EVALUATION OF LONG PULSED-ND: YAG LASER IN THE TREATMENT OF ONYCHOMYCOSIS Thesis Submitted for Partial Fulfillment of Master Degree in Dermatology, Venereology and Andrology By Eman Mohamed Akmal Ahmad (M.B.B.CH) Faculty of Medicine – Ain Shams University Supervised By Prof. Dr. Hoda Ahmed Monieb Professor of Dermatology and Venereology Faculty of Medicine Ain-Shams University Prof. Dr. Mohammed Taha Mahmoud Professor of Microbiology Faculty of Veterinary Medicine Zagazig University Dr. Mary Fikry Matta Lecturer of Dermatology and Venereology Faculty of Medicine Ain-Shams University Faculty of Medicine - Ain-Shams University 2013 ببسسمم هللاهللا االلررححممنن االلررححييمم إقسأ باظن زبك إقسأ باظن زبك االلررًً خخللقق11خخللقق ااﻹﻹًًععااىى ههيي ععللقق22 إإققسسأأ ووززببكك ااﻷﻷككسسمم33االلررًً ععللنن ببااللققللنن44ععللنن ااﻹﻹًًععااىى ههاا للنن ييععللنن55 صصددقق هللاهللا االلععظظييمم ظظووززةة االلععللقق ااﻵﻵييااثث ))55--11(( AAcckknnoowwlleeddggmmeenntt First of all, thanks to Allah the most merciful for giving me the strength to complete this work. I would like to express my gratefulness and respect to Prof. Dr. Hoda Ahmed Monieb, Professor of Dermatology, Venereology and Andrology, Ain Shams University for her moral and sincere scientific support and for kind observation and valuable advice that were essential for this work to be achieved. I would like to express my thanks and gratitude to Prof. Dr. Mohammed Taha Mahmoud, Professor of Microbiology, Faculty of Veterinary medicine-Zagazeg University for his priceless help and his kind supervision. I would like to express my gratitude and respect to Dr. Mary Fekry Matta, Lecturer of Dermatology, Venereology and Andrology, Ain Shams University for her valuable time, remarkable efforts, help and guidance. I would like to express my gratefulness and respect to Assist Prof.Dr Ahmed Fathy Albedewey, Assit Professor of Dermatology, Venereology and Andrology, National Center for Radiation Research and Technology for his observation and valuable advice that were essential for this work to be achieved. I would like to express my gratitude and respect to Dr. Noha Fawzy Ibrahim , Lecturer of Dermatology, Venereology and Andrology, National Center for Radiation Research and Technology for her valuable time, remarkable efforts, help and guidance. Finally I wish to express my deepest gratitude and appreciation to all my Family for their patience, moral support and encouragement. EEmmaann MMoohhaammeedd List of Contents Title Page No. Introduction ......................................... Error! Bookmark not defined. Aim of the Work .................................................................................... 21 Review of Literature . Onychomycosis .......................................................................... 24 o Definition ....................................................................... 5 o Nail Apparatus .............................................................. 5 o Epidemiology of onychomycosis .................................. 13 o Etiology ........................................................................ 16 o Pathophysiology and clinical presentation ................ 33 o Complications .............................................................. 44 o Differential diagnosis .................................................. 46 o Diagnosis of onychomycosis ........................................ 53 o Management................................................................ 74 . Laser and Infections .............................................................. 107 o Introduction ................................................................. 87 o Bactericidal effect of lasers ......................................... 87 o Fungicidal effects of lasers ......................................... 90 Patients and Methods ....................................................................... 122 Results .................................................................................................. 134 Discussion ............................................................................................ 174 Conclusion ............................................................................................ 188 Recommendations .............................................................................. 189 Summary .............................................................................................. 191 References ................................................................................................ 1 Arabic Summary List of Tables Table No. Title Page No. Table (1): Diagnosis of onychomycosis caused by dermatophytes .............................................................73 Table (2): Classification of approved antifungal drugs .........96 Table (3): Sex distribution of patients in the study. ........... 134 Table (4): Age distribution of patients in the study. ........... 135 Table (5): Residence distribution of patients in the study. ...... 136 Table (6): Occupations of patients in the study. .................. 137 Table (7): Predisposing factors of onychomycosis in patients of the study. ............................................... 139 Table (8): Number of diseased nails in patients of the study. ........................................................................... 140 Table (9): Duration of onychomycosis (years). ...................... 142 Table (10): Patient’s complaints of the disease (onychomycosis). ....................................................... 143 Table (11): Clinical presentations of onychomycosis in the total number of fingernails and toenails. ...................................................................... 144 Table (12): Identification of fungi into genera and species of the 20 fungal isolates obtained from cases of onychomycosis. ................................. 146 Table (13): Mycological response to treatment at the first follow up ............................................................ 150 Table (14): Comparison between the mycologically negative and the mycologically positive patients as regards chronic paronychia as a predisposing factor of onychomycosis at first follow up results. ............................................. 152 List of Tables (Cont…) Table No. Title Page No. Table (15): Comparison between the mycologically negative and the mycologically positive patients as regards exposure to humidity as a predisposing factor of onychomycosis at first follow up results. ......................................... 153 Table (16): Comparison between the mycologically negative and the mycologically positive patients as regards number of nail affection at first follow up results. ......................................... 155 Table (17): Comparison of the Duration of onychomycosis between the mycologically negative and the mycologically positive patients at first follow up results. ........................ 157 Table (18): Clinical presentations of onychomycosis in mycologically positive and mycologically negative patients at the first follow up. .............. 158 Table (19): Comparison of the fungal species isolate between the mycologically negative and the mycologically positive patients at first follow up results. ...................................................... 160 Table (20): Relation between first and second follow up. ................................................................................ 161 Table (21): Mycological response to treatment at the second follow up. ....................................................... 162 Table (22): Side effects noticed during the treatment. ......... 166 List of Figures Fig. No. Title Page No. Figure (1): Schematic drawing of nail anatomy sagittal section .......................................................... 25 Figure (2): The proximal matrix forms the superficial part of the nail plate and the distal matrix makes the under-surface part of the nail plate ................................................ 26 Figure (3): A diagram showing front view of nail anatomy ...................................................................... 28 Figure (4): Schematic diagram of spores of the three common genera of dermatophytes: ....................... 37 Figure (5): Trichophyton macroconidia .................................... 38 Figure (6): a) Macromorphology of Trichophyton mentagrophytes colonies. b) Macromorphology of Trichophyton rubrum colonies front and back view. ................. 39 Figure (7): Microsporum microcondia ...................................... 40 Figure (8): Microsporum colonies in culture ........................... 41 Figure (9): Macroconidia of Epidermophyton floccosum .................................................................... 42 Figure (10): Colonies of Epidermophyton floccosum ............. 43 Figure (11): C.Albicans under microscope ................................. 47 Figure (12): C.albicans on saburaud’s dextrose agar .............. 48 Figure (13): Microscopic morphology of Scopulariopsis showing chains of single-celled globose to pyriform, usually truncate, with a rounded distal portion conidia ................................ 49 Figure (14): Scytalidium species in culture produce woolly colonies and both surface and reverse colony colour range from white to brown pigmented hyphae ................................... 50 Figure (15): Clinical picture &nail invasion in DLSO ............ 55 Figure (16): Clinical picture & nail invasion in SWO ............. 57 List of Figures (Cont…) Fig.