A randomized paired comparison of photodynamic therapy and topical 5-fluorouracil in the treatment of actinic keratoses

An overview of topical photodynamic therapy in dermatology

This article is a review of the use of topical photodynamic therapy in dermatology and its current role in 2009 and future developments. The content of this article was presented at the EPPM in Wroclaw, September 2009.

Methyl aminolevulinate (Metvix®) photodynamic therapy - practical pearls

Topical photodynamic therapy (PDT) is an effective treatment for certain non-melanoma skin cancers (NMSCs), including superficial and nodular basal cell carcinomas (sBCC and nBCC), actinic keratosis (AK) and Bowen's disease. Methyl aminolevulinate (MAL, Metvix) is licensed in Europe for use in PDT for sBCC, nBCC and thin or non-hyperkeratotic and non-pigmented AK on the face and scalp, where other therapies are unsuitable. Optimal PDT response can be achieved through appropriate patient selection and lesion preparation. Evidence of efficacy is reviewed from guidelines and clinical experience. Red light from an LED source offers a relatively efficient method of activating the photodynamic reaction. The most common side effect of PDT is pain, burning or stinging discomfort at the site of treatment, although most patients do not request pain relief. The incidental observation of surface fluorescence three hours after photosensitizer application can be utilized for tumour detection as well as delineation. Topical PDT using Metvix MAL offers a practical non-invasive therapy option with the potential for high efficacy and good cosmesis.

Porphyrin and nonporphyrin photosensitizers in oncology: preclinical and clinical advances in photodynamic therapy

Photodynamic therapy (PDT) is now a well-recognized modality for the treatment of cancer. While PDT has developed progressively over the last century, great advances have been observed in the field in recent years. The concept of dual selectivity of PDT agents is now widely accepted due to the relative specificity and selectivity of PDT along with the absence of harmful side effects often encountered with chemotherapy or radiotherapy. Traditionally, porphyrin-based photosensitizers have dominated the PDT field but these first generation photosensitizers have several disadvantages, with poor light absorption and cutaneous photosensitivity being the predominant side effects. As a result, the requirement for new photosensitizers, including second generation porphyrins and porphyrin derivatives as well as third generation photosensitizers has arisen, with the aim of alleviating the problems encountered with first generation porphyrins and improving the efficacy of PDT. The investigation of nonporphyrin photosensitizers for the development of novel PDT agents has been considerably less extensive than porphyrin-based compounds; however, structural modification of nonporphyrin photosensitizers has allowed for manipulation of the photochemotherapeutic properties. The aim of this review is to provide an insight into PDT photosensitizers clinically approved for application in oncology, as well as those which show significant potential in ongoing preclinical studies.

Intraindividual, right-left comparison of topical 5-aminolevulinic acid photodynamic therapy vs. 5% imiquimod cream for actinic keratoses on the upper extremities

BACKGROUND

Actinic keratoses (AKs) are considered as in situ squamous cell carcinoma. Early and effective treatment is important. Objective To compare the efficacy, cosmetic outcome and patient preference of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) with that of 5% imiquimod (IMIQ) cream in patients with AKs on the dorsa of hands and forearms.

METHODS

Subjects received two ALA-PDT treatment sessions and one or two courses of imiquimod (three times per week for 4 weeks each). Treatments were randomly allocated to alternate upper extremities. Assessments included lesion response one and six months after treatment, cosmetic outcome evaluated by the investigators and patients' preference 6 months after treatment. Efficacy end point included the individual AK lesion clearance rate.

RESULTS

Thirty patients with 256 lesions were included in the study. At the first follow-up, treatment with ALA-PDT resulted in significantly larger rate of cured lesions relative to 5% IMIQ cream (70.16% vs. 18.26%). At the second follow-up both treatments showed a high rate of cured lesions (65.32% for PDT vs. 55.65% for IMIQ cream). Response rates obtained in grade I lesions were higher for both treatments (71.64% for PDT vs. 72.13% for IMIQ), while treatment with PDT resulted in a significant larger rate of cured grade II lesions (57.89% for PDT vs. 37.03 for IMIQ). Difference in cosmetic outcome was not statistically significant. Results for subject preference favoured ALA-PDT.

CONCLUSIONS

Our study shows that ALA-PDT and 5% IMIQ cream are both attractive treatment options for upper extremities AKs with comparable efficacy and cosmetic outcomes.

[Precancerous and early invasive carcinomas: non-surgical treatment of head and facial skin]

Chronic exposure to sunlight with its high proportion of high energy ultraviolet light is the main cause of the common cutaneous precancerous lesions and carcinomas of the head and neck. This causes a field cancerization effect frequently with multiple actinic keratoses (AKs), basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs). Although demonstrating the best cure rates and lowest recurrence rates, surgical excision rapidly progresses to its limits. Field cancerization requires field therapy. Non-specific caustic agents may remove superficial lesions, however, the modern therapeutic modalities such as topical cytotoxic treatment with 5-fluorouracil, photodynamic therapy with 5-aminolevulinic acid (ALA) or its methyl ester (MeALA), the topical immune response modifier imiquimod or the local application of the cyclooxygenase inhibitor diclofenac are more specific and effective. Intralesional and perilesional injections of cytotoxic agents and interferons as well as the new targeted anti-cancer drugs are further alternatives. The most important aspect, however, is the prophylaxis of chronic photodamage.

Topical methyl-aminolevulinate photodynamic therapy using red light-emitting diode light for treatment of multiple actinic keratoses: A randomized, double-blind, placebo-controlled study

BACKGROUND

The use of light-emitting diode light offers practical advantages in photodynamic therapy (PDT) with topical methyl-aminolevulinate (MAL) for management of actinic keratoses (AK).

OBJECTIVE

We sought to evaluate the efficacy of MAL PDT using red light-emitting diode light.

METHODS

We conducted a multicenter, double-blind, randomized study. A total of 49 patients with 363 AK lesions had 16.8% MAL cream applied under occlusion for 3 hours, and 47 patients with 360 AK lesions had vehicle cream similarly applied. The lesions were then illuminated (630 nm, light dose 37 J/cm2) with repeated treatment 1 week later. Complete lesion and patient (all lesions showing complete response) response rates were evaluated 3 months after last treatment.

RESULTS

MAL PDT was superior (P<.0001) to vehicle PDT with respect to lesion complete response (86.2% vs 52.2%, odds ratio 6.9 [95% confidence interval 4.7-10.3]) and patient complete response (59.2% vs 14.9%, odds ratio 13.2 [95% confidence interval 4.1-43.1]).

LIMITATIONS

The study population may not be representative of all patients with AK.

CONCLUSION

MAL PDT using red light-emitting diode light is an appropriate treatment alternative for multiple AK lesions.

Multicentre intraindividual randomized trial of topical methyl aminolaevulinate-photodynamic therapy vs. cryotherapy for multiple actinic keratoses on the extremities

BACKGROUND

Methyl aminolaevulinate-photodynamic therapy (MAL-PDT) is an effective treatment in facial/scalp actinic keratosis (AK).

OBJECTIVES

The aims of this study were to compare efficacy, safety, cosmetic outcome and patient preference of MAL-PDT vs. cryotherapy in patients with AK at other locations.

METHODS

A multicentre, controlled, randomized, open, intraindividual, right-left comparison was performed. Patients with nonhyperkeratotic AK were treated once with MAL-PDT and cryotherapy on either side of the body. At week 12, lesions showing noncomplete response were retreated. The primary efficacy variable was the lesion response at week 24. Investigator's assessment of cosmetic outcome, patient's preference in terms of cosmetic outcome and a patient preference questionnaire were also analysed at week 24.

RESULTS

In total, of 121 patients with 1343 lesions (98% located on the extremities and the remainder on the trunk and neck) were included. Both treatments provided a high mean percentage reduction in lesion count at week 24 with significantly higher efficacy for cryotherapy: 78% for MAL-PDT and 88% for cryotherapy (P=0.002, per protocol population). Investigator's assessment of cosmetic outcome was significantly better for MAL-PDT than cryotherapy (P<0.001), 79% of lesions having an excellent cosmetic outcome with MAL-PDT vs. 56% with cryotherapy at week 24. The cosmetic outcome achieved by MAL-PDT compared with cryotherapy was also preferred by patients (50% vs. 22%, respectively, P<0.001), and 59% of patients would prefer to have any new lesions treated with MAL-PDT compared with 25% with cryotherapy (P<0.001). Both treatment regimens were safe and well tolerated.

CONCLUSIONS

MAL-PDT showed inferior efficacy for treatment of non-face/scalp AK compared with cryotherapy. However, both treatments showed high efficacy, and MAL-PDT conveyed the advantages of better cosmesis and higher patient preference.

Photodynamic therapy in the treatment of actinic keratosis

The efficacy of photodynamic therapy (PDT) with 5-aminolevulinate and methyl aminolevulinate in the treatment of actinic keratosis has been demonstrated in a large number of clinical studies over the last several years. Here, we recapitulate the major findings, comparing the various photosensitizers, light sources and therapeutic regimens, and present a retrospective analysis of 142 own cases treated with 259 PDTs. In addition, we also discuss the value of PDT in comparison with cryotherapy or 5-fluorouracil. The efficacy and the low risk of side effects of PDT have resulted in a high patient preference in clinical trials.

Split-face-study using two different light sources for topical PDT of actinic keratoses:non-inferiority of the LED system

BACKGROUND

Photodynamic therapy (PDT) with 5-amino-4-oxo-pentanoate (methylaminolevulinate, MAL) is an effective and safe treatment option for actinic keratoses. Light-emitting diodes (LED) are suitable light sources for topical PDT. To evaluate the efficacy, painfulness, patient satisfaction and cosmesis of LED-based PDT a prospective, randomized and controlled split-face study was performed.

METHODS

Topical ALA-PDT was administered to 17 patients whose actinic ker-atoses (n = 131) were symmetrically distributed and suitable for a two-side comparison. After incubation with MAL (16%), irradiation was performed with the incoherent lamp (160 mW cm(-2); 100 J cm(-2), PDT 1200L, Waldmann Medizintechnik, Villingen-Schwenningen, Germany) on one side and the LED system (120 mW cm(-2); 40 J cm(-2), LEDA, WaveLight AG, Erlangen, Germany) on the other side. The patients were followed by re-evaluation up to 6 months.

RESULTS

Six months following treatment there was no significant difference between the infiltration and keratosis scores in both treatment regimes (p = 0.812). The remission rate was 78.5% (LED system) vs.80.3% (incoherent lamp). There was no significant difference between both light sources regarding the pain during therapy (p = 0.988). There was no significant difference between both treatment regimes regarding patient satisfaction (p = 1).

CONCLUSIONS

LEDA-based MAL-PDT is an effective alternative for the treatment of atinic keratoses. The remission rates and cosmetic results are not inferior to PDT using incoherent light systems. Both treatment regimes are similarly painful.

Photodynamische Therapie bei epithelialen Hauttumoren

During the last years photodynamic therapy (PDT) has progressively established itself as a standard treatment for non-melanoma skin cancer. A number of clinical studies have demonstrated its efficacy--also compared to other treatment modalities--as well as good acceptance by patients and outstanding cosmetic results. For Bowen disease and superficial basal cell carcinoma, PDT can be regarded as the first-line non-invasive treatment. In the treatment of actinic keratoses PDT should be considered when cosmesis is crucial or in cases of field cancerization. In nodular basal cell carcinoma, effectiveness for lesions up to a thickness of 2 mm is well documented. In summary the evidence level seems sufficient to regard PDT as valuable treatment modality of which patients should not be deprived.

Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy

Psoriasis is a chronic skin disease that affects millions of people throughout the world. Even though cutaneous signs and symptoms are the most common clinical manifestations, the nails can be involved in up to 50% of cases, and their involvement remains an important yet often overlooked aspect of the disease. There is a broad spectrum of nail dystrophies associated with psoriasis, ranging from the common pitting and loosening of the nail plate to the less frequent discoloration and splinter hemorrhages seen in the nail bed. This article discusses the normal anatomy and embryology of the nail unit as well as the current understanding of the pathogenesis of the disease. It also provides an extensive review of the existing literature with respect to psoriatic nail therapy. Although there have been many recent advances in the treatment of the cutaneous form of the disease-most notably in the field of immunotherapies-the options for nail psoriasis are far more limited. While a number of treatment alternatives currently exist for nail disease, the general paucity of clear evidence regarding these choices often makes it difficult to select the most efficient, safe, and optimal treatment for the patient. Even though the current literature has shown some support for the use of topical, intralesional, radiation, systemic, and combination therapies for nail psoriasis, the available studies lack sufficient power to extrapolate a standardized therapeutic regimen. Therefore, until better-documented evidence validating the treatment options emerges within the literature, clinicians and patients are left with a vague and relatively unproven approach to psoriatic nail disease.

Treatment of post-transplant premalignant skin disease: a randomized intrapatient comparative study of 5-fluorouracil cream and topical photodynamic therapy

BACKGROUND

Organ transplant recipients (OTR) are at high risk of developing nonmelanoma skin cancer and premalignant epidermal dysplasia (carcinoma in situ/ Bowen's disease and actinic keratoses). Epidermal dysplasia is often widespread and there are few comparative studies of available treatments.

OBJECTIVES

To compare topical methylaminolaevulinate (MAL) photodynamic therapy (PDT) with topical 5% fluorouracil (5-FU) cream in the treatment of post-transplant epidermal dysplasia.

METHODS

Eight OTRs with epidermal dysplasia were recruited to an open-label, single-centre, randomized, intrapatient comparative study. Treatment with two cycles of topical MAL PDT 1 week apart was randomly assigned to one area of epidermal dysplasia, and 5-FU cream was applied twice daily for 3 weeks to a clinically and histologically comparable area. Patients were reviewed at 1, 3 and 6 months after treatment. The main outcome measures were complete resolution rate (CRR), overall reduction in lesional area, treatment-associated pain and erythema, cosmetic outcome and global patient preference.

RESULTS

At all time points evaluated after completion of treatment, PDT was more effective than 5-FU in achieving complete resolution: eight of nine lesional areas cleared with PDT (CRR 89%, 95% CI: 0.52-0.99), compared with one of nine lesional areas treated with 5-FU (CRR 11%, 95% CI: 0.003-0.48) (P = 0.02). The mean lesional area reduction was also proportionately greater with PDT than with 5-FU (100% vs. 79% respectively). Cosmetic outcome and patient preference were also superior in the PDT-treated group.

CONCLUSIONS

Compared with topical 5-FU, MAL PDT was a more effective and cosmetically acceptable treatment for epidermal dysplasia in OTRs and was preferred by patients. Further studies are now required to confirm these results and to examine the effect of treating epidermal dysplasia with PDT on subsequent development of squamous cell carcinoma in this high risk population.

Randomized, double-blind, prospective study to compare topical 5-aminolaevulinic acid methylester with topical 5-aminolaevulinic acid photodynamic therapy for extensive scalp actinic keratosis

BACKGROUND

5-aminolaevlinic acid methylester (MAL) and 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) are both effective treatment options for actinic keratosis (AK). While MAL is significantly more expensive than ALA, no studies have directly compared their efficacy in the treatment of extensive scalp AK.

OBJECTIVES

To compare the efficacy and adverse effects of MAL-PDT with ALA-PDT in the treatment of scalp AK.

METHODS

Sixteen male patients aged 59-87 years with extensive scalp AK were randomized into a double-blind, split-scalp prospective study. Two treatment fields were defined (right and left frontoparietal scalp) and treated 2 weeks apart. These fields were randomized to receive either MAL or ALA as first or second treatment. MAL cream was applied for 3 h; 20% ALA cream was applied for 5 h. A blinded observer assessed efficacy comparing AK counts before and 1 month after treatment. Pain was assessed using a visual analogue scale at 3, 6, 12 and 16 min.

RESULTS

Fifteen patients completed treatment to both fields. There was a mean reduction from baseline in AK counts with the use of ALA-PDT of 6.2 +/- 1.9 compared with 5.6 +/- 3.2 with MAL-PDT (P = 0.588). All patients experienced pain which was of greater intensity in the ALA-treated side at all time points: 3 min (P = 0.151), 6 min (P = 0.085), 12 min (P = 0.012) and 16 min (P = 0.029). Similarly, duration of discomfort post-procedure persisted for longer following treatment with ALA when compared with MAL-PDT (P = 0.044).

CONCLUSIONS

This study demonstrates that both ALA-PDT and MAL-PDT result in a significant reduction in scalp AK. There is no significant difference in efficacy. However, ALA-PDT is more painful than MAL-PDT in the treatment of extensive scalp AK.

Effect of Subcutaneous Infiltration Anesthesia on Pain in Photodynamic Therapy: A Controlled Open Pilot Trial

BACKGROUND

Photodynamic therapy (PDT) has been established as a treatment option for nonmelanoma skin cancer, such as superficial basal cell carcinoma, actinic keratoses, or Bowen's disease.

OBJECTIVE

A major drawback of PDT is pain during treatment that can cause extreme distress for some patients.

METHODS

This study was a controlled, open trial comparing PDT in 16 patients on one side of the face with orally administered analgesics and PDT on the contralateral side of the face with subcutaneous infiltration anesthesia (SIA). The 5-aminolevulinic acid gel was applied 5 hours before treatment. Pain was assessed by the patient using a visual analog scale directly after treatment.

RESULTS

Fifteen of 16 (94%) patients reported less pain during PDT after SIA compared to oral analgesics only. This effect was significant (Wilcoxon test for matched pairs, p= .001). No side effects due to SIA were observed.

CONCLUSION

SIA is an effective and rather safe method for the control of PDT-associated pain.

Guidelines for the management of actinic keratoses

These guidelines stemmed from a consensus meeting held by the British Photobiology Group (BPG) in 1999. Following this meeting one of the authors (J.M.M.) was invited to draw up guidelines for the management of actinic keratoses by the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Relevant evidence was sought using the search terms 'solar keratosis' and 'actinic keratosis' in Medline from 1966 onwards. Additional and earlier literature was reviewed on the basis of references within post-1966 publications. All articles of apparent relevance were reviewed independently of the nature of the publication. The quality of the evidence elicited has been indicated. The National Ambulatory Medical Care Survey (U.S.A.) was used for further data on topical chemotherapy. Papers were reviewed and discussed by the contributors to the BPG Workshop (see Acknowledgments). Recommendations are evidence based where possible. Strength of recommendation is coupled with quality of evidence. Strength of recommendation includes consideration of apparent cost-benefit and practical considerations. Quality of evidence reflects the nature of the trial structure that provides data of efficacy.

Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: An international consensus

Topical photodynamic therapy (PDT) is used to treat nonmelanoma skin cancers, such as actinic keratoses, Bowen's disease, and basal cell carcinoma (superficial and nodular). This article presents up-to-date, practical, evidence-based recommendations on the use of topical PDT using 5-aminolevulinic acid or methyl aminolevulinate for the treatment (and prevention) of nonmelanoma skin cancers. A systematic literature review was conducted (using MEDLINE), and recommendations were made on the basis of the quality of evidence for efficacy, safety/tolerability, cosmetic outcome, and patient satisfaction/preference. Topical PDT is highly effective in the treatment of actinic keratoses, Bowen's disease, superficial and thin nodular basal cell carcinomas, with cosmesis typically superior to that achieved with existing standard therapies. PDT may also be a means of preventing certain nonmelanoma skin cancers in immunosuppressed patients.

Pain induced by photodynamic therapy of warts

BACKGROUND

Photodynamic therapy with topical 5-aminolevulinic acid (ALA), followed by irradiation with red light (ALA-PDT), is used for non-melanoma skin cancer and other dermatological diseases. Pain during and after light exposure is a well-known adverse advent that may be a limiting factor for treatment, particularly, in viral warts.

METHODS

To assess the pain induced by ALA-PDT, we asked 45 patients enrolled in a randomized, placebo-controlled trial with six consecutive ALA- and placebo-PDT treatments for recalcitrant foot and hand warts to fill in questionnaires about pain immediately and 24 h after each treatment.

RESULTS

Immediately and 24 h after each of the six treatments, pain intensity was significantly higher in warts treated with ALA-PDT than in warts treated with placebo-PDT (P<0.028). Severe or unbearable pain was reported from a median of 17% (6-31%) of the ALA -treated warts and from a median of 2% (0-15%) from the placebo-treated warts immediately after the treatments. With increasing treatments, no significant change in pain intensity was observed and no significant relation was found between the pain intensity and the relative change in wart area. The pain was primarily characterized as burning and shooting. The pain lasted about 30 h (range: 1-96 h).

CONCLUSION

We conclude that pain induced by ALA-PDT is of such intensity in about one-fifth of the warts that pain relief is indicated.

Evaluation of the effectiveness of imiquimod and 5-fluorouracil for the treatment of actinic keratosis: Critical review and meta-analysis of efficacy studies

BACKGROUND

Actinic keratosis lesions occur frequently on sun-exposed skin of Caucasians. They become more prevalent with advancing age and are important in identifying the risk factor of those people possibly predisposed to invasive squamous cell carcinoma. Topical therapies are useful alternatives to cryotherapy for treating diffuse actinic damage and a number of preparations have been developed for treating actinic keratosis.

OBJECTIVES

A cumulative meta-analysis was performed to determine the efficacy of imiquimod 5% cream, which presents a new alternative topical therapy for actinic keratosis, and to compare it to 5-fluorouracil for the treatment of actinic keratosis lesions of the face and scalp.

METHODS

We searched MEDLINE (1966 to October 2004) for relevant studies evaluating the efficacy of actinic keratosis topical agents imiquimod and 5-fluorouracil (0.5%, 1%, and 5%). Studies included in this meta-analysis required a dosage regimen that was not significantly different from that approved by Health Canada and the U.S. FDA. Studies also required a well-defined treatment duration and followup period, with the primary efficacy variable being the complete (100%) clearance of all actinic keratosis lesions defined as the proportion of patients at followup with no clinically visible lesions in the treatment area. To determine the average efficacy rate for both drugs, the data from each study were combined for that drug.

RESULTS

Ten studies were included in the analysis. The average efficacy rate for each drug (with 95% confidence interval) was 5-fluorouracil, 52 +/- 18% (n = 6 studies, 145 subjects) and imiquimod, 70 +/- 12% (n = 4 studies, 393 subjects).

CONCLUSIONS

The results of this meta-analysis show that both imiquimod and 5-fluorouracil are effective methods for the treatment of actinic keratosis and provide a useful alternative to cryotherapy. However, this analysis suggests that imiquimod may have higher efficacy than 5-fluorouracil for actinic keratosis lesions located on the face and scalp and therefore provides another option to dermatologists.

Light Patch: Preliminary Report of a Novel Form of Blue Light Delivery for the Treatment of Actinic Keratosis

OBJECTIVE

To evaluate a novel light patch formulated for blue light delivery and topical activation of gamma-aminolevulinic acid (ALA) during photodynamic therapy for the treatment of actinic keratosis (AK).

MATERIALS AND METHODS

Ten volunteers with past unsuccessful treatment of AK were enrolled. Areas with AK lesions were treated with 20% ALA (Levulan) for an incubation period of 1 hour. Half of the area was treated with blue light patches (the patch emits 431 to 515 nm wavelength, 55.6 mJ/cm2 over 20 minutes), and the other half was left uncovered (control). The percentage of visible AK lesions cleared at the 3-month follow-up determined therapeutic efficacy.

RESULTS

The mean lesion count for all treatment areas was decreased from 7.60 to 2.40 (p<.01). The subjects had slight burning or itching and mild to moderate erythema. One subject developed a blister at the treatment site. Controls had clearance of 30%, 17%, and 20% for the face, scalp, and hands, respectively. Patients were satisfied with the results and noticed an improvement in skin texture.

CONCLUSION

Preliminary results show that the blue light patch is a potentially safe, effective, and alternative method for light delivery and topical ALA activation during photodynamic therapy of AK.

Topical Photodynamic Therapy Using Intense Pulsed Light for Treatment of Actinic Keratosis: Clinical and Histopathologic Evaluation

BACKGROUND

Photodynamic therapy (PDT) is suitable for the treatment of actinic keratosis, and, recently, topical PDT using intense pulsed light as a light source has been reported. However, evaluations of its therapeutic effects have been clinically based.

OBJECTIVE

The objective of this study was to confirm the histopathologic resolution of actinic keratosis treated by topical PDT using intense pulsed light as a light source.

METHODS

Twelve actinic keratosis lesions in seven patients were treated with 5-aminolevulinic acid-PDT using intense pulsed light as a light source. After a single treatment, the clinical response was assessed and histopathologic examinations were performed on clinically resolved lesions.

RESULTS

Six of 12 (50%) lesions showed clinical clearance after a single treatment, but histologic examinations showed that only 5 of the 12 (42%) lesions had been removed. No complications, such as pigmentary changes or scarring, were observed.

CONCLUSION

Intense pulsed light is potentially an effective light source for PDT. However, the determination of complete remission in actinic keratosis requires caution, and long-term follow-up or histologic confirmation may be required.

Terapia fotodinámica en dermatología

Photodynamic therapy (PDT) is a therapeutic modality based on the photooxidation of biological materials induced by a photosensitizer, which selectively locates itself in certain tumorous cells or tissues, so that when illuminated by a light of the right length and at a sufficient dose, these cells are destroyed. In dermatology, PDT with topical 5-aminolevulinic acid or 5-methyl aminolevulinate is very effective in the treatment of actinic keratoses, basal cell carcinomas and Bowen's disease. In addition, very promising results have been obtained in inflammatory pathologies like morphea or sarcoidosis, infections like warts, and cosmetic processes such as photoaging, among others. This article reviews the most significant aspects of PDT in dermatology. First of all, we will review the basic fundamentals of photodynamic treatment. Next, we will outline its clinical applications in dermatology, both in oncological applications and all those dermatological processes in which PDT may play a role in their management. We will also discuss its promising cosmetic application in the treatment of photoaging. We will complete the review with photodiagnosis and the different non-invasive ways to monitor the effectiveness of PDT.

Topical photodynamic therapy

Topical photodynamic therapy is a therapeutic modality in development, thus arises grate interest among dermatologists worldwide. It is an effective therapy for actinic keratosis, superficial BCC and Bowenos disease. Treatment efficacy, good cosmetics, low risk of skin cancer, low invasiveness, low rate of adverse events, facility for treating multiple or large lesions, especially in poor healing sites and, for penile, digital and facial involvement, low general toxicity and possibility of repeating the treatments with the same efficiency, enable topical photodynamic therapy to become increasingly practiced treatment modality. Researching aimed topical photodynamic therapy to prove as a treatment modality for clinical use in other dermatoses, is in experimental phase. To answer the question when dermatologist should consider using topical photodynamic therapy treatment modatility, we are present available date.

Photodynamic Therapy

ALA-PDT is a safe, well-tolerated, and effective treatment for many dermatologic conditions. Current data most strongly support its use in the treatment of actinic damage, but further investigation into alternative uses continues. Current efficacy is limited primarily by the depth of penetration of the photosensitizing agent and the activating light source. Even with this limitation, the potential applications of PDT are numerous. As new technology is developed to overcome current restraints, the future of PDT is wide open.

Actinic keratoses, basal cell carcinoma, and squamous cell carcinoma: uncommon treatments

This contribution will discuss the treatment of actinic keratoses, basal cell carcinomas, and squamous cell carcinoma using methods that are not routinely established but have been used for a long period. The purpose of this article is simply to expand the reader's knowledge of what has been or could be used to treat such lesions. This article should not be interpreted as advocating the use of the methods discussed because there are obviously efficient well-established treatments for these lesions.

Rejuvenation of the aging hand

This article reviews aging of the hand and the treatment options for cosmetic rejuvenation. Options available for cutaneous rejuvenation include microdermabrasion, chemical peeling, intense light sources, and laser therapy, including pigment lasers, ablative resurfacing, and noninvasive rejuvenation. Protuberant veins of the aging hand can be treated effectively with sclerotherapy. The soft tissue atrophy of the aging hand is best treated with fat augmentation. The article concludes with a mention of new fillers that are just beginning to be used for soft tissue atrophy of the hand.

Photoschadigung und Photoalterung - Pravention und Behandlung. Photodamage and photoaging - prevention and treatment

The exposure of human skin to environmental and artificial ultraviolet irradiation has increased significantly. This is not only due to an increased solar UV irradiation as a consequence of the stratospheric ozone depletion, but also the result of an inappropriate social behaviour with the use of tanning parlors being very popular. Besides this, leisure activities and living style with travelling to equatorial regions also add to the individual annual UV load. Since the population in industrialised countries shows an increasing total life span, in parallel the cumulative life time dose of solar and artificial UV-irradiation is dramatically augmented. In addition to the common longterm detrimental effects like immunosuppression and skin cancer, the photooxidative damage due to energy absorption of UV photons in an oxygenized environment leads to alterations of cells, subcellular compartments and macromolecules. The clinical manifestations of UV/ROS induced disturbances result in photoaged skin with wrinkle formation, laxity, leathery appearance as well as fragility, impaired wound healing and higher vulnerability. Strategies to prevent or to minimize photoaging and intrinsic aging of the skin necessarily include protection against UV irradiation and antioxidant homoeostasis. New developments of therapeutic interventions including DNA repair enzymes will be discussed.

Therapieoptionen bei epithelialen Hauttumoren

There has been worldwide a significant rise in the incidence of epithelial skin tumors and their precursors in the past years with an increased number of younger patients affected. The risk factors are identified. The choice of the appropriate treatment for each individual is crucial. Major consideration include high cure rate, low long-term recurrence rate and few side effects. In the following article different therapeutic approaches for actinic keratoses, Bowen's disease, basal cell carcinoma and squamous cell carcinoma are presented and analysed.

Photodynamische Therapie mit Methylaminooxopentanoat (MetvixR) und einer Breitbandlichtquelle (PhotoDyn 501): Praktische Erfahrungen bei Problem-Patienten mit Aktinischen Keratosen und Basalzellkarzinomen. Photodynamic therapy with methylaminooxopentanoate (MetvixR) and a broad band light source (PhotoDyn 501): Experiences in complicated patients with actinic keratoses and basal cell carcinomas

BACKGROUND

Actinic keratoses (AK) and basal cell carcinomas (BCC) may represent a therapeutic challenge because of special subtypes, location, previous therapy or accompanying diseases. Photodynamic therapy (PDT) offers a semi-conservative treatment option for selected indications.

PATIENTS AND METHODS

28 outpatients who had been admitted as complicated dermato-oncologic cases because of AK (n = 22) and BCC (n = 6) were treated with PDT, using methylaminooxopentanoate (MAOP, Methyl-Ala, Metvix) and a broad band light source (PhotoDyn 501). The treatment was evaluated for efficacy and subjective tolerance (local discomfort and pain).

RESULTS

A complete remission (CR) was achieved in 11/22 AK (50%) and 4/6 BCC (67%) cases. All three cases of a superficial BCC subtype underwent a CR. Among responders, tolerance was good in 12/15 cases (80%), as compared to 4/13 cases (31%) in non-responders. Focusing on 16/28 patients with good tolerance (57%), there was a CR in 12 cases (75% rate), whereas for the 12/28 patients with moderate to poor tolerance a CR was achieved in only 3 cases (25% rate). In a subgroup of 8 patients who, partly due to secondary diseases, were taking systemic retinoids or immunosuppressive-cytostatic medications, a CR was achieved in 3/8 cases (38%) with a good tolerance in only 1/8 cases (13%).

CONCLUSION

These observations confirm a good efficacy and tolerance of PDT in > or = 50% of a AK/BCC problem patient cohort. We found indications for 1) a positive correlation between efficacy and subjective tolerance as well as 2) the presumptive existence of a retinoid-dependent cutaneous PDT hyperalgesia. Effective pain control seems to be an essential cofactor for the success of PDT.

A randomized controlled clinical trial of topical photodynamic therapy with methyl aminolaevulinate in the treatment of actinic keratoses in transplant recipients

BACKGROUND

Transplant recipients have an increased propensity to develop multiple actinic keratoses, which demonstrate an increased transformation rate into invasive squamous cell carcinoma.

OBJECTIVE

To evaluate the efficacy and tolerability of topical photodynamic therapy with the new highly tumour-selective photosensitizer methyl aminolaevulinate vs. placebo in the treatment of actinic keratoses in transplant recipients.

METHODS

Seventeen transplant recipients with a total number of 129 mild to moderate actinic keratoses were enrolled in a prospective, randomized, double-blind, placebo-controlled study. Two lesional areas within a patient were randomized for two consecutive treatments of topical photodynamic therapy 1 week apart using either methyl aminolaevulinate or placebo cream. Sites were illuminated with 75 J cm(-2) of visible light delivered at 80 mW cm(-2) by a noncoherent light source. Complete resolution and reduction in the number or size of actinic keratoses within the lesional area relative to the initial findings were evaluated at weeks 4, 8 and 16 after treatment.

RESULTS

The lesional areas treated with methyl aminolaevulinate were clinically cleared in 13 of 17 patients at 16 weeks. A partial response was recorded in a further three. No reduction in the size or number of actinic keratoses was observed in one area treated with methyl aminolaevulinate and in all placebo-treated areas. Adverse events, such as erythema, oedema and crust formation, were mild to moderate, and treatment was well tolerated by all patients.

CONCLUSION

Photodynamic therapy using methyl aminolaevulinate is a safe and effective treatment for actinic keratoses in transplant recipients. It may also reduce the risk of transformation of actinic keratoses to invasive, potentially fatal, squamous cell carcinoma.

Topical photodynamic therapy in clinical dermatology

The growing incidence of cutaneous malignancies each year necessitates the development of new and more effective methods for both the diagnosis and the treatment of cancerous lesions, while assuring better cosmetic results and improving patient satisfaction. With that in mind, the use of topical photodynamic therapy (PDT) has been explored in the treatment as well as the diagnosis of various cutaneous malignancies. Using the intrinsic cellular haem biosynthetic pathway and principles of photoillumination, topical PDT carries the goal of selectively targeting abnormal cells, while preserving the normal surrounding structures. This paper will discuss the various applications and data on the use of topical PDT in dermatology.