Laser device treatment for hair stimulation, nail fungus lacking data

National report - Laser and light therapies for hair stimulation and the treatment of nail fungus have a place in the dermatologist’s toolbox, but it is somewhere on the second shelf, according to two experts.

Until more data is available on the effectiveness of laser and light technologies for treating nail fungus and for hair growth, clinicians’ best option may be to continue to use tried-and-true therapies.

Nail care

Photothermal and photochemical modalities are two frequently reported laser options for treating nail dermatophyte, according to Molly Wanner, M.D., M.B.A., a dermatologist at Massachusetts General Hospital and instructor at Harvard Medical School, Boston.

Among photothermal devices, the two lasers that are most commonly used are the 1064 nm and 1320 nm wavelengths, which have been studied for onychomycosis treatment, according to Dr. Wanner.

Dr. Wanner

“There are a number of different companies that manufacture lasers at the 1064 (nm) wavelength. The lasers use light and laser to generate heat, and it’s that heat that’s affecting the fungus,” Dr. Wanner says.

The photochemical approach involves photodynamic therapy (PDT) combined with topical 5-aminolevulinic acid (ALA).

“PDT has been studied for nail fungus and ALA has been shown to reduce the growth of Trichophytonrubrum by about 50 percent,” Dr. Wanner says.

The problem with this therapeutic option is that photothermal and photochemical approaches lack strong evidence, according to Dr. Wanner. Available studies are small, some don’t have controls, and they offer only short-term follow-up.

“At this point, we don’t know if these lasers are actually killing the fungus or just slowing its growth,” she says. “That’s why follow-up (beyond six months) is very important. It takes 12 to 18 months for a toenail to regrow.”

Because ALA is a fungistatic, risk of recurrence is going to be an issue, according to Dr. Wanner.

“In fact, there was one prospective trial that was uncontrolled which did show that at about one year, 43 percent had a negative culture or clinical clearance, but in a year and a half, that was down to about 36 percent (Sotiriou E, Koussidou-Eremonti T, Chaidemenos G, et al. Acta Derm Venereol. 2010;90(2):216-217),” Dr. Wanner says.

There is another option, Dr. Wanner says. Clinicians can try the photochemical approach, with a dual wavelength 870 nm and 930 nm laser.

“The way it’s thought to have an effect on the fungus is altering metabolic function and structural function of the fungus,” she says. “With this particular laser, again it’s the same issue as with the 1064 and 1320. The studies are small studies, with short-term follow-up. We really need more information.”

Dr. Wanner’s advice to colleagues is to continue to rely on proven systemic and topical therapies for nail fungus.

“The bottom line is there is not enough data to recommend (laser) treatments and risk of recurrence is unknown,” she says. “But results from topical therapies have been disappointing, and a lot of patients are concerned about the potential side effects with the systemic therapies, so, I do think that there is a future role for the use of light to treat dermatophyte.”

Dr. Avram

Stimulating hair growth

Marc Avram, M.D., clinical professor of dermatology, Weill Cornell Medical School, and in private practice in New York, says today’s laser hair stimulation technology comes in the form of low-level light therapy.

“The big difference between lasers that we usually use for the skin and those for hair stimulation is the amount of energy they give out is a fraction of that of the typical cosmetic laser,” Dr. Avram says.

“What’s interesting is some of the devices use the same wavelength of light that we use to remove hair. … it turns out if you use high energy of that wavelength of light, it seems to destroy hair, and if you use very low energy of the same wavelength of light, it actually stimulates the hair follicle.”

Low-level laser light therapy, however, seems only to work in a minority of patients, says Dr. Avram, who has published research on laser hair stimulation and authored the book Hair Transplantation in 2010.

“We do not have a lot of convincing data,” he says.

Minoxidil and finasteride, and hair transplantation surgeries, are well-studied and have shown long-term efficacy and positive outcomes for treating hair loss. Laser hair stimulation devices, however, were first cleared by the Food and Drug Administration in 2007, and offer only a smattering of small studies.

Dr. Avram authored one of those studies, published June 2009 in the Journal of Cosmetic Laser Therapy. This study included seven patients exposed to low-level light therapy twice weekly for 20 minutes per session, for three to six months. Patients demonstrated evidence the therapy decreased vellus hairs and increased terminal hairs and shaft diameter. But none of the changes were statistically significant.

At this point, dermatologists recommending light therapy for hair stimulation are working in the dark. There is no standard wavelength or standard energy used for these devices, nor is there a standard treatment protocol, and studies have not shown what types of patients may benefit from this therapy, Dr. Avram says. He recommends either the available laser therapy caps or laser therapy comb as a second-line option, when medical therapies don’t produce desired results.

“Laser therapy is not a first-line treatment for people with hair loss,” he says. “First, identify why the hair loss is happening. Many people who present with hair loss are not candidates for laser combs because their hair loss is for different reasons. If there is any question about the diagnosis, do a biopsy.”

Dr. Avram says he has seen hundreds of patients who have tried the at-home devices for hair stimulation and about 20 to 30 percent of those patients seem to derive benefit. The devices appear safe, but Dr. Avram says he educates patients about how they should not shine the light directly into their eyes. DT

Disclosures: Drs. Avram and Wanner report no relevant financial interests.

A patient before (left) and after four treatments with the 1320 nm CoolTouch laser. (Photos: Molly Wanner, M.D.)