The significance of adjusting fluence lies in its direct control over penetration depth. By manipulating the laser's energy level, you determine the vertical extent of the Micro-Treatment Zones (MTZs) created within the nail plate. This adjustment is the critical factor that transforms a standard laser application into a customized delivery system for topical antifungal agents.
The primary function of fluence adjustment is to match the depth of the micro-pores to the thickness of the nail plate and the severity of the lesion. Higher energy levels create deeper channels, which directly correlates with a higher penetration rate for therapeutic drugs.
The Mechanics of Depth and Delivery
Controlling Micro-Pore Depth
Fluence is the energy density delivered to the tissue. In the context of the nail plate, it dictates how deeply the laser ablates the keratin structure.
Higher energy settings result in deeper micro-pores. Lower energy settings result in superficial channels. This vertical control is essential because fungal infections often reside deep within the nail bed, protected by the nail plate itself.
Enhancing Drug Permeability
The nail plate acts as a formidable barrier to topical medications. Creating physical channels (MTZs) breaks this barrier.
There is a positive correlation between fluence levels and the penetration rate of drug markers. By increasing fluence, you create a more effective "highway" for drugs to travel through the nail plate and reach the site of infection.
Customizing the Treatment Strategy
Adapting to Nail Anatomy
Nail thickness varies significantly between patients and even between different toes on the same foot.
A "one-size-fits-all" energy setting will likely fail on thickened, dystrophic nails or cause unnecessary trauma to thin nails. Practitioners must adjust fluence to ensure the channels traverse the specific thickness of the patient's nail plate.
Addressing Lesion Severity
The location and severity of the fungal colony determine the necessary treatment depth.
For superficial white onychomycosis, lower fluence may suffice. However, for severe subungual onychomycosis, higher fluence is required to drive the micro-pores—and subsequently the medication—deep enough to impact the lesion.
Balancing Efficacy with Patient Safety
The Risk of Melanin Absorption
While the nail plate itself is relatively inert regarding pigment, the surrounding skin (proximal nail fold and hyponychium) is not.
When treating the nail unit, incidental exposure to surrounding skin is a risk factor. High-performance systems capable of high fluence can cause thermal damage if the patient's skin type is not considered.
Adjusting for Fitzpatrick Skin Types
Energy density must be modulated based on the patient's skin tone to prevent burns.
Patients with lighter skin (Fitzpatrick Types I and II) can generally tolerate higher energy densities (e.g., 20–25 J/cm²) to maximize efficacy. Conversely, patients with darker skin (e.g., Type IV) require reduced fluence (e.g., 8–14 J/cm²) to prevent excessive heat absorption by epidermal melanin.
Making the Right Choice for Your Goal
To achieve optimal therapeutic outcomes, you must weigh the need for deep penetration against the safety profile of the patient's surrounding tissue.
- If your primary focus is treating thickened or severe nails: Prioritize higher fluence settings to maximize the depth of drug delivery channels and ensure medication reaches the nail bed.
- If your primary focus is patient safety (Darker Skin Types): Reduce the fluence to the 8–14 J/cm² range to minimize the risk of thermal injury to melanin-rich skin surrounding the nail.
Success relies on precisely calibrating the energy to breach the nail barrier without compromising the integrity of the surrounding anatomy.
Summary Table:
| Factor | Low Fluence (8–14 J/cm²) | High Fluence (20–25 J/cm²) |
|---|---|---|
| Penetration Depth | Superficial Channels | Deep Micro-Pores |
| Nail Condition | Thin or superficial lesions | Thickened or dystrophic nails |
| Skin Safety | Ideal for Darker Skin (Type IV) | Lighter Skin (Types I-II) |
| Primary Goal | Minimize thermal risk | Maximize drug delivery rate |
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References
- Xiuhao Guan, Hong‐Duo Chen. Fractionated carbon dioxide (CO2) laser treatment contributes to trans-nail penetration of rhodamine B and changes of cytokine microenvironment. DOI: 10.1007/s10103-020-03232-7
This article is also based on technical information from Belislaser Knowledge Base .
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