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Device-based therapies have been used for onychomycosis patients with intolerance to systemic treatments. Photodynamic therapy (PDT) improves onychomycosis, while fractional carbon dioxide (FrCO 2 ) augments the topical drug delivery. Comparative studies between PDT alone and laser-assisted one are lacking. We aimed to evaluate the efficacy of PDT alone versus FrCO 2 -assisted PDT for treatment of onychomycosis. Twenty-one patients with bilateral onychomycosis of toenails with nearly the same degree of affection were enrolled in this prospective intra-patient-controlled study. The right affected toenail was treated  via  PDT alone. The left toenail was treated  via  a FrCO 2  followed immediately by PDT. The sessions were bimonthly for a total of six sessions. Direct microscopy, fungal cultures, clinical evaluation, onychomycosis severity index scoring, and patient’s satisfaction were assessed before and 12 weeks after the last session. Both treatments reduced significantly the onychomycosis severity index ( p  &lt; .05) without significant difference between them. The improvement in nail appearance and patient’s satisfaction were higher in laser-assisted PDT than PDT alone ( p  &lt; .05). Both treatments effectively reduced the severity of onychomycosis with a high degree of safety and tolerability. Fractional CO 2 -assisted PDT enhanced the clinical outcome  via  improving the nail appearance and patient’s satisfaction.Key messagePhotodynamic therapy has a good success rate in clearing onychomycosis. Addition of fractional CO 2  to photodynamic therapy improves the nail appearance and induces better satisfaction to treatment. Photodynamic therapy has a good success rate in clearing onychomycosis. Addition of fractional CO 2  to photodynamic therapy improves the nail appearance and induces better satisfaction to treatment.

journal of dermatological treatment

Fractional CO 2 -assisted photodynamic therapy improves the clinical outcome and patient’s satisfaction in toenail onychomycosis treatment: an intra-patient comparative single-center study