Laser Therapy for Onychomycosis in Patients Wih Diabetes at Risk for Diabetic Foot Complications (LASER-1)

In a sham controlled double-blind trial we aim to establish the efficacy and safety of local application of laser therapy in patients with diabetes with onychomycosis and risk factors for diabetes related foot complications. Onychomycosis leads to thickened and distorted nails, which in turn leads to increased local pressure. The combination of onychomycosis and neuropathy or peripheral arterial disease (PAD) increases the risk of developing diabetes related foot complications. Usual care for high-risk patients with diabetes and onychomycosis is completely symptomatic with frequent skiving and clipping of the nails. No effective curative local therapies exist and systemic agents are often withheld due to concerns for side effects and interactions.

Aim: The primary aim is to evaluate the efficacy of 4 sessions N-YAG 1064nM laser application on the one-year clinical and microbiological cure rate in a randomised, double-blinded sham-controlled design with blinded outcome assessment.

Study population: Patients with diabetes mellitus, with an increased risk for diabetic foot ulcers.

Intervention: local laser treatment from a podiatrist and the other group receives treatment according to a control procedure. The laser procedure will be performed as a sham procedure by a second podiatrist.

Main study parameters/endpoints: The effect of 4 sessions of laser therapy on cure rate (clinical and microbiological) after one year.

Study Overview

• Status: Completed
• Conditions: Onychomycosis
• Intervention / Treatment: Device: Nd:YAG laser pulse therapy; Device: Sham procedure

Detailed Description

Setting of the study: Hospital, outpatient departments (Foot clinic, Isala, Zwolle)

Inclusion criteria: Patients with clinical suspicion and microbiologic confirmation of onychomycosis , diagnosis of T1DM or T2DM, 18 years or older, at risk for diabetic foot ulcers defined by a modified Simm's classification score 1 or 2 with either neuropathy or PAD, nail involvement of at least 25% of the target nail.

Exclusion criteria: no microbiologic confirmation, Simms' classification score 3, the presence or history of diabetic foot ulcers, ischemic pain, ankle brachial index < 0.9, patients receiving dialysis, severe renal insufficiently (eGFR below 30 ml/min), a documented toe pressure below 50 mmHg, use of systemic or topical antifungal agents 3 months prior to inclusion, use of immunosuppressive drugs, presence of psoriasis, lichen planus, or other abnormalities that could result in clinically abnormal toenails, a history of epilepsy and insufficient knowledge of the Dutch language. Patients with a dark skin color (Fitzpatrick 4 and 5) are excluded since dark skin color is associated with dark nails, which theoretically leads to increased temperatures during laser application

• Study Type: Interventional
• Enrollment (Actual): 64
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Netherlands
  • Zwolle, Netherlands, 8000 GK
    • Isala Diabetes Centre, Isala Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Diabetes
• Over 18 years old
• Clinically suspicion with microbiologic confirmation of onychomycosis
• Patient is at risk for diabetic foot ulcers defines as Simms score 1, 2 .

Exclusion Criteria:

• Patients without the microbiological confirmation of fungal nail infection
• Patients with an active or history of a diabetic foot ulcer
• Patients who used systemic or topical anti fungal agents during the preceding 3 months
• Patients with ischemic rest pain
• Patients with ankle brachial index < 0.9
• Patients with a documented toe pressure below 50 mmHg
• Patients receiving dialysis, severe renal insufficiently (eGFR below 30 ml/min)
• Patients with an insufficient knowledge of the Dutch language to understand requirements of the study
• Patients with a dark skin color (Fitspatrick 4 and 5)
• Patients who uses immunosuppressive medication
• Patient suffering from nail psoriasis , lichen planus, or other abnormalities that could result in clinically abnormal toenails.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Nd:YAG laser pulse therapy; Nd:YAG laser pulse therapy Patients are treated with laser session in week 0, 2, 4, and 12. The settings are; 1064 nm, spot size 3 mm, 20 J /cm2, 5 Hz, power 10 W, pulse duration 132 millisecond. A maximum of two sequential sessions (one session on the horizontal and one the vertical passing) will be applied to eliminate potential safety issues in those patients with a lack protective sensibility.	Device: Nd:YAG laser pulse therapy; Other Names: S30 PODYLAS
Sham Comparator: Sham; Sham treatment Patients are treated with a sham session in week 0, 2, 4, and 12. The study settings are similar to the laser except the laser beam. Because the patient is also blinded, they can't see the procedure. The sound and the beeps are audible similar to the laser treatment.	Device: Sham procedure; Sham procedure

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
complete cure of the target nail	after one year the clinical and microbiological cure rate of the target nail will be compared with usual care in the placebo group.	outcome measured after 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Microbiological cure of the target nail	Patient with a negative microbiologic results of the target nail at week 52 will be regarded as having a microbiological cure. Patients with negative microbiological results at week 30 and positive microbiologic results at week 52 will be regarded as having a second infection. Patients with positive microbiologic results (with the same species) at week 30 and positive results at week 52 (the same species) will be regarded as treatment failure.	outcome measured after 1 year
Complete clinical cure of the target nail	Complete cure is defined as a completely normal nail, or negative microbiological results in case minor abnormalities are present.	outcome measured after 1 year
Markedly clinically improved target nail	A markedly improved nail is defined as a nail with less than 10% abnormalities without hyperkeratosis after 52 weeks in nails that were affected more than 10% of the surface area.	outcome measured after 1 year
Onychomycosis severity index below 6 (in patients with scores >6 at study entry) of the target nail		outcome measured after 1 year
Complete clinical cure of all affected toes		outcome measured after 1 year
Change in quality of life	WHO-5 and NailQol questionnaires are taken at baseline and week 52. Translated disease specific questionnaire; NailQol	outcome measured after 1 year
Change surface healthy target nail / all clinically infected toes patients free of hyperkeratosis		outcome after 52 weeks

Collaborators and Investigators

• Sponsor: Medical Research Foundation, The Netherlands
• Investigators: Study Director: H.J.G. Bilo, professor MD, Isala Diabetes Centre, Zwolle; Study Director: Nanne Kleefstra, MD PhD, Isala Diabetes Centre,Zwolle; Principal Investigator: G.W.D. Landman, MD PhD, Isala Diabetes Centre, Zwolle; Principal Investigator: Leonie Nijenhuis - Rosien, Bsc, Isala Diabetes Centre, Zwolle

Publications and helpful links

General Publications

• Nijenhuis-Rosien L, Kleefstra N, Wolfhagen MJ, Groenier KH, Bilo HJ, Landman GW. Laser therapy for onychomycosis in patients with diabetes at risk for foot complications: study protocol for a randomized, double-blind, controlled trial (LASER-1). Trials. 2015 Mar 22;16:108. doi: 10.1186/s13063-015-0622-4.

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2015
• Primary Completion (Actual): July 7, 2017
• Study Completion (Actual): July 7, 2017

Study Registration Dates

• First Submitted: November 22, 2013
• First Submitted That Met QC Criteria: November 22, 2013
• First Posted (Estimate): November 27, 2013

Study Record Updates

• Last Update Posted (Actual): March 21, 2018
• Last Update Submitted That Met QC Criteria: March 20, 2018
• Last Verified: March 1, 2018

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Skin Diseases; Infections; Endocrine System Diseases; Diabetic Angiopathies; Leg Ulcer; Skin Ulcer; Diabetes Complications; Diabetes Mellitus; Diabetic Neuropathies; Bacterial Infections and Mycoses; Skin Diseases, Infectious; Mycoses; Tinea; Dermatomycoses; Nail Diseases; Foot Ulcer; Diabetic Foot; Onychomycosis
• Other Study ID Numbers: NL46084.075.13 (Other Grant/Funding Number: NL46084.075.13)

Plan for Individual participant data (IPD)

Study Data/Documents

1. Study Protocol