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
