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Issue March 2001

New Approach for the Therapy of Onychomycoses
Laser Treatment in Combination with low-dose systemical Antimycotics

The treatment of advanced onychomycoses is in general time-consuming and cost-intensive. Even by therapies with potent systemical antimycotics over a period of several months, in general only cure rates of approximately 70 percent can be achieved. The duration of the treatment can be reduced by supplementing the medicamentous therapy by a laser treatment. This innovative and interesting therapy approach for the dermatological practice was introduced at the 34th conference of the Deutschsprachige Mykologische Gesellschaft (DMykG) [German-language Mycological Society] in Berlin in September last year. A further clinically relevant subject addressed at the conference have been the frequently misdiagnosed zoophilic mycoses.
The mycology still holds unexpected potentials, emphasized professor Dr. med. Hans Christian Korting, Dermatologische Klinik und Poliklinik of the Ludwig-Maximilians-University Munich (Dermatological Clinic and Outpatient Clinic) in his welcoming speech in the presence of about 400 conference participants as chairman of the society, founded 40 years ago. The DMykG attaches great importance to the support of academic young talents for whom prizes are awarded on a yearly basis. The award for clinical mycology was won in Berlin by Dr. Katrin Hohaus, Universitäts-Klinikum Dresden (University Clinical Center), for her future-oriented work "Differentiation of candida strains by lectin-mediated agglutination kinetics".

As the lectures relating to molecular mycology in the conference programme showed, new challenges are to be faced again and again in an interdisciplinary field as the mycology. A topic for the future is the possibility to extract new medicinal substances or principal substances for new pharmaceutical agents from fungi, predicted professor Dr. Monika Schäfer-Korting of the Department Pharmacy of the Freie Universität Berlin (Free University) who had taken on the organization and scientific direction of the conference in cooperation with professor Dr. med. Hans-Jürgen Tietz of the Humboldt-University Berlin's Dermatologische Klinik of the Universitätsklinikum (Dermatologic Clinic of the University Clinical Center) Charité.

Duty of Notification
for Zoophilic Mycoses?

Tietz sees an increasing number of zoophilic mycoses in his clinical daily routine what he attributes to the growing fondness for travelling of the population. Thus, there had been a rare incidence of the microsporosis produced by the pathogen microsporum canis in the newly formed federal states of Germany before the Wende. The contact with straying cats in mediterranean vacation regions has lead, however, to a rapid rise of the disease. Annually approximately 10000 new cases become known, according to Tietz. The suspected number of unknown cases is however much higher according to his estimation. Patients presented in the Charité have not seldom already gone through a therapeutical odyssey due to the fact that the infection is frequently misdiagnosed and inappropriately treated in too many cases. In some cases children had been in fact scalped by surgical measures after unsuccessful therapies. These damages are irreparable, Tietz warned and regretted that this form of mycosis is not identified and treated in time in many places. This even though, systemical antimycotics equally effective and tolerable are available such as the azole derivative Fluconazol. In view of the contagiousness of the microsporum, a reintroduction of a duty of notification for such mycoses has to be considered, according to Tietz.

Professor Dr. Monika Schäfer-Korting and Professor Dr. med. Hans-Jürgen Tietz jointly organized the 34th Conference of the Deutschsprachige Mykologische Gesellschaft (German-language Mycological Society) in Berlin in September last Year.

a Therapeutical Challenge

Because of their practice relevance and growing importance, special importance had been attached to dermatomycoses and in particular onychomycoses in the course of the conference. The experts were agreed on the fact that the onychomycoses belong to the infectious diseases with frequent incidence on the one hand and the necessity to undergo an extremely difficult, long-term and consequent therapy on the other hand. It is true that also in the year 2000 a breakthrough in the therapy of the onychomycosis cannot be announced but there are new promising therapy-concepts and -patterns with the support of systemical antimycotics.

Dr. med. Volker Kunzelmann, practising dermatologist, Dessau, presented a likewise interesting and innovative therapy approach. Since the treatment of advanced onychomycoses is time-consuming and complicated, and even by performing several months' therapies with modern systemical antimycotics only cure rates of approximately 70 percent are achievable, the objective has to consist in reducing the duration of treatment and optimizing the therapy effect.

Since the removal of the affected nail substance is regarded as effective supplementation of the medicamentous therapy, it seems obvious to use laser systems for this purpose, by which the nail areas infested by fungi could be accurately removed. The Erbium YAG-laser allows the precise removal of the infected nail substance till close to the nail matrix and is thus superior to all conventional alternatives, Kunzelmann explained. The treated areas after the laser application are histologically verifiable sterile and optimally prepared for the following antimycotic therapy.

In an examination of 50 patients (average age: 52 years) a medicamentous therapy with low-dose systemical Terbinafin, Fluconazol oder Itraconazol has been carried out after the laser treatment. 27 patients had more than five infected toe-nails. The duration of the disease was on average seven years. 43 patients had already undergone without success a local systemical treatment or they had been subject to a combined antimycotic treatment before the examination. The mycological native preparation supplied in 86 percent of the cases and the culture of moulds in 62 percent positive results before the therapy start. As pathogen trichophyton rubrum (n = 32), trichophyton mentagrophytes (n = 5) and mixed infections with trichophyton rubrum and candida albicans have been proven. In the course of the examinations there were still some positive native preparations, however, no more positive cultures. The time until the complete healing was four to nine months and thus significantly below the results of current drug studies. The applied cumulative active substance doses of the systemical antimycotics and the therapy costs could be reduced by up to one third compared with the exclusively medicamentous therapy.


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