Conventional vs. daylight photodynamic therapy for patients with actinic keratosis on face and scalp: 12-month follow-up results of a randomized, intra-individual comparative analysis

The use of photodynamic therapy in medical practice

Cancer therapy, especially for tumors near sensitive areas, demands precise treatment. This review explores photodynamic therapy (PDT), a method leveraging photosensitizers (PS), specific wavelength light, and oxygen to target cancer effectively. Recent advancements affirm PDT's efficacy, utilizing ROS generation to induce cancer cell death. With a history spanning over decades, PDT's dynamic evolution has expanded its application across dermatology, oncology, and dentistry. This review aims to dissect PDT's principles, from its inception to contemporary medical applications, highlighting its role in modern cancer treatment strategies.

Field Cancerization Therapies for the Management of Actinic Keratosis: An Updated Review

Field cancerization theory highlights that the skin surrounding actinic keratoses (AK) is also at increased risk for possible malignant transformation; thus, field-directed treatments may both reduce the risk of AK recurrence and potentially reduce the risk of development of cutaneous squamous cell carcinoma (cSCC). Photodynamic therapy (PDT) with either aminolevulinic acid (ALA) or methylaminolevulinate (MAL), as well as topical treatments such as 5-fluorouracil (5-FU), diclofenac gel, piroxicam, imiquimod, and ingenol mebutate, have all shown higher efficacy than vehicle treatments. PDT is widely recognized for its high efficacy; however, concerns for associated pain have driven new studies to begin using alternative illumination and pretreatment techniques, including lasers. Among topical treatments, a combination of 5-FU and salicylic acid (5-FU-SA) has shown to be the most effective but also causes the most adverse reactions. Tirbanibulin, a new topical agent approved for use in 2020, boasts a favorable safety profile in comparison with imiquimod, 5-FU, and diclofenac. Meanwhile, ingenol mebutate is no longer recommended for the treatment of AKs due to concerns for increased risk of cSCC development. Moving forward, an increasing number of studies push for standardization of outcome measures to better predict risk of future cSCC and use of more effective measures of cost to better guide patients. Here, we present an updated and comprehensive narrative review both confirming the efficacy of previously mentioned therapies as well as highlighting new approaches to PDT and discussing the use of lasers and novel topical treatments for treatment of AK.

A Review of MAL-PDT for the Treatment Strategy of Actinic Keratosis: Broader Clinical Perspectives Beyond the Data and Guideline Recommendations

Methyl aminolevulinate (MAL) is a topical compound approved for use with photodynamic therapy (PDT) for the treatment of actinic keratosis (AK) and field cancerization in certain countries. There exists a high burden of disease for patients with AK: repeated treatments are required, there is a known risk of progression to keratinocyte carcinoma, and cosmetic appearance is affected. Delivery of PDT using MAL is a flexible treatment strategy available in many forms; red light, daylight, or artificial daylight can be used for illumination, all of which result in high AK clearance rates and low recurrence. MAL-PDT protocols continue to evolve to further improve adherence and treatment outcomes. Here, we used PubMed to search MEDLINE to identify guidelines, consensus recommendations, and studies describing the use of MAL for the treatment of AK. The aim of this targeted review is to consider various MAL-PDT treatment strategies on the basis of published literature, with a focus on personalizing treatment for the heterogeneous AK population.

Global Trends and Research Progress of Photodynamic Therapy in Skin Cancer: A Bibliometric Analysis and Literature Review

Background

Based on photochemical reactions through the combined use of light and photosensitizers, photodynamic therapy (PDT) is gaining popularity for the treatment of skin cancer. Various photosensitizers and treatment regimens are continuously being developed for enhancing the efficacy of PDT on skin cancer. Reviewing the development history of PDT on skin cancer, and summarizing its development direction and research status, is conducive to the further research.

Methods

To evaluate the research trends and map knowledge structure, all publications covering PDT on skin cancer were retrieved and extracted from Web of Science database. We applied VOSviewer and CiteSpace softwares to evaluate and visualize the countries, institutes, authors, keywords and research trends. Literature review was performed for the analysis of the research status of PDT on skin cancer.

Results

A total of 2662 publications were identified. The elements, mechanism, pros and cons, representative molecular photosensitizers, current challenges and research progress of PDT on skin cancer were reviewed and summarized.

Conclusion

This study provides a comprehensive display of the field of PDT on skin cancer, which will help researchers further explore the mechanism and application of PDT more effectively and intuitively.

Advances in Topical Treatments of Cutaneous Malignancies

Surgical excision has been the preferred treatment for cutaneous malignancies, but can be affected by various considerations. Noninvasive, self-administered topical treatments represent an alternative option. The aim of this review was to evaluate and summarize evidence-based recommendations for topical treatments of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (CSCC), in situ melanoma (MIS), and extramammary Paget's disease (EMPD). Studies were reviewed on PubMed. Included studies were summarized, assessed for biases, and assigned a level of evidence to develop treatment recommendations. For the treatment of superficial BCC, complete clearance rates ranged from 90 to 93% for 5% 5-fluorouracil (5-FU) and 71 to 76% for imiquimod (IMQ). For the treatment of nodular BCC, clearance rates for photodynamic therapy (PDT) were 91% at 3 months, with a sustained lesion clearance response rate of 76% after 5 years of follow-up. Clearance rates were 53 to 76% with IMQ. For squamous cell carcinoma in situ, clearance rates ranged from 52 to 98% for PDT, 67 to 92% for 5-FU, and 75 to 93% for IMQ. For MIS, clearance rates ranged from 53 to 92% for IMQ. For EMPD, 54% of 110 patients in cohort studies and case series had a clinical complete response with IMQ. While surgical intervention remains the standard of care for skin cancer, non-invasive, self-administered topical treatments are highly desirable alternative options. Ultimately, the patient and provider should find a treatment modality that aligns with the patient's expectations and maintenance of quality of life.

Methyl Aminolaevulinic Acid versus Aminolaevulinic Acid Photodynamic Therapy of Actinic Keratosis with Low Doses of Red-Light LED Illumination: Results of Long-Term Follow-Up

Photodynamic therapy (PDT) treatment for multiple actinic keratosis (AK) has been found effective when lower doses of red light were used with methyl aminolaevulinic acid (MAL). The aim of this study was to compare the results of lower doses of red light conventional PDT (h-PDT, 16 J/cm2) with MAL and aminolaevulinic acid (ALA) in a long-term follow-up. Patients with more than five symmetrical AK on the scalp who were candidates for PDT were selected and divided randomly between MAL and ALA treatment and patients were followed at 3 and 12 months. The responses were assessed by counting the total AK and the AK per patient. Pain and adverse events were also compiled. A total of 46 patients were treated, 24 with MAL, and 22 with ALA. The two groups were comparable at baseline (p > 0.005). No significant differences were found in the results of both treatments at 12 months, despite ALA exhibiting slightly better results at 3 months. No differences in pain and adverse events were assessed. Both ALA and MAL were effective when lower doses of red light were used in c-PDT. Long term efficacy was also documented. Further studies are necessary to determine the inferior point of red-light illumination without losing efficacy.

The Role and Effectiveness of Photodynamic Therapy on Patients With Actinic Keratosis: A Systematic Review and Meta-Analysis

Actinic keratoses (AKs) are the most common neoplastic lesions and are recognized as a precursor to squamous cell skin cancer. Photodynamic therapy (PDT) is a therapeutic option for multiple AKs in line with field cancerization. The aim of this study was to assess the effectiveness of PDT on patients with AKs using a meta-analysis, in order to evaluate the possible superiority of one treatment over the others. For this purpose, the PubMed, MEDLINE, Scopus, OVID, Science Direct, British Journal of Dermatology, Research Gate, and Embase databases were searched in March 2022. The search terms used were 'photodynamic therapy' and 'actinic keratosis'. We utilized the random-effects meta-analysis model to compare methyl aminolevulinate PDT (MAL-PDT) and the combination of a nanoscale-lipid vesicle formulation with the prodrug 5-aminolevulinic acid (BF-200 ALA) on a complete response (CR) of the lesions. Our meta-analysis indicated that the comparison of BF-200 ALA versus MAL-PDT showed marginally higher CRs than MAL-PDT.

Actinic keratosis (review of literature)

Actinic keratosis is an important medical and social problem, the correct diagnosis and treatment of which will help to avoid the development of invasive forms of cutaneous squamous cell carcinoma. With the further development of the early diagnosis of cancer, including skin cancer, the increase in human life expectancy, and the popularization of travel to exotic countries, the number of cases of actinic keratosis among the population will continue to grow. In this regard, it is important to discuss the causes and pathogenesis of the disease, the varied clinical picture of the disease, methods of non-invasive diagnostics, as well as methods of treatment, of which there are a great many in the treatment of actinic keratosis today. However, each of the methods has both advantages and disadvantages, and in the global trend towards a personalized approach to treatment, it is important to choose from the standpoint of evidence-based medicine the most suitable for each individual patient. Moreover, after treatment of actinic keratosis, relapses often occur, which are the result of insufficient diagnosis and the development of incorrect treatment tactics. The review article provides the clinical picture of actinic keratosis, diagnostic and therapeutic methods, and their comparison with each other in terms of efficacy and safety

Combined versus conventional photodynamic therapy with 5-aminolaevulinic acid nanoemulsion (BF-200 ALA) for actinic keratosis: A randomized, single-blind, prospective study

BACKGROUND

Photodynamic therapy (PDT) has become one of the most effective therapies for the treatment of actinic keratosis, allowing the removal of more than one lesion in a single session. However, the pain sustained by the patient during treatment and local skin reactions can limit its use.

OBJECTIVES

To determine the efficacy and safety of combined PDT (daylight PDT followed by conventional PDT) vs conventional PDT 12 weeks after treatment.

METHODS

The study was performed as a randomized, single-center, non-inferiority clinical trial with two parallel groups. A total of 51 patients with grade I and II AKs on the scalp or face were randomized. Twenty-five patients received one session of combined PDT (combPDT), and 26 patients received one session of conventional PDT (cPDT). The primary endpoint was the reduction of AKs, 12 weeks after treatment. The secondary endpoint was the reduction in pain and local skin reaction.

RESULTS

The reduction rate of grade I and II AKs was similar in combPDT and cPDT, showing no statistically significant differences between both groups, 76.67% vs 86.63% [P = .094] and 80.48% vs 83.08% [P = .679], respectively. However, pain was significantly lower in the combPDT group (2.56 vs 5, P < .01), as were local skin reactions.

CONCLUSIONS

CombPDT has proven to be as effective as cPDT for the treatment of grade I and II AKs located on the scalp and face. Furthermore, combPDT has been shown to be considerably more tolerable than cPDT, causing only mild local skin reactions.

Guidelines of care for the management of actinic keratosis

BACKGROUND

Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma.

OBJECTIVE

This analysis examined the literature related to the management of AK to provide evidence-based recommendations for treatment. Grading, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs are also discussed.

METHODS

A multidisciplinary Work Group conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus.

RESULTS

Analysis of the evidence resulted in 18 recommendations.

LIMITATIONS

This analysis is based on the best available evidence at the time it was conducted. The pragmatic decision to limit the literature review to English language randomized trials may have excluded data published in other languages or limited identification of relevant long-term follow-up data.

CONCLUSIONS

Strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are made for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Chinese guidelines on the clinical application of 5-aminolevulinic acid-based photodynamic therapy in dermatology (2021 edition)

Photodynamic Therapy with 5-aminolevulinic acid (ALA-PDT) has been widely applied in the treatment of skin diseases in China. To further standardize, guide, and promote the clinical applications of ALA-PDT in dermatology, the Chinese Society of Dermatology, Chinese Association of Rehabilitation Dermatology, Photomedicine Therapeutic Equipment Group of Committee on Skin Disease, and Cosmetic Dermatology of China Association of Medical Equipment invited relevant experts engaged in ALA-PDT to revise and update the first edition of "Clinical application of 5-aminolevulinic acid-based photodynamic therapy: an expert consensus statement" and establish a more current edition, to provide an updated reference for Chinese dermatologists in clinical practice. In the guideline, the expert group reached consensus opinions on ALA-PDT with regard to mechanisms of action, therapeutic protocol, clinical applications, adverse reactions and countermeasures, precautions, care, and evaluation of efficacy.

Real-life evaluation of the treatment of actinic keratoses by textile photodynamic therapy (FLUXMEDICARE® device)

INTRODUCTION

Actinic keratoses (AK) are a common precancerous skin condition in dermatology practice. Photodynamic therapy (PDT) with ALA or MAL is an effective but painful treatment of fields of cancerization particularly when conventional illumination sources and irradiation rates are used. Two prior studies showed that illumination with textile PDT was not inferior to conventional PDT. FLUXMEDICARE® (FLX-PDT) is the first medical device marketed with textile based lighting . We performeda real-life study to evaluate efficacy and tolerance of this device.

METHODS

We carried out a single-center retrospective study. We collected data from patients treated with FLX-PDT with MAL for AKs localized on scalp and temples between November 2018 and November 2019. The primary endpoint was complete clearance rate (CR) at 3 months-follow up.

RESULTS

Data of 39 patients were reviewed in the study, with a total of 417 AKs. The CR rate was 72.6 % (95 %CI 67.9-77.0) at 3 months-follow up and 67.5 % (95 %CI 61.2-73.3) at 6 months-follow up. The median pain felt during the session was 0 and there wasn't erythema after the session for 64.1 %.

CONCLUSION

Our real-life study confirms efficacy and safety of textile PDT by FLUXMEDICARE device in the treatment of scalp and temples AKs, with excellent tolerance and minimal pain reported.

Daylight Photodynamic Therapy: An Update

Daylight photodynamic therapy (dPDT) uses sunlight as a light source to treat superficial skin cancer. Using sunlight as a therapeutic device has been present for centuries, forming the basis of photodynamic therapy in the 20th century. Compared to conventional PDT, dPDT can be a less painful, more convenient and an effective alternative. The first clinical uses of dPDT on skin cancers began in Copenhagen in 2008. Currently, aminolevulinic acid-mediated dPDT has been approved to treat actinic keratosis patients in Europe. In this review article, we introduce the history and mechanism of dPDT and focus on the pros and cons of dPDT in treating superficial skin cancers. The future applications of dPDT on other skin diseases are expected to expand as conventional PDT evolves.

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.

Utility of Photodynamic Therapy in Dentistry: Current Concepts

The significant growth in scientific and technological advancements within the field of dentistry has resulted in a wide range of novel treatment modalities for dentists to use. Photodynamic therapy (PDT) is an emerging, non-invasive treatment method, involving photosensitizers, light of a specific wavelength and the generation of singlet oxygen and reactive oxygen species (ROS) to eliminate unwanted eukaryotic cells (e.g., malignancies in the oral cavity) or pathogenic microorganisms. The aim of this review article is to summarize the history, general concepts, advantages and disadvantages of PDT and to provide examples for current indications of PDT in various subspecialties of dentistry (oral and maxillofacial surgery, oral medicine, endodontics, preventive dentistry, periodontology and implantology), in addition to presenting some images from our own experiences about the clinical success with PDT.

Field cancerization: Treatment

The goal of field cancerization treatment is to reduce the risk of developing keratinocyte carcinoma. Selecting the appropriate therapy depends on the degree of field cancerization and the number of invasive cutaneous squamous cell carcinomas. Other considerations include treatment efficacy, cost, side effects, and patient preference. Field therapies are preferred because they address clinically visible disease and subclinical atypia. However, lesion-directed therapies are useful for lesions that are more difficult to treat or those where a histologic diagnosis is required. Patients with extensive field cancerization benefit from a combination of field-directed and lesion-directed treatments. The second article in this continuing medical education series provides a framework to guide evidence-based decision making for field cancerization treatment.

Daylight photodynamic therapy for the management of actinic cheilitis

Early identification and adequate treatment of actinic cheilitis (AC), which affects the lower lip vermillion and is considered a precursor of squamous cell carcinoma, is mandatory. Photodynamic therapy (PDT) has been successfully used in AC. PDT with the use of daylight (DLPDT) is equally effective and more convenient than the conventional PDT. Data on short and long-term efficacy of DLPDT in AC are limited. Our primary purpose was to assess efficacy of DLPDT in AC as well as safety and tolerance. Twenty-two individuals with histologically confirmed AC received 2 MAL (5-aminolevulinic acid)-DLPDT sessions 1 week apart. Patients were evaluated clinically 3, 6, and 12 months after treatment. Non-complete responders were biopsied and excluded from the study if histological alterations were indicative of AC. Adverse events were recorded from baseline to the end of the 12-month follow-up period. Twenty patients completed the study. Overall, complete clinical response 12 months after treatment was 80% (16/20), while an association between treatment response and grade of dysplasia was observed (p = 0.016). With respect to response by grade, complete clinical response achieved in grade I AC was 100% (12/12) and 50% (4/8) in grade II AC. Main adverse events included mild erythema, oedema, and scaling, with no pain associated with DLPDT. According to our results, DLPDT seems to be of significant benefit for the treatment of grade I AC. Combination with the other treatment modalities could improve the efficacy in grade II AC. Further studies are needed for the assessment of late recurrences.

Daylight photodynamic therapy with methyl aminolevulinate cream is as effective as conventional photodynamic therapy with blue light in the treatment of actinic keratosis: a controlled randomized intra-individual study

BACKGROUND

We know the efficacy of daylight phototherapy dynamic (DL-PDT) in the treatment of actinic keratosis (AK). But the almost studies have compared daylight with red light using methyl aminolevulinate cream and not with blue light. PDT with blue light is another conventional PDT that is effective in the treatment of AKs.

OBJECTIVES

The aim of this study is to assess the efficacy and the safety of DL-PDT vs. PDT in blue light in the treatment of AKs.

METHODS

This randomized, controlled, intra-individual efficacy and safety study enrolled 26 subjects. AKs on the face/scalp were treated once, with DL-PDT on one side and c-PDT on the contralateral side. Primary endpoints for DL-PDT at week 12 were efficacy with clearance of AKs and safety with assessment of pain. Lesions with complete response 12 weeks after one treatment session were followed until week 24.

RESULTS

More than 1000 AK were studied. At week 12, the raw number of disappeared AK lesions at 3-month follow-up was 19.6 (±6.0) for DL-PDT and 20.0 (±6.9) for c-PDT with P = 0.8460 (90.5% vs. 94.2% of AK disappearance, respectively). The response was maintained at 6 months (90.0% and 94.6% of AK reduction, respectively). DL-PDT was nearly painless than c-PDT with light blue: 1.2 vs. 5.1, respectively (P < 0.0001).

CONCLUSIONS

Daylight-PDT seems as effective as c-PDT with light blue and DL-PDT is less painful. The response of DL-PDT was sustainable until 6 months.

Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects

Actinic keratoses are dysplastic proliferations of keratinocytes with potential for malignant transformation. Clinically, actinic keratoses present as macules, papules, or hyperkeratotic plaques with an erythematous background that occur on photoexposed areas. At initial stages, they may be better identified by palpation rather than by visual inspection. They may also be pigmented and show variable degrees of infiltration; when multiple they then constitute the so-called field cancerization. Their prevalence ranges from 11% to 60% in Caucasian individuals above 40 years. Ultraviolet radiation is the main factor involved in pathogenesis, but individual factors also play a role in the predisposing to lesions appearance. Diagnosis of lesions is based on clinical and dermoscopic examination, but in some situations histopathological analysis may be necessary. The risk of transformation into squamous cell carcinoma is the major concern regarding actinic keratoses. Therapeutic modalities for actinic keratoses include topical medications, and ablative and surgical methods; the best treatment option should always be individualized according to the patient.

Updates on Treatment Approaches for Cutaneous Field Cancerization

Purpose of Review

Field cancerization describes the phenomenon that multiple heterogenous mutations may arise in an area exposed to chronic carcinogenic stimuli. Advances in the understanding of cutaneous field cancerization have led to novel therapeutic approaches to the management of actinic keratoses (AKs). Herein, we review the literature on the pathophysiology and emerging research of field cancerization in dermatology.

Recent Findings

The classification systems for grading AK lesions are being refined with investigations focusing on their clinical utility. There is a growing shift towards field-directed treatment for AKs as the importance of field cancerization becomes clearer. Current field-directed therapies are being optimized and novel therapeutic modalities are being studied.

Summary

Field cancerization underlies the transformation of photodamaged skin into AKs and potentially cutaneous SCC (cSCC). Clinically meaningful classification systems for AKs are needed to better inform decisions regarding treatment. As we learn more about the role of field characterization in photodamage, AKs and cSCCs, therapeutic strategies are becoming more field-directed rather than lesion-directed.

Modern aspects of photodynamic therapy of actinic keratoses

Currently, photodynamic therapy (PDT) remains the most effective treatment for actinic keratosis (AK). With the increase in the incidence of AK, mainly due to the popularization of recreation in countries with increased insolation, there is an increasing interest in developing new methods of diagnostics and treatment and improving the existing ones. Studies that are aimed at determining the final efficacy of PDT, taking into account the resulting adverse reactions and long-term cosmetic results, are becoming increasingly popular. The nature of the light needed to excite a photosensitizer (PS) opens up new possibilities in the field of experimental studies that are aimed at reducing adverse reactions with similar efficacy of the applied therapy. In the review article, we presented the results of our own and foreign studies on the diagnosis and treatment of AK for 2017–2019, namely: we determined the possibilities of using sources with natural and short-wave radiation at different depths of skin lesions; presented a classification of the growth of AK in the basal layer of the epidermis, which increases the possibility of predicting the outcomes of the disease; showed the prevailing efficiency of fluorescent diagnostics compared with traditional diagnostic methods; evaluated the advantages of PDT using natural light and artificial sources of radiation; described the possibility of using a combination of drugs to increase the effectiveness of PDT in difficult to treat areas and in AK foci with a high degree of damage to the basal layer of the epidermis. 

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.

Split-face study comparing conventional MAL photodynamic therapy in multiple actinic keratosis with complete time vs. half-time red light LED conventional illumination

BACKGROUND

Conventional photodynamic therapy (PDT) with methylaminolevulinic acid (MAL) and daylight PDT have demonstrated similar efficacy in the treatment of actinic keratosis (AK). The reason for the use of daylight is to reduce pain during illumination but daylight has the limitation of the weather conditions. The difference in the doses of red light applied between these two methods suggests that an intermediate dose with red light conventional illumination could be effective in PDT of AK.

OBJECTIVE

To compare the efficiency of conventional MAL-PDT with half-time conventional red light illumination in patients with multiple AK.

MATERIAL AND METHODS

Adult patients with more than five symmetrically distributed AK were selected. After randomization, one area was treated with conventional PDT (Aktilite^® , 630 nm, 37 J/cm² , 8 min), while the contralateral was illuminated half time (Aktilite^® , 630 nm, 37 J/cm² , 4 min). Patients evaluated pain in each different side. Patients were evaluated at baseline, 3 and 6 months after PDT treatment by a blinded dermatologist. A questionnaire to be done at home 24 h after completing treatment was deliver to the patients to evaluate any side-effects.

RESULTS

A total of 774 lesions were treated, 385 with conventional PDT and 389 with half-time PDT (P > 0.05). Conventional PDT was 85% of complete response of AK (327/385) at 3 months, and half-time PDT was 82% (319/389). At 6 months, conventional PDT was 70% (268/385) of complete response and half-time PDT was 65% (252/389). Pain during illumination was significantly lower in the VAS with the half-time protocol with a mean of 5.59 (SD 1.48) vs. 6.41 (SD 1.66) in conventional PDT. No difference in adverse effects was found between protocols.

CONCLUSION

Conventional PDT with half-time illumination in multiple actinic keratosis is as effective as complete time illumination and decreased pain significantly.

Prevalence, Discontinuation Rate, and Risk Factors for Severe Local Site Reactions with Topical Field Treatment Options for Actinic Keratosis of the Face and Scalp

Actinic keratoses (AKs) are common lesions on chronically sun damaged skin, which are morphologically characterized by lower third to full thickness atypia of epidermal keratinocytes. These lesions carry a risk of progression towards invasive squamous cell carcinoma (SCC); therefore, treatment of visible lesions and the field in case of field cancerization is recommended. Treatment of AK includes the destruction of atypical keratinocytes that clinically presents with various degrees of erythema, scaling, crusting, erosion, and other visible and subjective symptoms. Such inflammatory reactions may have an impact on the patient’s social life and have shown to decrease compliance and adherence to therapy. Additionally, as various topical treatments have been proven to be effective in treating AK, tolerability of local site reactions (LSRs) might drive the decision for appropriate treatment in an individual scenario. Therefore, we aimed to review prevalence of severe LSRs among various topical treatments for AK. In addition, we summarized discontinuation rates due to LSRs and possible therapy-unrelated risk factors for the development of LSRs with increased severity.

New developments in the treatment of basal cell carcinoma: update on current and emerging treatment options with a focus on vismodegib

Basal cell carcinoma (BCC) is the most common form of skin cancer worldwide. Although most BCCs can be treated by relatively simple surgical or nonsurgical methods, some patients with BCC may eventually develop advanced disease which can either be locally destructive or even include metastatic spread. The present review summarizes the current literature on the treatment of both early and advanced BCC with a focus on the hedgehog inhibitor vismodegib which has become an integral part of the management of patients with advanced BCC since its regulatory approval in 2012.

The safety and efficacy of daylight photodynamic therapy in the treatment of actinic keratoses: a systematic review and meta-analysis

Daylight photodynamic therapy (DLPDT) is a novel therapeutic approach for actinic keratoses (AKs). This study aimed to evaluate the safety and efficacy of DLPDT in treating patients with AKs as compared to conventional photodynamic therapy (CPDT). PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for relevant randomized controlled trials (RCTs) published before November 2017, based on the following search terms: "solar keratoses", "actinic keratoses", "photodynamic therapy", "daylight photodynamic therapy", "conventional photodynamic therapy", and "randomized". The complete response rate, patient satisfaction, and patient-reported pain after intervention with DLPDT or CPDT were primarily measured. Sensitivity analysis was conducted to determine the reliability of results. Begg's and Egger's tests were used to assess the likelihood of publication bias. Eight RCTs, comprising a total of 424 patients with AKs treated with DLPDT or CPDT, were included. No significant difference was found between the lesion response rate and the mean lesion response in a comparison of DLPDT and CPDT treatments. Generally, DLPDT was associated with higher patient satisfaction than CPDT. The patients who underwent DLPDT experienced less pain than those who underwent CPDT. Most of our results were of high stability and low sensitivity. Meanwhile, no statistical evidence of publication bias among studies was found under all comparisons. In conclusion, DLPDT is a safe and effective therapy, which could help in selecting the most appropriate therapeutic method for treating AKs and in guiding physicians to optimize treatment strategies.

Daylight photodynamic therapy for field cancerization: lessons from molecular biology

Actinic keratoses (AKs) represent in-situ squamous cell carcinomas that potentially invade subepidermal structures and may metastasize. Until now, it is unpredictable to determine which AK lesions show this aggressive behavior. As AKs usually occur in large sun exposed areas, field-directed treatments have become the standard treatment regimen. Among these, conventional photodynamic therapy (cPDT) with 5-aminolaevulinic acid (ALA) or methyl-aminolevulinate (MAL) using red light is particularly effective in the treatment of AKs, but acceptance of the therapy is impaired by severe pain during treatment. Daylight PDT (dPDT) has demonstrated to be an equally effective alternative treatment option which is less painful. Recent attempts to determine the risk of AKs that demonstrate particular aggressive biological behavior by implementation of clinical and histological characteristics of AKs have not lead to conclusive results. Therefore, a look at the molecular biology of AKs could serve as a useful tool to develop a risk profiling for separation of those patients that are of particular risk to develop invasive tumor and, by this, to facilitate a more effective and adapted treatment option.

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.