Laser for Fungal Nail Infection (Onychomycosis)

Fungal nail infection is a very common disorder affecting about 10% of adults generally in the UK, rising to 50% of the over 70 year age bracket. It is caused by a fungus which attacks the fingernails or more commonly toenails. The fungus usually ends up deep down in the nail bed which is the skin under the nail. This fungus is often from the same group of fungi that causes Athlete’s foot and may be a secondary condition from that source. It is not considered a serious condition in healthy people but it can be unpleasant and untreated can cause more serious damage such as cellulitis in the surrounding tissue. People with conditions such as diabetes or those who have a weakened immune system can be more seriously affected. It is sometimes difficult to treat with over-the-counter anti-fungal products and this may take up to two years to clear the infection. Oral prescriptions can have side effects that prohibit their use. Laser treatments are therefore becoming a suitable alternative to completely solve the problem, but is only available privately.

The main symptoms of fungal nail infection are discoloured nails which turn white, black, yellow or even green and a thickening and brittling of the nail so it becomes fragile and crumbly. This makes cutting nails and caring for the hands and feet very difficult. It may also prevent the nail from being painted or manicured in the usual way. Untreated, the symptoms will only worsen and may spread to other digits or to other people in close contact with you. Even though it may be a purely cosmetic nuisance it does need to be dealt with to ensure it doesn’t spread or become more severe.

If you are considering fungal nail treatment, the following information will give you a basic understanding of the laser procedure. It can't answer all your questions, since a lot depends on your individual diagnosis. Please ask your practitioner about anything you don't understand.

Fungal nail infections, known medically as Onychomycosis, is caused by the growth of a fungus in the nail and possibly the nail bed. All fungal spores grow where the conditions are dark, moist and warm, and hands and feet are a perfect environment for them.

You can be infected from changing rooms or from an Athlete’s foot infection or even from cosmetic treatment such as manicures and pedicures if the equipment is not sterilised effectively. Wherever it comes from, once you have an infection it is difficult to treat as the fungus doesn’t just grow on the surface but spreads down into the nail and into the skin underneath.

The first sign of an infection is a discolouration of the nail usually starting white and spreading up the nail as it grows carrying the infection with it. If the blood supply from the nail bed is affected the nail may turn red or black, and if it leads to a bacterial infection there may be a green discolouration. The nail becomes thickened and difficult to cut or trim and through the pressure from shoes it can become brittle and fragile and portions can break off. Eventually, the nail bed and nail may separate, and that becomes a more difficult problem to rectify. The infection must be eliminated from the base of the nail bed entirely to remove the fungus. A healthy, infection free nail will then grow out, with the infected portion removed by normal trimming. Depending on the growth rate it can take up to a year for the nail to return to normal. During this time, good hygiene should prevent further infection, but it is a rigorous routine.

Left untreated the problem is highly unlikely to resolve itself. There is also the risk that the infection will spread from digit to digit and to other people you are in close contact with.

There are a variety of anti-fungal ‘paints’ available online or from pharmacists, High street chemists or supermarkets that involve filing the surface of the nail and applying some form of liquid regularly. Your GP can prescribe these treatments, or anti-fungal medication, but the side effects can be severe for oral treatments and some GPs are reluctant to recommend these drugs for such a mild infection.

Anti-fungal paints are in a liquid form and after roughening the surface of the nail with a file they are applied regularly to the surface. There are many brands with different active anti-fungal ingredients such as miconazole. Their effectiveness varies with each product but generally they may cure 60-80% of mild cases. For most people these products seem to be a good place to start when you are suffering from a mild infection. The product protocol has to be strictly adhered to and most experts say that the use of cosmetic nail varnish is not recommended during treatment.

There are plenty of home remedies which are touted, ranging from coconut oil, bleach, vinegar, menthol chest rub and herbs such as lavender or cloves, to name just a few. How effective these are is certainly debatable, and most of them have just one or two proponents and very little other evidence in support of their use.

Oral medication is only available on prescription and there are two main active anti-fungal ingredients used in these tablets - Terbinafine or Azoles, although there are others available. The side effects can include headaches, itching, loss of taste, nausea and diarrhoea. Anyone with liver or kidney problems or a heart disorder would probably not be prescribed these drugs for a relatively mild infection of their nails, and anyone taking them should be warned about the side effects. Liver function checks when taking Terbinafine and heart checks for Itraconazole are standard practice. Not surprisingly doctors and patients are often deterred from using these oral tablets for this condition.

Laser treatments is usually a last resort for eradicating a stubborn or widespread infection, after the realisation that other options are simply not effective enough. Lasers use high energy light to destroy the fungus in-situ without affecting the surrounding tissue. The treatment would usually start with filing the surface of the nail to thin it and allow deeper penetration of the laser light.

All treatments will need the new nail to grow from an un-infected nail base in order to replace the infected nail, and that can take from 3 -12 months depending on the person.

Usually, you should expect a treatment, whatever the method, to cure this disorder. As there is potential for the fungus to spread and re-infect other nails or even be passed onto other people, an improvement in the condition is not an acceptable outcome.

There are two types of laser treatment that are effective in treating fungal nail infections. Both would require any excessive thickening of the nail to be filed away before treatment began, and in both cases the uninfected nail will grow from the base of the nail to replace the infected portion which would be clipped away as usual from the top. Before and after photographs allow progress to be monitored. Some clinics also take clippings for microscope analysis to monitor the fungal infection.

The first type of laser treatments uses laser light typically emitted from Nd:YAG lasers with a wavelength of 1064nm of infra-red light. Examples of such brands of laser include PinPointe from Cynosure and ClearChoice from Alma Lasers.

The laser light is applied across the nail in short pulses by a clinician using the handpiece of the laser device. All the affected nails would be treated individually but it is relatively quick, taking about ten minutes to do one hand or foot. The treatment would then be repeated at four week intervals until the infection was gone. There is a mild sensation of discomfort with this treatment but it seems to vary a lot between individuals, their pain threshold and the state of their infection.

More recently there are now “cold” laser treatments available such as the Lunula treatment which is often found to be more comfortable for the client. The Lunula uses much lower wavelengths of light – 405nm and 635nm – which means that it is not relying on heat to kill the infection; hence the term cold laser. The whole foot or hand can be treated by placing it into a device that rotates the laser beams over the surface. It uses two wavelengths of light simultaneously; one to treat the fungus, and another to stimulate the blood supply to boost the immune response in that area. The cycle takes about twelve minutes per hand or foot and as the energy is lower there is minimum discomfort to the client.

Careful discussions regarding your reasons for wanting laser treatment for a fungal nail condition are very important. You must also make sure that this treatment can deliver what you want and how you would like to look afterwards. Your practitioner should be able to answer all your questions. Most podiatrists and chiropodists will charge an initial consultation fee which is then redeemable against the cost of a subsequent treatment. Cosmetic clinics vary in respect to this initial consultation but a quick telephone call should allow you to decide where to go for the best advice.

A medical history should also be taken to make sure that there are no reasons why you shouldn’t undertake treatment. You should be asked to sign a consent form which means that you have understood the potential benefits and risks associated with the procedure.
Photographs may also be taken by the practitioner for a "before and after" comparison, at a later date. This is useful to you, as well as the clinician, and is recommended as this helps to track progress through the course of treatment and establish an end-point.

In some cases, the level of severity of your fungal nail infection will be assessed using a grading scale; this is then used to determine how many treatment sessions would be advisable to optimally target the infection and destroy it. The more severe the grading (infection) the more sessions will be recommended.

All nail varnish must be removed completely before commencing a laser treatment.

The high-energy laser beam will be fired at the surface of the nail wherever it is infected. It is important to note that thickened nails must be filed before applying the laser. A podiatrist or chiropodist would be able to do this as part of the treatment; cosmetic clinics without this expert experience may not be willing to do this for you and may refer you to such a practitioner or require you to file the nail yourself. Obviously, it is best to ask about this before commencing treatment. You might decide that one visit to a specialist nail clinic is preferable to one visit there and a second to a cosmetic laser clinic. High energy laser treatment is going to feel uncomfortable but should not necessitate the use of local anaesthetic or painkiller. The cold laser treatments will not cause any discomfort and may be automated so the clinician sets up the laser machine but is not responsible for firing the laser. The number of treatments required depends on the state of infection, and therefore it varies according to the individual patient.

Although, it may appear that only a single nail, such as a big toenail, is affected by the fungal infection, all nails will be treated within the session to ensure that all fungus is destroyed and not allowed to lurk in nails which do not currently manifest symptoms.

Before embarking on laser treatment for a fungal nail infection, it is worth trying the anti-fungal paints that you can buy over-the-counter if you are willing to be disciplined about the treatment and follow the instructions carefully. You may need to choose a period when your nails are not going to be on display and when you can avoid coloured nail varnishes which may impair the treatment. If this is not effective, then speak to you GP to find out what they would recommend and to decide if a course of oral treatment might be suitable.

There shouldn’t be any down time following the procedure but comfortable and breathable shoes would be a sensible choice. The clinic may provide you with anti-fungal spray to treat shoes and socks to prevent any reinfection from your own footwear. Following the procedure there shouldn’t be any swelling or pain or redness in the treated area.

Although not strictly a complication, laser treatment is directed at the nail bed and this causes a warming sensation which can last for a minute or two as treatment is applied with the pulse of laser energy. This can be a painful sensation, due to the heat, but is considered tolerable and just uncomfortable. Any discomfort subsides quickly after treatment. You may wish to keep the area cool for up to 24 hours after treatment.

Laser treatment for fungal nail infection is generally considered to be side effect free, producing no harm to the nail or surrounding skin. The previously infected and damaged nail will shed naturally as the nail grows, bringing fresh, healthy, uninfected nail along to replace it.

It is the medicated route that has a whole host of contraindications attached, so laser treatment is usually a safer alternative for pregnant or breast feeding women or other people who have conditions that prevent them from taking the oral medication. However, the initial consultation should be thorough and you need to ask questions if you have any specific concerns.

Contra-indications would include those with diabetes or poor circulation or immune deficiency.

Most podiatry and chiropody clinics offer fungal nail treatments and should quote a price for their treatment to facilitate a cure. In cosmetic clinics, any trained laser practitioner who has received specific training for the treatment of fungal nails would also be able to administer the laser treatment. However, they may not be able to pre-file the nail themselves.

A registered podiatrist or chiropodist clinic may be the best place to get a course of treatment, although there are now also specialist cosmetic laser clinics who focus solely on the use of lasers in cosmetic medicine that can provide the full nail treatment.

There are many lasers being used nowadays by podiatrists, chiropodists and aestheticians that it can be very confusing. The best advice is to talk to the practitioner and look for clinics that are trained in this treatment application, and can show you some positive results from their own clients. The clinic may have a laser capable of this mode of use, but it is the operator who needs to be the expert in this application so ask for training certificates specifically for this indication.

Find a specialist treatment centre for fungal nail infections.  

The anti-fungal paint is available through the NHS on prescription in very severe cases, but it is widely available to buy over-the-counter from a variety of outlets, and this would avoid a doctor’s appointment for mild to moderate infections.

The two active ingredients prescribed on the NHS for oral treatment (medication) are terbinafine and itraconazole. It is worth asking about the active ingredient in your prescribed medicine and reading through all the contraindications and side effects or discussing this with your GP before opting for this route.

Laser treatment is only available privately so it is highly unlikely that anyone considering Laser nail treatment would be able to access this on the National Health Service.

We would however always recommend that you visit your General Practitioner before embarking on private treatment.

The average cost of one course of at-home anti-fungal nail paint for one nail is around £20, but many people find they need more than one bottle of liquid to completely cure their condition. It can take up to 18 months to work and the cost of the anti-fungal paint can then rise to £100 plus.

The price for laser treatment for fungal nail infections will depend on the area where you live, the severity of your fungal nail infection, and the type of laser treatment being used by the clinic or practitioner. Treatments may be priced per treatment session or as a course of treatments, as it is highly unlikely that one treatment session will cure the infection so you will need multiple sessions.

Expect to pay between £100 to £200 for a single session of laser treatment for a single hand or both hands or feet. Nail preparation may cost an additional £30 - £50.

Prices for the cold laser treatments start from around £75 to £100 for one hand or foot and £100 to £200 for two.
It’s likely that to cure a single hand or foot you will be looking to spend £500+, again depending on the severity of the infection.

Usually a course of treatments within a programme is priced with a discount on single treatment prices.

Having a course of laser treatments for a fungal nail infection seems to be the best way of getting rid of a stubborn infection. It is expensive compared to the over-the-counter anti-fungal paints or prescription medication, but it is effective and can solve the problem entirely. There are plenty of people who testify that they are most grateful and pleased to have finally remedied this very common nail infection and are thoroughly relieved to be finally free of infection.