Successful Treatment of Idiopathic Onychodystrophy With 300 Microsecond 1064 nm Nd:YAG Laser

July 2015 | Volume 14 | Issue 7 | Case Report | 750 | Copyright © 2015

Omer Ibrahim, MD,a Joseph Doumit MD FRCPC,b Alexandra Zhang MDc

aDepartment of Dermatology, Cleveland Clinic Foundation, Cleveland, OH bDepartment of Dermatology, University of Ottawa, Ottawa, Ontario, Canada cDepartment of Dermatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH

Abstract

Onychodystrophy is the temporary or permanent change in the nail structures. It can be secondary to an inflammatory condition or infectious disease, however many cases of onychodystrophy are idiopathic in nature. In secondary onychodystrophy the treatment is directed towards the underlying process, with subsequent improvement in the appearance of the affected nails depending on the etiology. Dystrophy secondary to onychomycosis is particularly difficult to treat. In permanent idiopathic nail dystrophy, treatment is often unsatisfactory. Destructive nail changes are not only cosmetically displeasing, but also at times physically painful and socially embarrassing. The literature on the treatment of purely idiopathic nail dystrophy is extremely scarce. To our knowledge there exists only one report of two cases of idiopathic onychodystrophy successfully treated with fractional carbon dioxide laser and topical corticosteroids. In this report, we present the first cases of idiopathic onychodystrophy successfully treated with a 1064 nm neodymium-doped yttrium aluminum garnet laser.

J Drugs Dermatol. 2015;14(7):750-752.

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INTRODUCTION

Onychodystrophy is defined as damage to the nail structures and can be temporary or permanent in nature.1 It can be physically painful and socially embarrassing. Pathogenesis may be idiopathic, secondary to infectious causes, most commonly dermatophyte infection, or associated with systemic disease.2 In onychodystrophy associated with dermatophyte onychomycosis, oral anti-fungal medications have shown cure rates from 50% to 80%, and laser treatments have yielded highly variable results with high rate of recurrence.3,4 Moreover, literature on the laser treatment of idiopathic onychodystrophy is extremely scant. A single report described the improvement in two cases following treatment with fractional carbon dioxide laser and topical steroids.2 Here we report the first cases of idiopathic nail dystrophy successfully treated with a 1064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser.

Case 1

A 56-year-old woman presented with dystrophy of her bilateral thumbnails of at least 10 years duration. On examination, her bilateral thumbs exhibited significant dystrophic changes (Figure 1A). She denied any inciting medications or systemic disease. Three clippings over the years were negative for dermatophyte infection on microscopy as well as fungal culture. A diagnosis of idiopathic onychodystrophy was made, and treatment of the dystrophic thumbnails with the 1064 nm Nd:YAG laser was initiated. The laser treatment was targeted at the nail plate, the nail folds, and the entire cuticle, in order to target the nail matrix. Laser settings included a spot size of 5 mm, fluence of 16 Joules/cm,2 and pulse duration of 300 microseconds at a rate of 7 Hz. Between 200 and 450 pulses were administered in total to both nails at each visit. The patient underwent six treatments, at 4 to 6 week intervals. Significant clinical improvement in the appearance of the bilateral thumbnails was noted at the end of her treatments (Figure 1B).

Case 2

A 73-year-old woman presented with persistent painful pincer-nail deformity of the bilateral thumbs of at least two years duration. On examination, significant lateral pincer-nail deformities were present in both thumbnails (Figure 2A). Nail biopsies over the years were negative for infection and the patient had no underlying contributing diseases. She underwent treatment with the 1064 nm Nd:YAG laser using the same parameters above, at an interval of 4 to 6 weeks between each session. Between 230 and 550 pulses in total were administered to both nails at each visit. After 9 treatments, the patient demonstrated substantial improvement in the deformity in her nails (Figure 2B) and significant reduction in pain from the dystrophic nail changes.

Case 3

A 46-year-old woman presented with dystrophic, yellow toenails bilaterally of about five years duration. On physical exam, her bilateral toenails exhibited significant yellowish discoloration, thickening, and increased curvature of the nail plate (Figure 3A). Work-up over the years revealed negative fungal cultures and negative personal history of cutaneous or systemic disease. As above, she underwent treatment with the 1064 nm Nd:YAG laser using the same parameters previously

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