Lasers for Fungus - Podiatrist's Comparison Analysis

By Marc Garfield, DPM. FACFAS
Williamsburg, VA

I began looking into laser onychomycosis treatments wanting to know 4 things:

• First, does it work or is it lights and bells and a bottle of Formula 3?
• Second, does it hurt and is it safe?
• Third, can I afford a device to deliver the treatment?
• Lastly, who is the best company to choose?

Cool Breeze by Cooltouch

Around 60K. Some blog responses confirm that the treatment often hurts. No published studies despite some doctor’s pervasive web coverage insisting that he has picked the world’s best laser. Why don’t any of these guys publish a study?

PinPointe

Marketing obligation contracts, fees for multiple treatments, 1 mm spot limitation, can only be used for onychomycosis, device is leased for ridiculous amounts of money and never owned, questionable efficacy despite unpublished research data. Low powered device, counts total pulses in fluence and then the total fluence for the whole treatment is what Aerolase uses per pulse. Takes 30-45 minutes. Recommends 1 treatment. Research shows that spores are not killed until temps around 80 deg Celsius are achieved. Other papers clearly show that you can only get to 50 degrees Celsius without anesthesia. So unless you retreat 3-6 weeks after the initial, your patient will never get rid of the fungus and that will be your reputation as a laser provider. Since they charge the provider for re-treatments, you lose money to treat the patient properly. Although they have restructured this agreement, I won’t do business with a company like this.

Noveon by Nomir

Similar marketing/leasing agreements as PinPoint. Expensive disposables used to be $300 per treatment, I have heard that the cost has come down. Uses cold lasers. Some researchers disagree as to whether this actually works. Specialized design is only useful for toenails. Company is rumored to be having financial troubles.

Fotona

Requires a 220 outlet so the device is stationary unless you pay an electrician about $800-$1000 each time you want to move the laser to another part of your office. The sales pitch tries to make you feel as though Fotona is the only laser that actually works for onychomycosis and your wasting large sums of money on anything else. Rubbed me like a used car salesman. They are just wrong about this, all of these devices work, some simply have enough power to clean up what others cannot get to. Nice packaging, research presented as peer reviewed but actually came out of a periodical published in Slovenia, by a journal owned and run by Fotona used only for Fotona research. Why they did not choose to publish a 100% success paper in a peer reviewed US or European Journal I do not know.

Cutera

Now FDA cleared. Closest competitor to Aerolase in terms of power range, but at $69K, it just does not make sense to spend that much unless you like the pretty hand piece with pretty lights.

Q Clear

Peer reviewed paper touts inhibition of fungus, not death, 2-12 J/cm2 pulses seems limiting, though the Hz is much faster, I was concerned that the device might not have enough power for all nails and warts. My own cold called reference checks yielded more enthusiastic Aerolase users than Q clear users.

Aerolase

115 V outlet so it can be moved to different exam rooms or moved to satellite offices. Design is portable. The 0.6ms pulse width is better tolerated for hair, vein, and toenail treatments. Versatile 2 and 5 mm spot sizes, power from 25-318J/cm2 - somehow the highest and best range of power of all the lasers above, pricing much more favorable than Cutera and others. No marketing contracts, leasing to own for less than Pinpointe rentals. Training and marketing supplies included with laser purchase. Hochman paper and my upcoming limited but promising initial experience paper indicates promising results and the only (Non Q switched) 1064 paper that has been peer reviewed in the U.S.

With the 318 J/cm2, I have the power to pump up a treatment if I am not getting results on the first try. Since I am leasing, I get to determine who is charged for retreatment. With some lasers there are marketing quota and treatment quotas in the contract. Moreover, some of these devices are designed to require hand piece replacements ranging from hundreds to thousands of dollars several times per year, not covered in your warranty, they consider it disposables at thousands of dollars per change.

Aerolase Downsides: hand piece is bigger and less ergonomic. Treatment hoses could be longer. Screw on lenses take about 10 seconds to change. These are minor concessions considering that from my experience, the device works well, I have talked to 3 dermatologists that have owned this laser for 3-5 years without incurring any maintenance costs after initial purchase. It is a well made solid piece of equipment.

Other considerations

Some companies make a fortune on hand piece replacements not covered under warranty, considered normal use wear and tear like tires.

Heat sensors on other devices are supposed to prevent you from overheating the nail. After a few uses you won’t want or need that type of feedback. A little overheating zap lets the patient know that you’re not just holding an overpriced flashlight and probably does some good in killing fungus.

Laser nail treatment exists in the rare pure medical capitalism market. Patients will care if your device works and works better than the next guy with a laser. Income on laser treatments is significant, but increasing number of laser providers will drive down fees. If someone near you buys a laser, why should patients come to you for treatment?

Cutera tops out at 255j/cm sq; Q-clear and PinPoint are under powered; Fotona maxes out at 300J/cm sq vs Aerolase 318. Cutera only gets fluence of 14 on a 5mm spot, which is only 28% as much as the Aerolase fluence of 51 on 5mm, and Cutera’s 200 j/cm2 is ONLY on a 1.5mm spot at single-pulse mode.

Cool Breeze has internal unpublished data demonstrating 75% cure rate. Cool Breeze by CoolTouch is a 1320nm not 1064nm laser, so it’s not a good match as 1320 has no melanin absorption and less hemoglobin absorption than 1064.

Noveon takes a ½ hour and uses a cold laser. When these fail patients will come to you and when asked by their friends, you will be the doctor that is recommended.