Pharmacoeconomic Considerations in Treating Actinic Keratosis: An Update

Revisiting the evidence of photodynamic therapy for oral potentially malignant disorders and oral squamous cell carcinoma: an overview of systematic reviews

BACKGROUND

This study summarized the available evidence about the use of photodynamic therapy (PDT) for the management of oral potentially malignant disorders (OPMD) and oral squamous cell carcinoma (OSCC).

METHODS

An overview of systematic reviews was undertaken based on the 2020 PRISMA statement. Electronic searches were performed in five databases. Studies published up to November 2022 were included. Risk of bias was assessed with the AMSTAR 2 tool.

RESULTS

A total of 30 studies enrolling 9,245 individuals with OPMD (n=7,487) or OSCC (n=1,758) met the selection criteria. All studies examined the efficacy and/or safety of PDT. OPMD were investigated individually in 82.8% of the studies, the most common being oral lichen planus and actinic cheilitis. OSCC was addressed separately in 10.3% of the studies, while only 6.9% evaluated both OPMD and OSCC. Fourteen different types of photosensitizers were described. PDT was used according to the following setting parameters: 417-670 nm, 10-500 mW/cm², 1.5-200 J/cm², and 0.5-143 minutes. Regarding OPMD, leukoerythroplakia showed the best response rates, while oral lichen planus presented a partial or no response in nearly 75% of documented cases. A complete response was observed in 85.9% of OSCC cases, while 14.1% had no resolution.

CONCLUSION

Overall, the response to PDT depended on the type of OPMD/OSCC and the parameters used. Although PDT is an emerging candidate for the treatment of OPMD and OSCC, there is heterogeneity of the methodologies used and the clinical data obtained, particularly regarding the follow-up period.

Field Therapy for Actinic Keratosis: A Structured Review of the Literature on Efficacy, Cost, and Adherence

BACKGROUND

Although there are evidence-based guidelines for actinic keratosis management, selecting a cost-effective field therapy is challenging because of limited studies comparing cost, efficacy, and adherence among treatments.

OBJECTIVE

To review the literature on field-directed therapies for actinic keratosis, comparing efficacy, cost, and adherence data for topical and in-office treatments.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and Google Scholar databases were searched from October 2020 to March 2021 for articles on field therapy for actinic keratosis. Total cost per regimen was estimated using wholesale acquisition cost package prices and Medicare coverage rates for May 2021. Effective cost was approximated by dividing total cost by complete response rate.

RESULTS

Efficacy data for various field therapies range widely, and long-term follow-up is limited. Cross-study comparisons are challenging because of heterogeneity of studies. Field-directed therapy with topical 5-fluorouracil and photodynamic therapy have similar effective cost. Adherence may significantly affect real-world efficacy and long-term clearance; this would favor shorter duration topical regimens or in-office procedures.

CONCLUSION

Standardization of future studies examining efficacy of field treatments for actinic keratosis will allow comparison across treatments. In-office treatments such as photodynamic therapy represent a cost-effective alternative to topical therapies with comparable efficacy.

Socioeconomic impact of high-cost drugs in Brazilian dermatology. Legal and financial aspects, and impact on clinical practice

The technological advancement of the pharmaceutical industry, resulting from the techniques of molecular biology and expansion of the knowledge of immunopathogenesis, has modified the therapeutic arsenal used in dermatology. Scientific research and regulatory standards cause drug costs to rise, thus making their use impossible in most public policies. In order to make high-cost drugs viable in the public health network, the Specialized Pharmaceutical Assistance Component was created. However, despite the frequent incorporation of medications, the constant requirement of drugs through lawsuits leads to exorbitant costs to the state budget. The present work analyzed through a descriptive observational study, the current situation of the Specialized Component and the involvement of medicines used in dermatology, through legal reviews, financial analyses, and medical articles, aiming at future incorporations for the specialty. When assessing the legal demands for dermatological drugs in the state of São Paulo, the specialty still has a low participation and psoriasis is the main disease involved in requiring drugs through the judicial system in the state. New methods of access to raw materials must be created to reduce legal issues. Cost-effectiveness and public planning studies are mandatory for incorporating new dermatological therapies.

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications - field cancerization, photorejuvenation and inflammatory/infective dermatoses

In addition to approved indications in non-melanoma skin cancer in immunocompetent patients, topical photodynamic therapy (PDT) has also been studied for its place in the treatment of, as well as its potential to prevent, superficial skin cancers in immune-suppressed patients, although sustained clearance rates are lower than for immune-competent individuals. PDT using a nanoemulsion of ALA in a daylight or conventional PDT protocol has been approved for use in field cancerization, although evidence of the potential of the treatment to prevent new SCC remained limited. High-quality evidence supports a strong recommendation for the use of topical PDT in photorejuvenation as well as for acne, refractory warts, cutaneous leishmaniasis and in onychomycosis, although these indications currently lack approvals for use and protocols remain to be optimized, with more comparative evidence with established therapies required to establish its place in practice. Adverse events across all indications for PDT can be minimized through the use of modified and low-irradiance regimens, with a low risk of contact allergy to photosensitizer prodrugs, and no other significant documented longer-term risks with no current evidence of cumulative toxicity or photocarcinogenic risk. The literature on the pharmacoeconomics for using PDT is also reviewed, although accurate comparisons are difficult to establish in different healthcare settings, comparing hospital/office-based therapies of PDT and surgery with topical ointments, requiring inclusion of number of visits, real-world efficacy as well as considering the value to be placed on cosmetic outcome and patient preference. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical photodynamic therapy in Dermatology prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

Non-invasive monitoring of subclinical and clinical actinic keratosis of face and scalp under topical treatment with ingenol mebutate gel 150 mcg/g by means of reflectance confocal microscopy and optical coherence tomography: New perspectives and comparison of diagnostic techniques

Actinic keratosis (AK) corresponds to the earliest stage of in situ squamous cell carcinoma and arises on chronically sun-exposed skin. Around the clinically evident AKs, the apparently healthy epidermis may contain different grades of atypia that can be detected by noninvasive imaging techniques such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT). Subclinical actinic keratosis (sAK) has captured increasing interest as a potential target of field therapies. The aim of this study was to evaluate in vivo the changes in the field cancerization undergoing treatment with topical ingenol mebutate by combining RCM and OCT. Twenty patients with field cancerization of the face and scalp were treated with ingenol mebutate gel (150 mcg/g) for three consecutive days on an area of 25 cm² containing at least two AKs, two sAKs and two apparently healthy sites. About 120 lesions were evaluated through clinical investigation and clinical, dermoscopical, RCM and OCT images at day 0, 4, 14 and 56 based on the diagnostic criteria for AKs. Main pathological features improved in both AKs and sAKs, in particular the epidermal thickness measured by OCT and the epidermal atypia graded by RCM. Local skin reactions (LSR) arose predominantly in the lesional area compared with healthy skin. A complete clearance was detected in 58% for AKs, and in 55% and 72% for sAKs measured by RCM and OCT, respectively. Both OCT and RCM allow the morphological representation of field cancerization including subclinical lesions and provide complementary information. Ingenol mebutate is effective not only in clinically evident but also in sAKs. The differences in LSR highlight the potential selectivity of the treatment.

Actinic keratosis and imiquimod: a review of novel carriers and patents

INTRODUCTION

Actinic keratosis is one of the most common disorder characterized by erythematic and generally attached scaly lesions which are present either alone or in clusters. World Health Organization defines actinic keratosis as a common intraepidermal neoplasm of sun-damaged skin, characterized by variable atypia of keratinocytes.

AREAS COVERED

At the beginning of the 20th century, a new immunomodulator molecule, imiquimod, appears in the market for the treatment of actinic keratosis but suffers from the pitfalls of the conventional approach of dosage form preparation including high dose, poor stability and more side effects. The present article attempts to compile the scatter information related to actinic keratosis and imiquimod at one place. The special emphasis will be made on the information available in various research articles and patents with respect to the efforts made for overcoming shortcomings associated with imiquimod by novel drug delivery or other approaches.

EXPERT OPINION

The conventional drug delivery systems are unsuccessful to improve the actinic keratosis. The patient acceptance and compliance with these treatments are generally poor due to associated side effects, poor cosmetic outcomes and high costs. Therefore, several available and reported novel therapeutic approaches are being developed in order to provide better action.

Field Cancerization Therapies for Management of Actinic Keratosis: A Narrative Review

Actinic keratoses (AKs) are atypical, precancerous proliferations of keratinocytes that develop because of chronic exposure to ultraviolet (UV) radiation. Treatment of AK can be lesion-directed or field-directed. Field cancerization theory postulates that the skin surrounding AK is also at increased risk for possible malignant transformation since it has been exposed to the same chronic UV light. Field-directed therapies thus have the potential to address subclinical damage, reduce AK recurrence rates, and potentially reduce the risk of squamous cell carcinoma (SCC) development. Published clinical studies have found lesion clearance rates ranging from 81 to 91% for photodynamic therapy (PDT) with either aminolevulinic acid (ALA) or methylaminolevulinate (MAL). Clinical studies have also been published on various topical treatments. Complete clinical clearance (CCC) was significantly higher in patients treated with a combination of 5-fluorouracil and salicylic acid (5-FU-SA) than in the vehicle group across multiple studies, and CCC ranged between 46 and 48% following treatment with imiquimod. Additionally, treatment with diclofenac sodium (DFS) found reduction in lesion sizes to range from 67 to 75%. Reported results have been similar for another non-steroidal anti-inflammatory drug (NSAID), piroxicam, which has more cyclooxygenase (COX)-1 activity than DFS. Active treatments with ingenol mebutate were also significantly more effective than vehicle at clearing AK lesions. All treatments resulted in mild, localized skin reactions. PDT using conventional light sources was associated with increased severity of pain and/or discomfort, while PDT using daylight as the light source was associated with less pain and occasionally no pain at all. Though no widely accepted algorithm for the treatment of AKs exists, field-directed therapy can be particularly useful for treating photo-exposed areas containing multiple AKs. Additional research with more direct comparisons between these field-directed therapies will help clinicians determine the best therapeutic approach. Here, we provide a balanced and comprehensive narrative review of the literature, considering both light-based and topical therapies with a focus on their field-therapy aspects, and propose a therapeutic algorithm for selecting an appropriate treatment in the clinical setting.