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Konisky H, Klinger R, Coe L, Jaller JA, Cohen JL, Kobets K. A focused review on laser- and energy-assisted drug delivery for nail disorders. Lasers Med Sci 2024; 39:39. [PMID: 38240827 PMCID: PMC10799127 DOI: 10.1007/s10103-024-03992-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024]
Abstract
The purpose of this review is to consolidate and summarize laser-assisted drug delivery (LADD) for nail diseases, particularly onychomycosis and psoriasis. A PubMed search was conducted in June 2023 using search terms (1) "laser assisted drug delivery" AND "nail," (2) "laser" AND "nail," and (3) "nail disorder" AND "laser treatment." References of papers were also reviewed, yielding 15 papers for this review. Fractional ablative CO2 laser (FACL) and Er:YAG laser can be used for LADD of topical medications such as amorolfine, terbinafine, and tioconazole to treat onychomycosis. A fungal culture should be performed to determine the type of dermatophyte, which will help determine which topical will be most effective. Laser settings varied between studies, but overall LADD tended to be more effective than topical treatments alone. Laser-assisted photodynamic therapy (PDT) was also found to be effective in treating onychomycosis. For psoriatic nails, LADD was used to deliver calcipotriol-betamethasone dipropionate foam, tazarotene, triamcinolone, or methotrexate into the nail. Again, LADD was found to be significantly more effective than topical treatment alone. FACL was the only laser noted for use for LADD in both diseases. Laser-assisted drug delivery for nail disease is a newer approach for onychomycosis and nail psoriasis with several benefits and drawbacks. Dermatologists should discuss the option of LADD with their patients who have recalcitrant onychomycosis or nail psoriasis.
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Affiliation(s)
- Hailey Konisky
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA.
| | - Raquel Klinger
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Lesley Coe
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Jose A Jaller
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Joel L Cohen
- AboutSkin Dermatology and DermSurgery, Greenwood Village, CO, USA
| | - Kseniya Kobets
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Ave, Bronx, NY, 10461, USA
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2
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Luo OD, Bose R, Bawazir MA, Thuraisingam T, Ghazawi FM. A Review of the Dermatologic Clinical Applications of Topical Photodynamic Therapy. J Cutan Med Surg 2024; 28:NP1. [PMID: 38243786 DOI: 10.1177/12034754231216969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Topical photodynamic therapy is a widely approved therapy for actinic keratoses and low-risk nonmelanoma skin cancers with a rapidly growing range of emerging indications for other cutaneous diseases. This review summarizes the best-available evidence to provide a clinical update for dermatologists on the approved and emerging indications of photodynamic therapy. The body of evidence suggests that photodynamic therapy is superior or noninferior to other available treatment modalities for actinic keratoses, low-risk basal cell carcinomas, Bowen's disease, skin field cancerization, chemoprevention of keratinocyte carcinomas in organ transplant recipients, photoaging, acne vulgaris, and cutaneous infections including verrucae, onychomycosis, and cutaneous leishmaniasis. There is emerging evidence that photodynamic therapy plays a role in the management of actinic cheilitis, early-stage mycosis fungoides, extramammary Paget disease, lichen sclerosis, and folliculitis decalvans but there are no comparative studies with other active treatment modalities. Common barriers to topical photodynamic therapy include procedural pain, costs, and the time required for treatment delivery. There is significant heterogeneity in the photodynamic therapy protocols reported in the literature, including different photosensitizers, light sources, number of treatments, time between treatments, and use of procedural analgesia. Topical photodynamic therapy should be considered in the management of a spectrum of inflammatory, neoplastic, and infectious dermatoses. However, more comparative research is required to determine its role in the treatment algorithm for these dermatologic conditions and more methodological research is required to optimize photodynamic therapy protocols to improve the tolerability of the procedure for patients.
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Affiliation(s)
- Owen Dan Luo
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Reetesh Bose
- Division of Dermatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed A Bawazir
- Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Thusanth Thuraisingam
- Division of Dermatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Dermatology, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Feras M Ghazawi
- Division of Dermatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Dermatology, Department of Medicine, McGill University, Montreal, QC, Canada
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Ng WHS, Smith SD. Laser-Assisted Drug Delivery: A Systematic Review of Safety and Adverse Events. Pharmaceutics 2022; 14:pharmaceutics14122738. [PMID: 36559233 PMCID: PMC9787022 DOI: 10.3390/pharmaceutics14122738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Laser-assisted drug delivery (LADD) is an increasingly studied and applied methodology for drug delivery. It has been used in a wide variety of clinical applications. Given the relatively low barrier to entry for clinicians as well as ongoing research in this area, the authors aimed to review outcomes relating to safety in laser-assisted drug delivery. A systematic review was conducted, with the databases PubMed, Medline and Embase searched in September 2022. Included articles were those that mentioned laser-assisted drug delivery in human subjects that also reported adverse effects or safety outcomes. There were no language-based exclusions. Conference abstracts and literature reviews were excluded. The results were then tabulated and categorized according to the application of LADD. In total, 501 articles were obtained. Following deduplication, screening, and full text review 70 articles of various study designs were included. Common findings were erythema, oedema, pain, and crusting following LADD. Several notably more severe adverse effects such as generalized urticaria, infection, scarring and dyspigmentation were noted. However, these events were varied depending on the clinical use of LADD. Relevant negatives were also noted whereby no studies reported life-threatening adverse effects. Limitations included limited details regarding the adverse effects within the full texts, lack of follow-up, and risk of bias. In conclusion, there were multiple adverse effects that clinicians should consider prior to carrying out LADD, where treatment goals and patient tolerability should be considered. Further evidence is needed to quantitatively determine these risks.
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Affiliation(s)
| | - Saxon D. Smith
- ANU Medical School, ANU College of Health and Medicine, Australian National University, Canberra, ACT 2601, Australia
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4
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Labadie JG, Ibrahim SA, Worley B, Kang BY, Rakita U, Rigali S, Arndt KA, Bernstein E, Brauer JA, Chandra S, Didwania A, DiGiorgio C, Donelan M, Dover JS, Galadari H, Geronemus RG, Goldman MP, Haedersdal M, Hruza G, Ibrahimi OA, Kauvar A, Kelly KM, Krakowski AC, Miest R, Orringer JS, Ozog DM, Ross EV, Shumaker PR, Sobanko JF, Suozzi K, Taylor MB, Teng JMC, Uebelhoer NS, Waibel J, Wanner M, Ratchev I, Christensen RE, Poon E, Miller CH, Alam M. Evidence-Based Clinical Practice Guidelines for Laser-Assisted Drug Delivery. JAMA Dermatol 2022; 158:1193-1201. [PMID: 35976634 DOI: 10.1001/jamadermatol.2022.3234] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Laser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD. Objective To develop recommendations for the safe and effective use of LADD. Evidence Review A systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved. Findings Of the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline's 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections. Conclusions and Relevance This systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.
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Affiliation(s)
- Jessica G Labadie
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sarah A Ibrahim
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Brandon Worley
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Bianca Y Kang
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Uros Rakita
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Sarah Rigali
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Kenneth A Arndt
- SkinCare Physicians, Chestnut Hill, Massachusetts.,Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Eric Bernstein
- Main Line Center for Laser Surgery, Ardmore, Pennsylvania
| | - Jeremy A Brauer
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York
| | - Sunandana Chandra
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Aashish Didwania
- Department of Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Mattias Donelan
- Shriners Hospital for Children-Boston, Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey S Dover
- SkinCare Physicians, Chestnut Hill, Massachusetts.,Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Hassan Galadari
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | | | - Mitchel P Goldman
- Cosmetic Laser Dermatology, West Dermatology Company, San Diego, California
| | - Merete Haedersdal
- Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark.,Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - George Hruza
- Departments of Dermatology and Otolaryngology, St Louis University-Laser and Dermatologic Surgery Center, St Louis, Missouri
| | | | - Arielle Kauvar
- New York Laser & Skin Care, New York.,New York University Grossman School of Medicine, New York, New York
| | - Kristen M Kelly
- Department of Dermatology, University of California Irvine School of Medicine, Irvine
| | - Andrew C Krakowski
- Department of Dermatology, St. Luke's University Health Network, Easton, Pennsylvania
| | - Rachel Miest
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey S Orringer
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | | | - Peter R Shumaker
- Veterans Affairs San Diego Healthcare System and University of California, San Diego, California
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen Suozzi
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Mark B Taylor
- Gateway Aesthetic Institute & Laser Center, Salt Lake City, Utah
| | - Joyce M C Teng
- Department of Dermatology, School of Medicine, Stanford University, Stanford, California
| | | | - Jill Waibel
- Miami Dermatology and Laser Institute, Miami, Florida
| | - Molly Wanner
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ina Ratchev
- Section of Cutaneous Surgery, Northwestern Medical Group, Chicago, Illinois
| | - Rachel E Christensen
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Corinne H Miller
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ortner VK, Nguyen N, Brewer JR, Solovyeva V, Haedersdal M, Philipsen PA. Fractional CO 2 laser ablation leads to enhanced permeation of a fluorescent dye in healthy and mycotic nails-An imaging investigation of laser-tissue effects and their impact on ungual drug delivery. Lasers Surg Med 2022; 54:861-874. [PMID: 35451510 PMCID: PMC9544547 DOI: 10.1002/lsm.23541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/10/2022] [Accepted: 03/14/2022] [Indexed: 12/03/2022]
Abstract
Purpose Conventional oral antifungal therapies for onychomycosis (OM) often do not achieve complete cure and may be associated with adverse effects, medical interactions, and compliance issues restricting their use in a large group of patients. Topical treatment can bypass the systemic side effects but is limited by the physical barrier of the nail plate. Ablative fractional laser (AFL) treatment can be used to improve the penetration of topical drugs into the nail. This study visualized the effects of laser ablation of nail tissue and assessed their impact on the biodistribution of a fluorescent dye in healthy and fungal nail tissue. Methods For the qualitative assessment of CO2 AFL effects on healthy nail tissue, scanning electron microscopy (SEM), coherent anti‐Stokes Raman scattering microscopy (CARS‐M), and widefield fluorescence microscopy (WFM) were used. To quantitate the effect of laser‐pretreatment on the delivery of a fluorescent dye, ATTO‐647N, into healthy and fungal nail tissue, ablation depth, nail plate thickness, and ATTO‐647N fluorescence intensity in three nail plate layers were measured using WFM. A total of 30 nail clippings (healthy n = 18, fungal n = 12) were collected. An aqueous ATTO‐647N solution was directly applied to the dorsal surface of 24 nail samples (healthy n = 12, fungal n = 12) and incubated for 4 hours, of which half (healthy n = 6, fungal n = 6) had been pretreated with AFL (30 mJ/mb, 15% density, 300 Hz, pulse duration <1 ms). Results Imaging revealed a three‐layered nail structure, an AFL‐induced porous ablation crater, and changes in autofluorescence. While intact fungal samples showed a 106% higher ATTO‐647N signal intensity than healthy controls, microporation led to a significantly increased fluorophore permeation in all samples (p < 0.0001). AFL processing of nail tissue enhanced topical delivery of ATTO‐647N in all layers, (average increase: healthy +108%, fungal +33%), most pronounced in the top nail layer (healthy +122%, fungal +68%). While proportionally deeper ablation craters correlated moderately with higher fluorescence intensities in healthy nail tissue, fungal samples showed no significant relationship. Conclusion Fractional CO2 laser microporation is a simple way of enhancing the passive delivery of topically applied ATTO‐647N. Although the impaired nail plate barrier in OM leads to greater diffusion of the aqueous solution, AFL can increase the permeability of both structurally deficient and intact nails.
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Affiliation(s)
- Vinzent Kevin Ortner
- Department of Dermatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Nhi Nguyen
- Department of Dermatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Jonathan R Brewer
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Vita Solovyeva
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark.,Faculty of Mathematics and Science, University of Oldenburg, Oldenburg, Germany
| | - Merete Haedersdal
- Department of Dermatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Peter Alshede Philipsen
- Department of Dermatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
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6
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Wang D, Kuzma ML, Tan X, He TC, Dong C, Liu Z, Yang J. Phototherapy and optical waveguides for the treatment of infection. Adv Drug Deliv Rev 2021; 179:114036. [PMID: 34740763 PMCID: PMC8665112 DOI: 10.1016/j.addr.2021.114036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/11/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023]
Abstract
With rapid emergence of multi-drug resistant microbes, it is imperative to seek alternative means for infection control. Optical waveguides are an auspicious delivery method for precise administration of phototherapy. Studies have shown that phototherapy is promising in fighting against a myriad of infectious pathogens (i.e. viruses, bacteria, fungi, and protozoa) including biofilm-forming species and drug-resistant strains while evading treatment resistance. When administered via optical waveguides, phototherapy can treat both superficial and deep-tissue infections while minimizing off-site effects that afflict conventional phototherapy and pharmacotherapy. Despite great therapeutic potential, exact mechanisms, materials, and fabrication designs to optimize this promising treatment option are underexplored. This review outlines principles and applications of phototherapy and optical waveguides for infection control. Research advances, challenges, and outlook regarding this delivery system are rigorously discussed in a hope to inspire future developments of optical waveguide-mediated phototherapy for the management of infection and beyond.
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Affiliation(s)
- Dingbowen Wang
- Department of Biomedical Engineering, Materials Research Institute, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Michelle Laurel Kuzma
- Department of Biomedical Engineering, Materials Research Institute, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Xinyu Tan
- Department of Biomedical Engineering, Materials Research Institute, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA; Academy of Orthopedics, Provincial Key Laboratory of Bone and Joint Degenerative Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong Province 510280, China
| | - Tong-Chuan He
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Medical Center, Chicago, IL 60637, USA; Department of Surgery, The University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Cheng Dong
- Department of Biomedical Engineering, Materials Research Institute, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Zhiwen Liu
- Department of Electrical Engineering, Materials Research Institute, The Pennsylvania State University, University Park, PA 16802, USA
| | - Jian Yang
- Department of Biomedical Engineering, Materials Research Institute, The Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802, USA.
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Chang MJ, Qiu Y, Lipner SR. Race reporting and representation in onychomycosis clinical trials: A systematic review. Mycoses 2021; 64:954-966. [PMID: 33655595 DOI: 10.1111/myc.13262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Onychomycosis is the most common nail disease seen in clinical practice. Inclusion of diverse groups in onychomycosis clinical trials subjects is necessary to generalise efficacy data. OBJECTIVES We aimed to systematically review race and ethnicity reporting and representation, as well as, treatment outcomes in onychomycosis clinical trials. METHODS A PubMed search for onychomycosis clinical trials was performed in August 2020. Primary clinical trial data were included and post hoc analyses were excluded. Categorical variables were compared using chi-squared and Fisher's exact tests. Statistical significance was set at p < .05. Photos in articles were categorised by Fitzpatrick skin type. RESULTS Only 32/182 (17.5%) trials reported on race and/or ethnicity and only one trial compared treatment efficacy in different subgroups. Darker skin colours were infrequently depicted in articles. Topical treatment, location with ≥1 US-based site, industry funding type and publication date after 2000 were significantly associated with reporting of racial/ethnic data (p < .05 for all comparisons). LIMITATIONS Demographics on excluded subjects and methods of recruitment were not available. Assigning Fitzpatrick skin type is inherently subjective. CONCLUSIONS This study highlights a need for consistent reporting of races and ethnicities of onychomycosis clinical trial participants with subgroup analyses of treatment efficacies.
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Affiliation(s)
| | - Yuqing Qiu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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8
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Shehadeh W, Matz H, Ellenbogen E, Sprecher E, Artzi O. Pulse-Dye Laser Followed by Betamethasone-Calcipotriol and Fractional Ablative CO2-Laser-Assisted Delivery for Nail Psoriasis. Dermatol Surg 2021; 47:e111-6. [PMID: 33795567 DOI: 10.1097/DSS.0000000000002835] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nail psoriasis is a common and potentially debilitating condition for which no effective and safe nonsystemic therapy is currently available. Recently, laser-assisted drug delivery (LADD) is being increasingly used to facilitate transcutaneous penetration of topical treatments. OBJECTIVES We set to assess the efficacy and safety of combined pulse-dye laser and fractional CO2 laser-assisted betamethasonecalcipotriol gel delivery for the treatment of nail psoriasis. MATERIAL AND METHODS We conducted a prospective, intrapatient comparative study in a series of 22 patients with bilateral fingernail psoriasis. Nails on the randomized hand were treated with 3 monthly sessions of pulse-dye laser to the proximal and lateral nail folds followed by fractional ablative CO2 laser to the nail plate. Between treatments and one month following the last treatment, the participants applied betamethasone propionate-calcipotriol gel once daily to the nail plate. Clinical outcome was ascertained using nails photography, the Nail Psoriasis Severity Index (NAPSI) and patient satisfaction. RESULTS Seventeen completed the study. Three participants withdrew from the study because of treatment-associated pain. Treatment was associated with a statistically significant improvement of the NAPSI scale (p < .002). Patient satisfaction was high. CONCLUSION Combined PDL and fractional ablative CO2-LADD of betamethasone-calcipotriol gel should be considered for the treatment of nail psoriasis.
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9
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Alberdi E, Gómez C. Methylene blue vs methyl aminolevulinate photodynamic therapy in the treatment of mild-to-moderate toenail onychomycosis: Short- and medium-term effects. Dermatol Ther 2020; 33:e14280. [PMID: 32890444 DOI: 10.1111/dth.14280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 11/28/2022]
Abstract
Photodynamic therapy (PDT) has emerged as an interesting alternative option for onychomycosis treatment. The impact of a specific photosensitizer (PS) on the final result is an important factor to consider. We conducted a short- and medium-term controlled trial to compare the effectiveness of PDT in the treatment of mild-to-moderate onychomycosis when it is mediated by two different PSs. Twenty patients were randomized to receive nine sessions of PDT distributed over 16 weeks mediated either by methylene blue (MB/PDT group) or methyl aminolevulinate (MAL/PDT group). Onychomycosis severity index (OSI) and nail involvement were checked along the study. Complete cure, treatment success, and clinical improvement were tabulated at 16 and 40-week follow-ups. OSI scores decreased significantly along the study, from 12.1 ± 5.4 to 3.6 ± 3.2 (MB/PDT group) and from 14.8 ± 6.0 to 5.4 ± 4.4 (MAL/PDT group). At 16-week follow-up, only 20% of the patients in the MB/PDT group reached complete cure and none in the group of MAL/PDT. At 40-week follow-up, complete cure rates were 70% and 40% in the MB/PDT group and MAL/PDT group respectively. Both modalities showed good outcomes in treatment of moderate toenail onychomycosis. MB/PDT showed a faster action but with relapse rates slightly higher than MAL/PDT.
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Affiliation(s)
| | - Clara Gómez
- Institute of Physical Chemistry Rocasolano, CSIC, Madrid, Spain
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10
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Shen JJ, Jemec GB, Arendrup MC, Saunte DML. Photodynamic therapy treatment of superficial fungal infections: A systematic review. Photodiagnosis Photodyn Ther 2020; 31:101774. [DOI: 10.1016/j.pdpdt.2020.101774] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 01/31/2023]
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Abstract
BACKGROUND Onychomycosis refers to fungal infections of the nail apparatus that may cause pain, discomfort, and disfigurement. This is an update of a Cochrane Review published in 2007; a substantial amount of new research warrants a review exclusively on toenails. OBJECTIVES To assess the clinical and mycological effects of topical drugs and device-based therapies for toenail onychomycosis. SEARCH METHODS We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials. SELECTION CRITERIA Randomised controlled trials of topical and device-based therapies for onychomycosis in participants with toenail onychomycosis, confirmed by positive cultures, direct microscopy, or histological nail examination. Eligible comparators were placebo, vehicle, no treatment, or an active topical or device-based treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Primary outcomes were complete cure rate (normal-looking nail plus fungus elimination, determined with laboratory methods) and number of participants reporting treatment-related adverse events. MAIN RESULTS We included 56 studies (12,501 participants, average age: 27 to 68 years), with mainly mild-to-moderate onychomycosis without matrix involvement (where reported). Participants had more than one toenail affected. Most studies lasted 48 to 52 weeks; 23% reported disease duration (variable). Thirty-five studies specifically examined dermatophyte-caused onychomycosis. Forty-three studies were carried out in outpatient settings. Most studies assessed topical treatments, 9% devices, and 11% both. We rated three studies at low risk of bias across all domains. The most common high-risk domain was performance bias. We present results for key comparisons, where treatment duration was 36 or 48 weeks, and clinical outcomes were measured at 40 to 52 weeks. Based on two studies (460 participants), compared with vehicle, ciclopirox 8% lacquer may be more effective in achieving complete cure (risk ratio (RR) 9.29, 95% confidence interval (CI) 1.72 to 50.14; low-quality evidence) and is probably more effective in achieving mycological cure (RR 3.15, 95% CI 1.93 to 5.12; moderate-quality evidence). Ciclopirox lacquer may lead to increased adverse events, commonly application reactions, rashes, and nail alteration (e.g. colour, shape). However, the 95% CI indicates that ciclopirox lacquer may actually make little or no difference (RR 1.61, 95% CI 0.89 to 2.92; low-quality evidence). Efinaconazole 10% solution is more effective than vehicle in achieving complete cure (RR 3.54, 95% CI 2.24 to 5.60; 3 studies, 1716 participants) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53; 2 studies, 1655 participants) (both high-quality evidence) and is probably more effective in achieving mycological cure (RR 2.31, 95% CI 1.08 to 4.94; 3 studies, 1716 participants; moderate-quality evidence). Risk of adverse events (such as dermatitis and vesicles) was slightly higher with efinaconazole (RR 1.10, 95% CI 1.01 to 1.20; 3 studies, 1701 participants; high-quality evidence). No other key comparison measured clinical cure. Based on two studies, compared with vehicle, tavaborole 5% solution is probably more effective in achieving complete cure (RR 7.40, 95% CI 2.71 to 20.24; 1198 participants), but probably has a higher risk of adverse events (application site reactions were most commonly reported) (RR 3.82, 95% CI 1.65 to 8.85; 1186 participants (both moderate-quality evidence)). Tavaborole improves mycological cure (RR 3.40, 95% CI 2.34 to 4.93; 1198 participants; high-quality evidence). Moderate-quality evidence from two studies (490 participants) indicates that P-3051 (ciclopirox 8% hydrolacquer) is probably more effective than the comparators ciclopirox 8% lacquer or amorolfine 5% in achieving complete cure (RR 2.43, 95% CI 1.32 to 4.48), but there is probably little or no difference between the treatments in achieving mycological cure (RR 1.08, 95% CI 0.85 to 1.37). We found no difference in the risk of adverse events (RR 0.60, 95% CI 0.19 to 1.92; 2 studies, 487 participants; low-quality evidence). The most common events were erythema, rash, and burning. Three studies (112 participants) compared 1064-nm Nd:YAG laser to no treatment or sham treatment. We are uncertain if there is a difference in adverse events (very low-quality evidence) (two studies; 85 participants). There may be little or no difference in mycological cure at 52 weeks (RR 1.04, 95% CI 0.59 to 1.85; 2 studies, 85 participants; low-quality evidence). Complete cure was not measured. One study (293 participants) compared luliconazole 5% solution to vehicle. We are uncertain whether luliconazole leads to higher rates of complete cure (very low-quality evidence). Low-quality evidence indicates there may be little or no difference in adverse events (RR 1.02, 95% CI 0.90 to 1.16) and there may be increased mycological cure with luliconazole; however, the 95% CI indicates that luliconazole may make little or no difference to mycological cure (RR 1.39, 95% CI 0.98 to 1.97). Commonly-reported adverse events were dry skin, paronychia, eczema, and hyperkeratosis, which improved or resolved post-treatment. AUTHORS' CONCLUSIONS Assessing complete cure, high-quality evidence supports the effectiveness of efinaconazole, moderate-quality evidence supports P-3051 (ciclopirox 8% hydrolacquer) and tavaborole, and low-quality evidence supports ciclopirox 8% lacquer. We are uncertain whether luliconazole 5% solution leads to complete cure (very low-quality evidence); this outcome was not measured by the 1064-nm Nd:YAG laser comparison. Although evidence supports topical treatments, complete cure rates with topical treatments are relatively low. We are uncertain if 1064-nm Nd:YAG laser increases adverse events compared with no treatment or sham treatment (very low-quality evidence). Low-quality evidence indicates that there is no difference in adverse events between P-3051 (ciclopirox hydrolacquer), luliconazole 5% solution, and their comparators. Ciclopirox 8% lacquer may increase adverse events (low-quality evidence). High- to moderate-quality evidence suggests increased adverse events with efinaconazole 10% solution or tavaborole 5% solution. We downgraded evidence for heterogeneity, lack of blinding, and small sample sizes. There is uncertainty about the effectiveness of device-based treatments, which were under-represented; 80% of studies assessed topical treatments, but we were unable to evaluate all of the currently relevant topical treatments. Future studies of topical and device-based therapies should be blinded, with patient-centred outcomes and an adequate sample size. They should specify the causative organism and directly compare treatments.
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Affiliation(s)
- Kelly Foley
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Aditya K Gupta
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Sarah Versteeg
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Rachel Mays
- Mediprobe Research Inc.645 Windermere RoadLondonONCanadaN5X 2P1
| | - Elmer Villanueva
- Xi'an Jiaotong‐Liverpool UniversityDepartment of Public Health111 Ren'ai Road, Dushu Lake Higher Education TownSuzhou Industrial ParkSuzhouJiangsuChina
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Morton CA, Szeimies RM, Basset-Séguin N, Calzavara-Pinton PG, Gilaberte Y, Haedersdal M, Hofbauer GFL, Hunger RE, Karrer S, Piaserico S, Ulrich C, Wennberg AM, Braathen LR. European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications - field cancerization, photorejuvenation and inflammatory/infective dermatoses. J Eur Acad Dermatol Venereol 2019; 34:17-29. [PMID: 31805604 DOI: 10.1111/jdv.16044] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022]
Abstract
In addition to approved indications in non-melanoma skin cancer in immunocompetent patients, topical photodynamic therapy (PDT) has also been studied for its place in the treatment of, as well as its potential to prevent, superficial skin cancers in immune-suppressed patients, although sustained clearance rates are lower than for immune-competent individuals. PDT using a nanoemulsion of ALA in a daylight or conventional PDT protocol has been approved for use in field cancerization, although evidence of the potential of the treatment to prevent new SCC remained limited. High-quality evidence supports a strong recommendation for the use of topical PDT in photorejuvenation as well as for acne, refractory warts, cutaneous leishmaniasis and in onychomycosis, although these indications currently lack approvals for use and protocols remain to be optimized, with more comparative evidence with established therapies required to establish its place in practice. Adverse events across all indications for PDT can be minimized through the use of modified and low-irradiance regimens, with a low risk of contact allergy to photosensitizer prodrugs, and no other significant documented longer-term risks with no current evidence of cumulative toxicity or photocarcinogenic risk. The literature on the pharmacoeconomics for using PDT is also reviewed, although accurate comparisons are difficult to establish in different healthcare settings, comparing hospital/office-based therapies of PDT and surgery with topical ointments, requiring inclusion of number of visits, real-world efficacy as well as considering the value to be placed on cosmetic outcome and patient preference. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical photodynamic therapy in Dermatology prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.
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Affiliation(s)
- C A Morton
- Department of Dermatology, Stirling Community Hospital, Stirling, UK
| | - R-M Szeimies
- Department of Dermatology, Regensburg University Hospital, Regensburg, Germany.,Department of Dermatology & Allergology, Klinikum Vest GmbH, Recklinghausen, Germany
| | - N Basset-Séguin
- Department of Dermatology, Hôpital Saint Louis, Paris, France
| | | | - Y Gilaberte
- Department of Dermatology, Hospital Universitario miguel servet IIS Aragón, Zaragoza, Spain
| | - M Haedersdal
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - G F L Hofbauer
- Department of Dermatology, Zürich University Hospital, Zürich, Switzerland
| | - R E Hunger
- Department of Dermatology Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Karrer
- Department of Dermatology, Regensburg University Hospital, Regensburg, Germany
| | - S Piaserico
- Unit of Dermatology, Department of Medicine, University of Padova, Padova, Italy
| | - C Ulrich
- Skin Cancer Centre, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - A-M Wennberg
- Department of Dermatology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol 2018; 80:853-867. [PMID: 29959962 DOI: 10.1016/j.jaad.2018.05.1260] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 11/16/2022]
Abstract
Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.
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Affiliation(s)
- Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York.
| | - Richard K Scher
- Department of Dermatology, Weill Cornell Medicine, New York, New York
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