Off-label photodynamic therapy for recalcitrant facial flat warts using topical 5-aminolevulinic acid

Advances and perspectives in use of semisolid formulations for photodynamic methods

Although nearly 30 years have passed since the introduction of the first clinically approved photosensitizer for photodynamic therapy, progress in developing new pharmaceutical formulations remains unsatisfactory. This review highlights that despite years of research, many recurring challenges and issues remain unresolved. The paper includes an analysis of selected essential studies involving aminolevulinic acid and its derivatives, as well as other photosensitizers with potential for development as medical products. Among various possible vehicles, special attention is given to gelatin, alginates, poly(ethylene oxide), polyacrylic acid, and chitosan. The focus is particularly on infectious and cancerous diseases. Key aspects of developing new semi-solid drug forms should prioritize the creation of easily manufacturable and biocompatible preparations for clinical use. At the same time, new formulations should preserve the primary function of photosensitizers, which is the generation of reactive oxygen species capable of destroying pathogenic cells or tumors. Additionally, the use of adjuvant properties of carriers, which can enhance the effectiveness of macrocycles, is emphasized, especially in chitosan-based antibacterial formulations. Current research indicates that many promising dyes and macrocyclic compounds with high potential as photosensitizers in photodynamic therapy remain unexplored in formulation and development work. This review outlines potential new and previously explored pathways for advancing photosensitizers as active pharmaceutical ingredients (APIs).

Topical 5-aminolevulinic acid photodynamic therapy for recalcitrant facial flat warts

Photodynamic therapy (PDT) uses light energy to excite a photosensitizing agent, leading to production of reactive oxygen species, which exert cytotoxic effects on targeted cells. PDT has emerged as a promising therapeutic modality for the treatment of flat warts caused by human papillomavirus (HPV) infection, by targeting infected keratinocytes and inactivating nonenveloped viral particles. Some patients with recalcitrant flat warts on the face who have poor response to traditional treatment often seek effective therapy to have the warts removed. In this report, we retrospectively evaluated the efficacy of topical 10% 5-aminolevulinic acid PDT (ALA-PDT) in the treatment of 15 patients with recalcitrant facial flat warts. Patients received treatment once every two weeks for a total of two or three sessions. At 24 weeks after the start of treatment, 86.67% of patients showed complete or excellent response. Further more, the remission rate of 100% lesion clearance was 46.67% (seven patients), and the remission rate of 70-100% lesion clearance was 40.00% (six patients). None of the patients experienced disease recurrence or progression. The adverse reactions were generally well tolerated by the patients and mostly resolved in a few days without special treatment. Our findings showed that topical 10% ALA-PDT is a safe and effective treatment for recalcitrant facial flat warts.

A multi centre real world observation to evaluate the efficacy of cryotherapy versus local hyperthermia for the treatment of plane warts

BACKGROUND

Most plane warts are recalcitrant to treatment. Both cryotherapy and local hyperthermia have been applied to treat plane warts. However, no direct comparative study on their respective efficacy and safety has ever been performed.

OBJECTIVE

To assess the efficacy and safety of local hyperthermia at 43±1°C versus liquid nitrogen cryotherapy for plane warts.

METHODS

Sequential patients with plane warts entered the study, either receiving cryotherapy or local hyperthermia therapy at the discretion of the patients and the recommendations of consultants. Cryotherapy with liquid nitrogen was delivered in two sessions two weeks apart, while local hyperthermia was delivered on three consecutive days, plus two similar treatments 10 ± 3 days later. The temperature over the treated skin surface was set at 43±1°C for 30 mins in each session. The primary outcome was the clearance rates of the lesions 6 months after treatment.

RESULTS

Among the 194 participants enrolled, 183 were included in the analysis at 6 months. Local hyperthermia and cryotherapy achieved clearance rates of 35.56% (48/135) and 31.25% (15/48), respectively (p=0.724); recurrence rates of 16.67% (8/48) and 53.33% (8/15) (p=0.01); and adverse events rates of 20.74% (28/135) and 83.33% (40/48), respectively (p<0.001). Cryotherapy had a higher pain score (p<0.001) and a longer healing time (p<0.001).

CONCLUSIONS

Local hyperthermia at 43°C and cryotherapy had similar efficacy for plane warts. Local hyperthermia had a safer profile than cryotherapy but it required more treatment visits during a treatment course. More patients preferred local hyperthermia due to its treatment friendly nature.

Photodynamic therapy using methylene blue and intense pulsed light versus intense pulsed light alone in treatment of verruca: A randomized controlled study

BACKGROUND

Many therapeutic modalities are available for treatment of warts, but no single therapy is universally effective. Photodynamic therapy (PDT) using intralesional methylene blue (MB) followed by intense pulsed light (IPL) could be a successful option for treatment by several mechanisms.

METHODS

This prospective randomized controlled trial was carried out on eighty patients with verrucae. Patients were randomized into three groups; group A (30 patients) received MB/IPL/PDT sessions, group B (30 Patients) received IPL sessions, and group C (control). Response was assessed by clinical and dermoscopy score (0,1, 2, or 3 according to extent of clinical and dermoscopic resolution), cure rate (percent of verrucae clinically and dermoscopy cleared), and imageJ analysis (surface area of wart and haemorrhagic structures or vessels).

RESULTS

Clinical and dermoscopic clearance was achieved in 43.3% and 20% of patients in groups A and B respectively. Cure rate was 40.9% for group A compared to 23.4% for group B. ImageJ analysis revealed more reduction of surface area in group A being 80.05 ± 27.12% for verrucae and 89.28 ± 19.19% for vessels and haemorrhagic dots compared to 48.16 ± 34.21% and 65.99 ± 30.58% in group B.

CONCLUSIONS

MB/IPL/PDT is an effective option for treatment of warts with a success rate of around 40%, based on clinical and dermoscopic assessment. The efficacy was found to be higher on using imageJ utilizing both the surface area of the wart and surface area of vessels and haemorrhagic dots with the latter being more effected by treatment.

Photodynamic viral inactivation: Recent advances and potential applications

Antibiotic-resistant bacteria, which are growing at a frightening rate worldwide, has put the world on a long-standing alert. The COVID-19 health crisis reinforced the pressing need to address a fast-developing pandemic. To mitigate these health emergencies and prevent economic collapse, cheap, practical, and easily applicable infection control techniques are essential worldwide. Application of light in the form of photodynamic action on microorganisms and viruses has been growing and is now successfully applied in several areas. The efficacy of this approach has been demonstrated in the fight against viruses, prompting additional efforts to advance the technique, including safety use protocols. In particular, its application to suppress respiratory tract infections and to provide decontamination of fluids, such as blood plasma and others, can become an inexpensive alternative strategy in the fight against viral and bacterial infections. Diverse early treatment methods based on photodynamic action enable an accelerated response to emerging threats prior to the availability of preventative drugs. In this review, we evaluate a vast number of photodynamic demonstrations and first-principle proofs carried out on viral control, revealing its potential and encouraging its rapid development toward safe clinical practice. This review highlights the main research trends and, as a futuristic exercise, anticipates potential situations where photodynamic treatment can provide a readily available solution.

Photodynamic therapy versus candida antigen immunotherapy in plane wart treatment: a comparative controlled study

INTRODUCTION

Plane warts, mostly found on the face, present a challenge to treat as most destructive methods can lead to unpleasant cosmetic outcome. Alternative therapeutic methods should be evaluated. The aim of this study is to evaluate the clinical efficacy and adverse effects of photodynamic therapy with methylene blue and intense pulsed light in comparison to candida antigen immunotherapy in the treatment of plane warts.

METHODS

The study included 39 patients with plane warts assigned into 3 groups. Group I received photodynamic therapy using methylene blue followed by IPL illumination, group II received immunotherapy using 0.1 ml of candida albicans antigen and group III received 0.1 ml saline as a control.

RESULTS

Complete response was detected in (46.1%) of patients in group I compared to (61.5%) in group II and no response in group III.

CONCLUSION

Candida antigen immunotherapy is superior to photodynamic therapy in plane warts treatment with absence of recurrence and comparable side effects in both groups.

Efficacy and safety of conventional versus daylight photodynamic therapy in children affected by multiple facial flat warts

BACKGROUND

facial flat warts (FFWs) are a superficial viral skin disease, extremely common in childhood. Recently, conventional photodynamic therapy (C-PDT) has been used for the treatment of FFWs with good outcome. The efficacy of daylight photodynamic therapy (DL-PDT) has not yet been evaluated.

OBJECTIVES

to investigate and assess the efficacy and safety of C-PDT versus DL-PDT using 10% aminolevulinic acid (ALA) in the treatment of recalcitrant FFWs in a paediatric setting.

MATERIALS AND METHODS

30 consecutive patients aged <18 years with FFWs of the face were included and randomly divided into two groups: group A (15 patients) was treated with C-PDT and group B (15 patients) with DL-PDT. Patients underwent treatments for three times with 1-month intervals. The response was assessed on week 4,812 and 24 (T4,T8,T12,T24) and scored as excellent (75-100% reduction of total wart count), very good (74-50% reduction), good (49-25% reduction), poor (<25% reduction or no response). Any adverse event occurring during/after ALA application/irradiation as well as pain intensity were recorded at each visit.

RESULTS

at T4 and T8 no excellent response was achieved in both groups. At week 12, excellent response was observed in 53.3% of group A patients vs 0% of group B patients, although in the latter 66.7% of patients achieved a very good response. Excellent outcome raised to 73.3% and 80% in group A and B, respectively, at week 24. Poor response to therapy was observed in 26.7% of patients in group A and 20% in group B. Both treatment modalities were well tolerated, with transient pain, irritation and hyperpigmentation as main side effects.

CONCLUSIONS

ALA-PDT is effective and safe for FFWs, with striking cosmetic results and no recurrence. Compared with conventional modality, DL-PDT is better tolerated, time-saving, nearly painless and greatly appreciated by young patients.

A comprehensive review of treatment options for recalcitrant nongenital cutaneous warts

Introduction: The treatment of recalcitrant nongenital cutaneous warts has always been challenging for dermatologists as they often recur and relapse. Multiple treatment options have been investigated to improve the outcome. This review provides an overview of the current treatment modalities and summarizes the efficacy and side effects of each treatment option for recalcitrant nongenital cutaneous warts.Methods: A PubMed search was performed through July 2019 to include all English language reports investigating the treatment for recalcitrant nongenital cutaneous warts, regardless of design.Results: A total of 144 studies were included in this review. The treatment options for recalcitrant nongenital cutaneous warts can be divided into three groups: destructive treatment, immunotherapy, and cytotoxic agents. Although both destructive therapies and cytotoxic agents demonstrated high complete response rates, immunotherapy, which is a minimally invasive method, was superior in terms of the clearance of distant warts. Intralesional mumps-measles-rubella injections and purified protein derivatives currently demonstrate high efficacy with well-established clinical evidence.Conclusions: Many upcoming treatment modalities, especially immunotherapy, are promising. However, more comparative studies are required to verify the efficacy and safety profile.

Chlorin, Phthalocyanine, and Porphyrin Types Derivatives in Phototreatment of Cutaneous Manifestations: A Review

Recent scientific research has shown the use of chlorin, phthalocyanines, and porphyrins derivatives as photosensitizers in photodynamic therapy in the treatment of various pathologies, including some of the major skin diseases. Thus, the main goal of this critical review is to catalog the papers that used these photosensitizers in the treatment of acne vulgaris, psoriasis, papillomavirus infections, cutaneous leishmaniasis, and skin rejuvenation, and to explore the photodynamic therapy mechanisms against these conditions alongside their clinical benefits.

A combination of 2940-nm laser and photodynamic therapy for treatment of recalcitrant facial flat warts

BACKGROUND

Photodynamic therapy (PDT) is one of the treatment options for generalized facial flat warts, which results in elimination of virus and inhibition of proliferation of warts due to photochemical and phototoxic reactions. In this research, we attempted to evaluate the efficacy and safety profiles of a combination of 2940-nm laser and PDT for the treatment of generalized recalcitrant facial flat warts.

METHODS

Retrospective analysis of the patients with recalcitrant facial warts was performed. Patients in the combined group (n = 40) were treated with a 2940-nm single spot abrasion followed by a PDT; while the PDT group (n = 40) received a PDT treatment only. The efficacy was assessed by the lesion numbers and lesion clearance rate. The effective rate was calculated with the cured and excellent response rates.

RESULTS

The combined group showed significant improvements in the total effective rate (77.5%vs. 57.5%, p = 0.0416) and average clearance rate (81.68±2.83% vs. 68.13 ± 3.97%, p = 0.0068) as compared with the PDT-only group. The degree of lesion clearance was positively correlated with the treatment times in both groups. After three months of follow-up, no relapse occurred in patients from either group. Furthermore, an accumulation of photosensitizer in the lesional areas was observed in the combined treatment group.

CONCLUSIONS

A combination of 2940-nm laser and PDT was safe and showed significantly more effect than PDT alone in treatment for recalcitrant facial flat warts, partially due to the improved uptake of photosensitizer after 2940-nm laser induced skin abrasion.

Excellent cosmetic result of daylight photodynamic therapy for facial flat warts in a child

FFW are among the most frequent infectious skin conditions. Although several pharmacological and physical topical treatments are available, results are often unsatisfactory in terms of efficacy (frequent recurrence) and cosmetic outcome (risk of scars, hyper- or hypopigmentation). We describe the case of multiple recalcitrant facial flat warts treated by daylight photodynamic therapy (DL-PDT) in an otherwise health 8-year-old female child, with complete clearance and excellent cosmetic result. The advantages of DL-PDT over conventional PDT in terms of tolerability, time and cost, especially in paediatric setting are discussed.

Antimicrobial effects of photodynamic therapy

The microorganisms that cause infections are increasing their resistance to antibiotics. In this context, alternative treatments are necessary. The antimicrobial photodynamic therapy (aPDT) is a therapeutic modality based on photosensitizing molecules that end up generating reactive oxygen species that induce the destruction of the target cells when are irradiated with light of a suitable wavelength and at a proper dose. The cells targeted by aPDT are all types of microorganisms (bacteria, fungi and parasites) including viruses and has been proven effective against representative members of all of them. In the field of dermatology, aPDT has been tested with promising results in different infections such as chronic ulcers, acne, onychomycosis and other cutaneous mycoses, as well as in leishmaniasis. Therefore, it is presented as a possible treatment option against the agents that cause skin and/or mucous infections.

Pneumonia treatment by photodynamic therapy with extracorporeal illumination - an experimental model

Infectious pneumonia is a major cause of morbidity/mortality, mainly because of the increasing rate of microorganisms resistant to antibiotics. Photodynamic Therapy (PDT) is emerging as a promising approach, as effects are based on oxidative stress, preventing microorganism resistance. In two previous studies, the in vitro inactivation of Streptococcus pneumoniae using indocyanine green (ICG) and infrared light source was a success killing 5 log₁₀ colony-forming units (CFU/mL) with only 10 μmol/L ICG. In this work, a proof-of-principle protocol was designed to treat lung infections by PDT using extracorporeal illumination with a 780 nm laser device and also ICG as photosensitizer. Hairless mice were infected with S. pneumoniae and PDT was performed two days after infection. For control groups, CFU recovery ranged between 10³-10⁴/mouse. For PDT group, however, no bacteria were recovered in 80% of the animals. Based on this result, animal survival was evaluated separately over 50 days. No deaths occurred in PDT group, whereas 60% of the control group died. Our results indicate that extracorporeal PDT has the potential for pneumonia treatment, and pulmonary decontamination with PDT may be used as a single therapy or as an antibiotics adjuvant.

Photodynamic therapy in dermatology beyond non-melanoma cancer: An update

Photodynamic therapy (PDT) employs a photosensitizer (PS) and visible light in the presence of oxygen, leading to production of cytotoxic reactive oxygen species, which can damage the cellular organelles and cause cell death. In dermatology, PDT has usually taken the form of topical application of a precursor in the heme biosynthesis pathway, called 5-aminolevulinic acid (or its methyl ester), so that an active PS, protoporphyrin IX accumulates in the skin. As PDT enhances dermal remodeling and resolves chronic inflamation, it has been used to treat cutaneous disorders include actinic keratoses, acne, viral warts, skin rejuvenation, psoriasis, localized scleroderma, some non-melanoma skin cancers and port-wine stains. Efforts are still needed to mitigate the side effects (principally pain) and improve the overall procedure.

5-Aminolaevulinic Acid-Based Photodynamic Therapy Restrains Pathological Hyperplasia of Fibroblasts

Background

This study aimed to explore whether 5-aminolaevulinic acid-based photodynamic therapy (ALA-PDT) restrains pathological hyperplasia of fibroblasts from hyperplastic scar tissues, and to investigate the potential mechanism.

Material/Methods

We used MTT assay, flow cytometry, and terminal-deoxynucleotidyl transferase mediated nick-end labeling (TUNEL) to examine the effects of ALA-PDT on proliferation, cell cycle, and apoptosis of fibroblasts isolated from hyperplastic scar tissues. The growth-promoting effect of fibroblasts on vascular endothelial cells was measured by cell co-culture. Real-time PCR and Western blot analysis were performed to detect the expression levels of transforming growth factor-β1 (TGF-β1), α-smooth muscle actin (α-SMA), Collagen I, Collagen III, vascular endothelial growth factor-A (VEGFA), and basic fibroblast growth factor (bFGF).

Results

ALA-PDT inhibited proliferation delayed cell cycle progress, promoted apoptosis of fibroblasts, and suppressed its growth-promoting effect on vascular endothelial cells, and decreased expression of TGF-β1, α-SMA, Collagen I, Collagen III, VEGFA, and bFGF.

Conclusions

ALA-PDT effectively restrained pathological hyperplasia of fibroblasts from hyperplastic scar tissues, which may provide a research basis for clinical therapy of hyperplastic scars.

Use of Er:YAG for the treatment of recalcitrant facial verruca plana

BACKGROUND

Recalcitrant facial verruca plana (FVP) may persist for years and full remission is not always achieved with conventional therapies. The clinical success rates reported for different lasers are highly variable and only one study evaluated the Er:YAG laser for the treatment of FVP.

OBJECTIVE

To determine whether Er:YAG is safe and effective for the treatment of recalcitrant FVP.

METHODS

Forty-six patients with recalcitrant FVP were treated by Er:YAG at four-week intervals. The patients' clinical response, adverse effects such as scarring and pigment change, recurrence and patient satisfaction were assessed. Patients were clinically evaluated after each session over a six-month follow-up.

RESULTS

A total of 550 lesions of 46 participants were treated with 1-3 passes. The patients received 1-4 laser sessions with one session on average. Thirty-two patients (62.5%) achieved a complete response with 458 lesions (83.3%) being completely and 30 (5.5%) being partially healed. The post-treatment side effects were post-inflammatory hyperpigmentation and mild scar formation. FVP recurred in 12 patients (26.0%). Twenty-six patients (56.5%) were completely satisfied and nine (19.5%) were mostly satisfied with the treatment.

CONCLUSIONS

Er:YAG laser is a good treatment option in patients with recalcitrant FVP, particularly for cosmetically sensitive areas.