Efficacy of combined photodynamic therapy and short-course systemic antimycotics versus standard of care for onychomycosis

Background. One of the most common nail diseases is onychomycosis, which is an infectious condition caused by pathogenic fungi. Due to increasing resistance of pathogens to traditional antifungal agents, as well as a number of issues related to systemic antifungal drugs (long duration of therapy, side effects), there is a demand for additional treatment methods, one of which is photodynamic therapy, characterized by a high safety profile and good patient compliance.

Objective. The aim of this study is to evaluate the effectiveness and safety of combined therapy for onychomycosis using photodynamic therapy.

Materials and methods. A prospective comparative study included 48 patients with confirmed clinical and microscopic diagnosis of onychomycosis. In the control group (24 individuals), standard treatment with systemic antifungal drugs was administered. The experimental group (24 individuals) received 8 sessions of photodynamic therapy with chlorin-based photosensitizer in combination with a shortened course of systemic antifungal agents. The efficacy and safety of the therapy were assessed at 3, 6, and 9 months through negativation of microscopic analysis and measurement of the area of visually healthy nail plate.

Results. Both groups of patients showed a positive trend in terms of mycological clearance, however, a comparative analysis revealed a 1,36-fold increase in the rate of early mycological cure already at the 3rd month of observation compared to the control group (р ≤ 0,05). Positive clinical dynamics were observed in both groups at all stages of observation, with the percentage of patients recovered by the 9th month being higher in the experimental group: 96% (23 patients) compared to 87,5% (21 patients) in the control group. Side effects were only recorded in the control group.

Conclusion. Photodynamic therapy presents a therapeutic alternative for the treatment of onychomycosis, allowing for a reduction in the duration and potential side effects associated with systemic antifungal medications, as well as achieving higher cure rates.

1. Tsykin A. A., Lomonosov K. M. Onychomycosis: etiology, diagnosis, clinic and treatment. RMZh. 2007; 19: 1371. (In Russ.)

2. Sergeev A. Yu. The experience of studying onychomycosis, approaches to their therapy and prevention. RMZh. 2001; 11: 461. (In Russ.)

3. Tlish M. M., Shavilova M. E. Onychomycosis of the feet: optimization of therapy for patients with contraindications to the use of systemic antifungal drugs. Lechebnoe delo. 2021; 2: 106-114. (In Russ.) DOI 10.24412/2071-5315-2021-12337.

4. Ermolaeva I. Yu., Nesterov A. S. Hepatotoxicity of antimycotic drugs as a factor limiting the treatment of onychomycosis in patients with impaired carbohydrate tolerance. Ulyanovskii mediko-biologicheskii zhurnal. 2021; 3: 71-78. (In Russ.) DOI: 10.34014/2227-1848-2021-3-71-78.

5. Vasenova V. Yu., Butov Yu. S. Modern possibilities of onychomycosis therapy. RMZh. 2016; 10: 623-627. (In Russ.)

6. Stepanova J. V. Onychomycosis. RMZh. 1999; 14: 648. (In Russ.)

7. Potekaev N. N. Onychomycosis. RMZh. 2001; 3: 138. (In Russ.)

8. Shikh E. V., Sizova O. S., Makhova A. A. The possibilities of using hepatoprotectors in the combined therapy of onychomycosis. RMZh. 2016; 14: 958-963. (In Russ.)

9. Lipova E. V., Sokolskaya A. A., Vitvitskaya Yu. G., Glazko I. I., Chekmarev A. S., Silyutina T. A., Frigo N. V. Onychomycosis (literature review). RMZh. 2023; 6: 21-24. (In Russ.)

10. Robres P., Aspiroz C., Rezusta A., Gilaberte Y. Usefulness of Photodynamic Therapy in the Management of Onychomycosis. Actas Dermosifiliogr. 2015; 106 (10): 795-805. DOI: 10.1016/j.ad.2015.08.005.

11. Vasenova V. Yu., Tsygankova E. I. Lasers and photodynamic therapy in treatment of onychomycoses. Klinicheskaya dermatologiya i venerologiya. 2024; 23 (3): 258263. (In Russ.)

12. Kornisheva V. G. Photodynamic therapy for onychomycosis (review). Problemy meditsinskoi mycologii. 2015; 17 (1): 3-7. (In Russ.)

13. Bowornsathitchai N., Thammahong A., Shoosanglertwijit J., Kitsongsermthon J., Wititsuwannakul J., Asawanonda P., Boontaveeyuwat E. Methylene bluemediated photodynamic therapy may be superior to 5% amorolfine nail lacquer for non-dermatophyte onychomycosis. Photodermatol Photoimmunol Photomed. 2021; 37 (3): 183-191. DOI: 10.1111/phpp.12624.

14. Figueiredo Souza L. W., Souza S. V., Botelho A. C. Randomized controlled trial comparing photodynamic therapy based on methylene blue dye and fluconazole for toenail onychomycosis. Dermatol Ther. 2014; 27 (1): 43-7. DOI: 10.1111/dth.12042.

15. Alberdi E., Gómez C. Methylene blue vs methyl aminolevulinate photodynamic therapy in combination with oral terbinafine in the treatment of severe dermatophytic toenail onychomycosis: Short- and long-term effects. Mycoses. 2020; 63 (8): 859-868. DOI: 10.1111/myc.13125.

16. Clinical recommendations. Mycoses of the scalp, trunk, hands and feet. All-Russian public organization "Russian Society of Dermatovenerologists and Cosmetologists". 2020. (In Russ.)

17. Lubeck D. P., Patrick D. L., McNulty P., Fifer S. K., Birnbaum J. Quality of life of persons with onychomycosis. Qual Life Res. 1993; 2 (5): 341-348. DOI: 10.1007/BF00449429.