulinate photodynamic therapy in combination with oral terbinafine in the treatment of severe dermatophytic toenail onychomycosis: short-and long-term effects. Mycoses 63(8):859–868. https://doi.org/10.1111/myc.13125CrossRefPubMed

15.

World Medical Association (2013) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 310(20):2191–2194. https://doi.org/10.1001/jama.2013.281053CrossRef

16.

Alberdi E, Gómez C (2020) Methylene blue vs methyl aminolevulinate photodynamic therapy in the treatment of mild-to-moderate toenail onychomycosis: short- and medium-term effect. Dermatol Ther 33(6):e14280. https://doi.org/10.1111/dth.14280CrossRefPubMed

17.

Carney C, Tosti A, Daniel R et al (2011) A new classification system for grading the severity of onychomycosis: onychomycosis severity index. Arch Dermatol 147(11):1277–1282. https://doi.org/10.1001/archdermatol.2011.267CrossRefPubMed

18.

El-Tatawy RA, Aliweh HA, Hegab DS, Talaat RAZ, Shams Eldeen MA (2019) Fractional carbon dioxide laser and topical tioconazole in the treatment of fingernail onychomycosis. Lasers Med Sci 34(9):1873–1880. https://doi.org/10.1007/s10103-019-02789-2CrossRefPubMed

19.

Zhang J, Zhang Y, Qin J et al (2021) Comparison of a fractional 2940-nm Er:YAG laser and 5% amorolfine lacquer combination therapy versus a 5% amorolfine lacquer monotherapy for the treatment of onychomycosis: a randomized controlled trial. Lasers Med Sci 36(1):147–152. https://doi.org/10.1007/s10103-020-03054-7CrossRefPubMed

20.

Bhatta AK, Keyal U, Huang X, Zhao JJ (2016) Fractional carbon-dioxide (CO₂) laser-assisted topical therapy for the treatment of onychomycosis. J Am Acad Dermatol 74(5):916–923. https://doi.org/10.1016/j.jaad.2015.12.002CrossRefPubMed

21.

Zhou BR, Lu Y, Permatasari F et al (2016) The efficacy of fractional carbon dioxide (CO₂) laser combined with luliconazole 1% cream for the treatment of onychomycosis: a randomized, controlled trial. Medicine (Baltimore) 95(44):e5141. https://doi.org/10.1097/MD.0000000000005141CrossRefPubMed

22.

Zaki AM, Abdo HM, Ebadah MA, Ibrahim SM (2020) Fractional CO₂ laser plus topical antifungal versus fractional CO₂ laser versus topical antifungal in the treatment of onychomycosis. Dermatol Ther 33(1):e13155. https://doi.org/10.1111/dth.13155CrossRefPubMed

23.

Arora S, Ranjan E (2020) Urea occlusion prior to single session fractional CO₂ laser as a treatment in onychomycosis. Indian J Dermatol Venereol Leprol 86(3):331–333. https://doi.org/10.4103/ijdvl.IJDVL_742_19CrossRefPubMed

24.

Bassiri-Jahromi S, Ehsani AH, Mirshams-Shahshahani M, Jamshidi B (2012) A comparative evaluation of combination therapy of fluconazole 1% and urea 40% compared with fluconazole 1% alone in a nail lacquer for treatment of onychomycosis: therapeutic trial. J Dermatolog Treat 23(6):453–456. https://doi.org/10.3109/09546634.2011.588191CrossRefPubMed

25.

Gilaberte Y, Robres MP, Frías MP, García-Doval I, Rezusta A, Aspiroz C (2017) Methyl aminolevulinate photodynamic therapy for onychomycosis: a multicentre, randomized, controlled clinical trial. J Eur Acad Dermatol Venereol 31(2):342–354. https://doi.org/10.1111/jdv.13842CrossRef

26.

Pan M, Heinecke G, Bernardo S, Tsui C, Levitt J (2013) Urea: a comprehensive review of the clinical literature. Dermatol Online J 19(11):20392CrossRefPubMed

27.

Seebacher C, Brasch J, Abeck D et al (2007) Onychomycosis. Mycoses 50(4):321–327. https://doi.org/10.1111/j.1439-0507.2006.01351.xCrossRefPubMed

28.

Hay RJ (2001) The future of onychomycosis therapy may involve a combination of approaches. Br J Dermatol 145(Suppl 60):3–8CrossRefPubMed

Title: Urea versus fractional Er:YAG laser pretreatment of methylene blue photodynamic therapy in the treatment of moderate toenail onychomycosis: short- and medium-term effects
Authors: Enrique Alberdi
Clara Gómez
Publication date: 31-10-2022
Publisher: Springer Berlin Heidelberg
Keywords: Photodynamic Therapy
Onychomycosis
Laser
Published in: Archives of Dermatological Research / Issue 4/2023
Print ISSN: 0340-3696
Electronic ISSN: 1432-069X
DOI: https://doi.org/10.1007/s00403-022-02448-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Urea versus fractional Er:YAG laser pretreatment of methylene blue photodynamic therapy in the treatment of moderate toenail onychomycosis: short- and medium-term effects

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

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