A randomized split-face clinical trial analyzing daylight photodynamic therapy with methyl aminolaevulinate vs ingenol mebutate gel for the treatment of multiple actinic keratoses of the face and the scalp

A randomized split-face clinical trial of conventional vs indoor-daylight photodynamic therapy for the treatment of multiple actinic keratosis of the face and scalp and photoaging

BACKGROUND

Recently, indoor daylight photodynamic therapy (idl-PDT) has been developed; however, its efficacy and tolerability remain to be assessed.

OBJECTIVE

This is a not-inferiority study to compare treatment outcomes of cPDT with a red LED lamp and idlPDT with a polychromatic white LED lamp in adult patients affected by symmetrical AKs of face and/or scalp.

METHODS

In this comparative, intra-patient, split-face, randomized clinical trial forty-three adult patients were enrolled. Two contralateral and symmetrical target areas of the face and/or scalp harboring at least 5 AKs were selected and randomized 1:1 to treatment with cPDT and idlPDT. The AKs number and cumulative area were assessed at baseline (T0). Efficacy and cosmetic outcome were assessed 3 months after treatment (T1).

RESULTS

Total AKs number and area reduced significantly with both idlPDT (p < .0001) and cPDT (p < .0001) in comparison to baseline. cPDT was more painful (p < .0001) and induced a more severe inflammation (p < .0001). Twenty-nine patients (70.7%) gave their overall preference to idlPDT (p < .001).

CONCLUSION

idlPDT may represent an alternative treatment protocol to cPDT for in-office treatment of AKs patients with better tolerability and a not inferior efficacy.

Actinic keratoses contiguous with squamous cell carcinomas are mostly non-hyperkeratotic and with severe dysplasia

AIMS

Actinic keratosis (AK) is a precursor of cutaneous squamous cell carcinoma (SCC). No validated parameters can predict which AKs will progress into SCCs, but especially thick AKs are under suspicion. The clinical and histopathological thickness of AKs is strongly correlated. This study aimed to investigate the thicknesses and degree of dysplasia of AKs contiguous with SCCs assuming these AKs represent the AKs that have undergone malignant transformation.

METHODS

Files of the Pathology Department, Hospital of Southern Jutland, Denmark, were reviewed. 111 cases met the inclusion criteria: a skin biopsy containing an invasive SCC. All SCCs merged with an AK at the edge. Degree of dysplasia, epidermal thickness and stratum corneum thicknesses of AKs were measured.

RESULTS

All AKs showed severe dysplasia. Most AKs had a stratum corneum thickness under 0.1 mm and an epidermal thickness under 0.5 mm, corresponding to clinically thin and non-hyperkeratotic AKs.

CONCLUSIONS

Our result suggests malignant progression potential of AKs regardless of thickness.

Italian expert consensus paper on the management of patients with actinic keratoses

Two round tables involving experts were organized in order to reach a consensus on the management of patients with actinic keratosis (AK). In the first, seven clinical questions were selected and analyzed by a systematic literature review, using a Population, Intervention, Control, and Outcomes framework; in the second, the experts discussed relevant evidences and a consensus statement for each question was developed. Consensus was reached among experts on how to best treat AK patients with respect to different clinical scenarios and special populations. Lesion-directed treatments are preferred in patients with few AKs. Patients with multiple AKs are challenging, with more than one treatment usually needed to achieve complete lesion clearance or a high lesion response rate, therapy should be personalized, based on previous treatments, patient, and lesion characteristics. Methyl aminolevulinate-PDT, DL (day light) PDT, and imiquimod cream were demonstrated to have the lowest percentage of new AKs after post treatment follow-up. For IMQ 5% and 3.75%, a higher intensity of skin reactions is associated with higher efficacy. Photodynamic therapy (PDT) is the most studied treatment for AKs on the arms. Regular sunscreen use helps preventing new AKs. Oral nicotinamide 500 mg twice daily, systemic retinoids and regular sunscreen use were demonstrated to reduce the number of new squamous cell carcinomas in patients with AKs. Limited evidence is available for the treatment of AKs in organ transplant recipients. There is no evidence in favor or against the use of any of the available treatments in patients suffering from hematological cancer.

Actinic Keratosis and Cutaneous Squamous Cell Carcinoma

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) and its precursors, actinic keratoses (AK), are common. Physicians of multiple specialties are confronted with their treatment.

METHODS

This review is based on publications retrieved by a selective search in PubMed, as well as on the German guidelines on AK and cSCC, skin cancer prevention, and surgery with histologic guidance.

RESULTS

Local treatments for AK include lesional cryotherapy, curettage, and laser ablation as well as field-directed treatments with topical agents, e.g., diclofenac plus hyaluronic acid, imiquimod, 5-fluorouracil, ingenol mebutate, and photodynamic therapy. These treatments can be administered in various sequences or combinations, depending on individual factors and the stage of the disease. The gold standard of treatment for cSCC is histologically confirmed complete resection; radiotherapy is an alternative. Locally uncontrollable or metastatic disease is treated with systemic drugs. The use of various chemotherapeutic agents, EGFR-directed therapies, and the PD-I inhibitor cemiplimab, either singly or in combination, has been described in uncontrolled trials and case series. Cemiplimab has a reported response rate of 47% and was recently approved for the treatment of advanced cSCC.

CONCLUSION

There are many options for the treatment of AK and cSCC that must be considered in the interdisciplinary care of these entities.

Sequential daylight photodynamic therapy and ingenol mebutate versus 2 sessions of daylight photodynamic therapy for the treatment of actinic keratosis: An observational, prospective, comparative study

BACKGROUND

Field-directed therapy, such as daylight-photodynamic therapy (DL-PDT) or ingenol mebutate (IM), is indicated for multiple actinic keratosis (AK) lesions located on contiguous areas of skin with significant sun damage.

OBJECTIVE

To compare the efficacy of sequential DL-PDT and IM treatment with that of 2 sessions of DL-PDT in AK patients.

MATERIAL AND METHODS

For this observational, multicenter, prospective study we recruited patients for whom DL-PDT was indicated for the treatment of AK lesions (grades I and II) located on the head. After 1 month of follow-up those who did not achieve a satisfactory clinical response received either a second session of DL-PDT or were treated with IM. Epidemiological and clinical data were collected and analyzed.

RESULTS

Forty-three patients were enrolled (39 male, 4 female). The mean (standard deviation, SD) age was 78 (7.84) years, and the mean (SD) number of AK lesions per patient was 9.58 (1.16). After the first session of DL-PDT, 27 patients (62.8%) required further treatment: 13 (48.1%) received a second session of DL-PDT and 14 (51.9%) were treated with IM. After 1 year of follow-up, lesion clearance rates were higher in patients who received 2 sessions of DL-PDT than those treated with sequential DL-PDT plus IM (75.2%vs 54.6%, p = 0.0013). Local skin reactions were more frequent in the DL-PDT plus IM group than the group treated with 2 sessions of DL-PDT (p = 0.0245).

CONCLUSIONS

The combination of DL-PDT plus IM appears to have no synergistic effect in the treatment of field cancerization, and offers no benefits over 2 sessions of DL-PDT monotherapy, although both combinations produced high lesion clearance rates, a good safety profile, excellent cosmetic outcome, and good patient satisfaction.

Photodynamic therapy: A hot topic in dermato-oncology

Photodynamic therapy (PDT) is a modern, non-invasive therapeutic method used for the destruction of various cells and tissues. It requires the simultaneous presence of three components: a photosensitizer (PS), a light source and oxygen. Precancerous skin lesions are conditions associated with a high likelihood of malignant transformation to squamous cell carcinoma. Data available so far indicate that PDT is a promising treatment method which can be successfully employed in several medical fields including dermatology, urology, ophthalmology, pneumology, cardiology, dentistry and immunology. Numerous authors therefore have studied this technique in order to improve its efficacy. As a result, significant advancement has been achieved with regard to PSs and drug delivery systems. Substantial progress was also obtained with respect to PDT for the treatment of precancerous skin lesions, several authors focusing their efforts on the study of daylight-PDT and on identifying methods of decreasing technique-related pain. This review reports on the most recent findings in PDT, with emphasis on cutaneous precancerous lesions.

Long-term efficacy data for daylight-PDT

INTRODUCTION

Conventional photodynamic therapy (c-PDT) is an established successful treatment for non-melanoma skin cancers (NMSC). Daylight PDT (DL-PDT) was introduced to overcome the main inconveniencies associated with c-PDT such as pain during illumination and long clinic visits. DL-PDT was shown to have similar short-term efficacy to c-PDT for the treatment of mild/moderate actinic keratosis (AKs) but it is associated with better tolerability. Since AKs tend to regress and reoccur over time, data on long-term efficacy of DL-PDT become crucial.

EVIDENCE ACQUISITION

We performed a systematic review search up to February 2018 of available studies on DL-PDT long-term efficacy using the MEDLINE database and made a manual search of selected references.

EVIDENCE SYNTHESIS

Most current studies on DL-PDT have limited follow-up periods of 3 to 6 months. Only 2 randomized, intra-individual studies provided efficacy data on AK treatment at 12 month-follow-up and supported the long-term efficacy of this novel treatment modality showing a low recurrence rate, varying from 8.7% to 13%. Current evidences for other NMSCs are limited and efficacy seems to be not as good as for AK.

CONCLUSIONS

DL-PDT is a very promising treatment for mild to moderate AKs of the face and scalp. Efficacy outcomes of DL-PDT are similar to those of c-PDT in the short-term. Additional studies are required to increase our knowledge on DL-PDT long-term efficacy, as limited data are currently available.

Daylight-Mediated Photodynamic Therapy With Methyl Aminolevulinate in Actinic Keratosis Treatment

BACKGROUND

Research has shown daylight-mediated photodynamic therapy (PDT) for the treatment of actinic keratosis (AK) to be effective, tolerable, and convenient, with excellent patient satisfaction and cosmesis. Although success has been demonstrated in areas with similar latitudes to Switzerland and Scandinavia, this treatment has not been studied in a Canadian population.

OBJECTIVES

The purpose of this study is to investigate the effectiveness, safety, and patient satisfaction of daylight-mediated methyl 5-aminolevulinate (MAL)-PDT to make recommendations for its use in Canadian practice.

METHODS

A retrospective chart review of patients who received treatment of daylight-mediated MAL-PDT for the indication of AK at the Institute of Cosmetic and Laser Surgery in Oakville, Ontario, between 2009 and 2016.

RESULTS

A total of 112 patients were included, consisting of 94 males and 18 females with a mean age of 63.79 years. A total of 177 sites were treated among all patients, mostly consisting of the face (n = 92) and scalp (n = 55). A total of 13.4% of patients experienced side effects, the most common being redness (n = 4) and scabbing (n = 4). Of the 42 patients who expressed their level of satisfaction, 83.3% reported being happy with the treatment, χ²(1) = 18.67, P ≤ .05; 6.3% of patients were noted to be completely clear, 86.6% had a good response, 0.9% had a mild response, and 0% had no response, χ²(1) = 101.04, P ≤ .05.

CONCLUSIONS

Daylight-mediated MAL-PDT is a suitable treatment option for AK lesions in a Canadian population due to the demonstrated efficacy, patient satisfaction, tolerability, and convenience.

Patient and physician satisfaction in an observational study with methyl aminolevulinate daylight photodynamic therapy in the treatment of multiple actinic keratoses of the face and scalp in six European countries

BACKGROUND

Guidelines recommend treating actinic keratoses (AKs) as they are recognized as precursors of invasive squamous cell carcinoma.

OBJECTIVE

The objective of this study was to collect real-world clinical data on the use of methyl aminolevulinate daylight photodynamic therapy (MAL DL-PDT) for the treatment of face and scalp AK in Europe.

METHODS

A prospective, multicenter, non-interventional study was conducted in six European countries in patients receiving a single treatment of MAL DL-PDT for face and/or scalp AK. Patient-reported outcomes were assessed by patient questionnaires at baseline and at 3 months after treatment, efficacy was assessed at 3 months using a 6-point global improvement scale, and adverse events (AE) were recorded at each visit.

RESULTS

Overall, 325 patients were enrolled from 52 investigational centres, 314 of whom attended the 3-month visit. Most patients had multiple lesions (58.4% had >10 lesions) with lesions mainly located on the scalp (60.0%) and/or forehead (54.2%). AKs were predominantly grade I (39.4%) or grade II (33.2%), and 10.5% of patients had grade III lesions. The proportions of patients and physicians that were overall satisfied to very satisfied with the MAL DL-PDT treatment were 80.4% and 90.3%, respectively. The vast majority of patients (90.0%) would consider using MAL DL-PDT again if needed. Physician-assessed efficacy at 3 months was at least much improved in 83.5% of patients, with 45.9% of patients requiring no retreatment. Related AEs were reported in 15% of patients.

CONCLUSION

Use of MAL DL-PDT for multiple face and/or scalp AKs resulted in high levels of patient and physician satisfaction in clinical practice in Europe, reflecting the good efficacy and high tolerability of this convenient procedure.

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.