Switching From Conventional Photodynamic Therapy to Daylight Photodynamic Therapy For Actinic Keratoses: Systematic Review and Meta-analysis

Skin field cancerisation: A systematic review of the literature regarding its treatment

INTRODUCTION

Skin neoplasms are the most frequent malignant lesions, increasing patient's morbidity when associated with skin field cancerisation. There is a need to understand the current therapies, both clinical and surgical.

METHODS

A systematic review was performed according to the PRISMA guideline, registered in PROSPERO: CRD42018114826, including studies from 2012 to 2019.

RESULTS

Seven hundred and eighty-two studies were found, of which 21 were included. Of these, 8 primary studies were randomised controlled trials: fractional CO₂ laser-assisted photodynamic therapy (PDT) vs. PDT (no significance), daylight PDT vs. PDT (no significance, daylight PDT had less adverse effects), trichloroacetic acid peel vs. 5-aminolaevulinic acid PDT (clinical improvement of aminolaevulinic acid PDT), 5-Fluorouracil 0.5%/Salicylic Acid 10% vs. vehicle (clinical improvement of 5-Fluorouracil 0.5%/Salicylic Acid 10%), photolyase vs. sun filters (no significance), sunscreens vs. sunscreens plus DNA repair enzymes (DNA Repair Enzymes was more effective in reducing field cancerisation). Only one systematic review was included in which there was effectiveness of daylight PDT in the treatment of actinic keratoses. The other 12 included studies had a lower level of evidence including surgical studies.

CONCLUSION

Clinical studies are more relevant in the treatment of the field cancerisation. There is a lack of surgical studies.

Clinical, histopathological and immunohistochemical evaluation of daylight photodynamic therapy in the treatment of field cancerization: a study of 30 cases

BACKGROUND

Actinic keratosis (AK) are pre-malignant lesions, precursors of squamous cell carcinoma (SCC). Normal skin adjacent to AK, may present initial mutations with potential risk for new neoplasms, currently known today as field cancerization (FC).

OBJECTIVES

To evaluate the effectiveness of daylight photodynamic therapy (PDT) with methyl amino levulinate (MAL) based on clinical evaluation, histological examination and immunohistochemical expression of p53 and Ki67.

MATERIAL AND METHODS

Thirty patients, over 35 years old, phototypes between I and III, presenting non-hypertrophic AK on the face or scalp. Two biopsies with 2 mm punch of the lesion and adjacent skin before and 60 days after daylight PDT were performed. Results: Improvement was seen in lesion thickness and Ki67. 19 (63.33%) lesions had atypia improvement with a p-value <.05, showing efficacy in treatment. After daylight PDT, 22 (73.33%) patients showed satisfactory esthetic improvement.

CONCLUSION

The study shows that PDT has cellular and molecular effects that support its indication in the control of carcinogenesis, as it decreases atypia and controls the expression of Ki67, reducing the proliferation of atypical cells. However, its indication following this study is still mainly aimed at clinical improvement of the skin, at this moment, probably due to the sample size.

The Role of Erythroid Differentiation Regulator 1 (ERDR1) in the Control of Proliferation and Photodynamic Therapy (PDT) Response

Erythroid differentiation regulator 1 (ERDR1) was newly identified as a secreted protein that plays an essential role in maintaining cell growth homeostasis. ERDR1 enhances apoptosis at high cell densities, leading to the inhibition of cell survival. Exogenous ERDR1 treatment decreases cancer cell proliferation and tumor growth as a result of increased apoptosis via the regulation of apoptosis-related gene expression. Moreover, ERDR1 plays a pivotal role in skin diseases; ERDR1 expression in actinic keratosis (AK) is negatively correlated with the increase in apoptosis. Because of its high specificity and efficiency, photodynamic therapy (PDT) is a common therapy for patients with various skin diseases, including cancer. Many studies indicate that apoptosis is mainly induced by PDT treatment. As an apoptosis inducer, the recovery of the ERDR1 expression after PDT is correlated with good therapeutic outcomes. Here, we review recent findings that highlight the function of ERDR1 in the control of apoptosis. Thus, ERDR1 may have a role in the apoptosis regulation of target cells in the lesions, as the recovery of its expression after PDT is correlated with good therapeutic outcomes.

A randomized, intraindividual, non-inferiority, Phase III study comparing daylight photodynamic therapy with BF-200 ALA gel and MAL cream for the treatment of actinic keratosis

Background

The most effective treatment modality for actinic keratosis (AK) is photodynamic therapy (PDT). Major obstacles of PDT are the need of a special illumination device and pain accompanying the illumination. These issues may be overcome by replacing an artificial high‐power light source with natural daylight for more extended illumination at lower light doses.

Objective

To determine whether BF‐200 ALA (a nanoemulsion gel containing 7.8% 5‐aminolaevulinic acid) is non‐inferior to MAL (a cream containing 16% methyl‐aminolaevulinate) in the treatment of mild‐to‐moderate AK with daylight PDT (dPDT). Non‐inferiority of the primary efficacy variable (total lesion clearance rate per patient's side 12 weeks after PDT) is established if the mean response for BF‐200 ALA is no worse than for MAL, within a statistical margin of Δ = −12.5%.

Methods

The study was performed as an intraindividual comparison with 52 patients in seven centres in Germany and Spain. Each patient received one dPDT. Results include clinical endpoints as well as 1‐year follow‐up results.

Results

Twelve weeks after a single dPDT, 79.8% of the AK lesions treated with BF‐200 ALA gel and 76.5% of the lesions treated with MAL cream were completely cleared. The median of differences was 0.0 with a one‐sided 97.5% CI of 0.0, establishing non‐inferiority (P < 0.0001). Results for secondary efficacy parameters were in line with the primary outcome. Recurrence rates 1 year after the treatment were 19.9% for lesions treated with BF‐200 ALA and 31.6% for lesions treated with MAL. Adverse reactions including pain were mostly mild and transient and identical to those previously described for dPDT.

Conclusion

Daylight PDT of AK with BF‐200 ALA is well‐tolerated and non‐inferior to MAL/dPDT. The study demonstrates a trend towards higher efficacies after 3 months and significantly lower recurrence rates after 1 year follow‐up.

Photodynamic therapy with the use of superluminescent diodes (sLED) in the treatment of actinic keratosis

BACKGROUND

Superluminescent diodes (sLED) appear to be an innovative and promising light source in photodynamic therapy (PDT), especially in actinic keratosis (AK) lesions treatment.

AIM

Assessment of tolerability and efficacy of sLED in topical 5-aminolevulinic acid (ALA) PDT of AK lesions.

METHODS

27 patients received ALA PDT with the use of sLED with "soft starter".

RESULTS

Tolerability of sLED lamp depended on the treated lesions field (extension) rather than on their thickness. In contrast sLED lamp efficacy depended on AK lesions thickness.

CONCLUSION

sLED PDT is highly effective in the treatment of grade I and II AK lesions. Grade III AK lesions require further treatment.

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.