Antimicrobial photodynamic therapy in onychomycosis management: A systematic review of clinical trials

Abstract

OBJECTIVES: Onychomycosis is a prevalent fungal nail infection often resistant to conventional antifungal therapies. Antimicrobial photodynamic therapy (aPDT) has emerged as a promising alternative, though its efficacy remains under investigation. This systematic review aimed to assess the effectiveness of aPDT in managing onychomycosis. METHODS: Conducted according to PRISMA guidelines and registered in PROSPERO (CRD42024520247), this review included clinical trials evaluating the antimicrobial efficacy of aPDT for onychomycosis. Searches were performed in PubMed, Scopus, Web of Science, Embase, Cochrane Library, ClinicalTrials.gov, and gray literature. Two reviewers independently screened, selected, and extracted data on study characteristics. Risk of bias was assessed using the Cochrane tool and Newcastle-Ottawa scale; certainty of evidence was evaluated using GRADE. RESULTS: Eighteen studies involving 591 participants (mean age: 54.2 years) met inclusion criteria. The most common light source was diode laser (450-700 nm), and photosensitizers included methylene blue, aminolevulinic acid, and methyl-5-aminolevulinate. aPDT significantly reduced onychomycosis severity (30-90 % OSI reduction) and achieved mycological cure rates up to 100 % when combined with fractional CO₂ laser. Clinical cure rates ranged from 20 % to 80 %, with notable improvements in nail appearance. Histological and microbiological analyses confirmed fungal reduction, and patient satisfaction was generally high. Overall, studies showed low risk of bias. The certainty of evidence was moderate for randomized controlled trials and low for non-randomized trials. CONCLUSION: aPDT demonstrates promising potential in onychomycosis management, showing clinical and microbiological efficacy. However, variability in protocols and outcomes requires further standardized clinical trials to establish optimal treatment parameters.