Topical ALA PDT for the treatment of severe acne vulgaris

Successful treatment of a lactating women with severe acne through the combination of fire needle and photodynamic therapy: A case report

Severe acne, characterized by cysts and nodules, can significantly impact a patient's self-image and quality of life [1]. In China, first-line treatments for severe acne typically include oral isotretinoin, topical benzoyl peroxide, and oral or topical antibiotics [2]. However, due to concerns about safety, oral isotretinoin and antibiotics are not recommended for lactating women, posing challenges in treating acne in this population and often leading to emotional distress. While photodynamic therapy has shown effectiveness in patients unwilling to take oral medications [3], treating severe acne during lactation remains a complex issue with limited research available. In this unique case, fire needle combined with photodynamic therapy was successfully utilized to address severe acne in a lactating patient. Following treatment, the patient experienced clearance of cysts, nodules, and pustules, as well as an improvement in depressive symptoms, yielding significant outcomes. Nevertheless, the efficacy and safety of this combined approach warrant further investigation through clinical trials.

A novel H‑tert immortalized human sebaceous gland cell line (XL-i-20) for the investigation of photodynamic therapy

BACKGROUND

Acne vulgaris is a species-specific human disease. To date, there has been no established human sebocyte cell line of Asian origin. Our previous study has demonstrated the efficacy of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) in the treatment of acne vulgaris, primarily attributed to its cytotoxic properties; however, its regulatory mechanism remains largely unknown.

OBJECTIVES

To establish an immortalized human sebocyte cell line derived from Chinese population and investigate the underlying mechanism of ALA-PDT.

METHODS

Human primary sebocytes were transfected with the human tert gene (h‑tert). The biological characteristics, including cell proliferation, cell markers, and sebum secretion function, were compared between primary sebocytes and the immortalized sebocytes (XL-i-20). Stimulations such as ALA-PDT, were applied respectively to both primary sebocytes and XL-i-20 cells to assess changes in their cellular functions. The transcriptome differences between primary sebocytes and XL-i-20 sebocytes were investigated using RNA-seq analysis. The XL-i-20 cell line was used to establish a sebaceous gland (SG) organoid culture, serving as a representative model of SG for the investigation of ALA-PDT.

RESULTS

The h‑tert immortalized sebocyte cell line exhibited the ability to be consecutively cultured for more than fifty passages. Both primary and immortalized cells expressed sebocyte markers such as epithelial membrane antigens (EMA, or MUC-1), Cytokeratin 7 (CK7) and adipose differentiation-related protein associated antigens (ADRP), and maintained sebum secretion function. The proliferative capacity of XL-i-20 was found to be significantly higher than that of primary sebocytes. The responses of XL-i-20 to ALA-PDT were indistinguishable from those elicited by primary sebocytes. Cell viability and sebum secretion were decreased after ALA-PDT in both two cell lines, and lipid-related proteins (SREBP-1/PPARγ) were down-regulated. The transcriptome data consistently demonstrated upregulation of genes related to inflammatory responses and downregulation of genes involved in lipid metabolism in both cell types following PDT. The analysis of common differential genes of primary sebocytes and XL-i-20 sebocytes post ALA-PDT showed that TNF signaling pathways, MAPK signaling pathways and JAK-STAT signaling pathways were activated. The SG organoids were spherical, which expressed markers of FANS and PLET1. Ki-67 was down-regulated after ALA-PDT.

CONCLUSIONS

We have developed an h‑tert immortalized sebocyte cell line from an Asian population. The cell line, XL-i-20, maintains the essential characteristics of its parent primary sebocytes. Moreover, XL-i-20 sebocyte exhibited a significant respond to ALA-PDT, demonstrating comparable phenotypic and molecular changes to primary sebocytes. Therefore, XL-i-20 and its derived SG organoid serve as appropriate in vitro models for investigating the efficacy and mechanisms of ALA-PDT in SG-related diseases.

Photodynamic therapy for severe acne

Acne is an inflammatory cutaneous disease affecting the pilosebaceous unit and hair follicles on the face, neck, back, and chest, with a typical onset in adolescence and, in some cases, persisting into adulthood. Systemic treatments with antibiotics or isotretinoin present many limitations, like antimicrobial resistance phenomena and teratogenicity, which appear more relevant in the pediatric population, both for the treatment-related risks and for the reticence of the parents. Photodynamic therapy (PDT) has already shown encouraging results in the treatment of acne in adult patients, with good aesthetic results compared to other therapies and few side effects. However, its use is still not standardized in the pediatric population. On this topic, we report our experience with PDT in a young patient affected by dorsal acne. After five sessions of ALA-PDT at monthly intervals, a remarkable improvement of the lesions was observed, with the healing of the inflamed nodules and pustules, resolution of the painful symptoms, and an acceptable cosmetic outcome. Our case is paradigmatic of the potentiality of PDT to treat difficult and resistant-to-treatment lesions. Despite being time-consuming, this procedure has been demonstrated to be safe and well-tolerated. Lastly, the therapy is also well accepted by parents, due to its minimal invasiveness and mild side effects, compared to the other therapeutic options.

Modified red light 5-aminolevulinic acid photodynamic therapy versus low-dose isotretinoin therapy for moderate to severe acne vulgaris: A prospective, randomized, multicenter study

BACKGROUND

Modified 5-aminolevulinic acid photodynamic therapy (M-PDT) and isotretinoin (ISO) are effective treatments for moderate to severe acne vulgaris.

OBJECTIVE

To evaluate the efficacy and adverse effects of M-PDT and ISO for moderate to severe acne vulgaris.

METHODS

A multicenter, randomized clinical trial was conducted with participants randomly assigned to the M-PDT group (up to 5 weekly sessions following manual comedone extraction) or the ISO group (oral ISO, 0.5 mg/kg/d for 6 months) and followed up to 6-months after therapy.

RESULTS

A total of 152 patients were allocated. The overall effective rates in the M-PDT group were significantly higher than the ISO group at 1 month (67.74% vs 10.26%), whereas the opposite was the case 1 month after treatment (75.81% vs 97.44%). Time to achieve 50% lesion improvement in the M-PDT group was significantly less than the ISO group (1 vs 8 weeks). Overall, 70.67% of the ISO group patients experienced systemic side effects such as hepatotoxicity, whereas side effects were skin-limited in the M-PDT group.

LIMITATIONS

Limitations of this study included relatively low numbers of participants and high withdrawal rate.

CONCLUSION

M-PDT offers a more rapid onset of improvement, comparable overall efficacy, good tolerability, and comparable durability of response compared with ISO.

ALA-PDT augments intense inflammation in the treatment of acne vulgaris by COX2/TREM1 mediated M1 macrophage polarization

Severe acne vulgaris is a common chronic inflammatory skin disease worldwide. 5-Aminolaevulinic acid photodynamic therapy (ALA-PDT) is effective and safe for severe acne. However, the mechanism is not fully understood. Intense acute inflammatory response at 24 h after ALA-PDT is reported positively correlated to the effectiveness. Inflammation regulation influence the progression or outcome of diseases. ALA-PDT may exert its therapeutic effect by augmenting intense inflammation and break the chronic inflammation. This study was set out to explore the mechanism of ALA-PDT augmenting intense acute inflammation in the treatment of acne. As a result, transcriptome microarrays analysis of severe acne patients showed that ALA-PDT significantly up-regulated expression of various inflammation-related genes, especially TREM1 and PTGS2, which were further confirmed by a C.acnes induced acne-like mouse ear model. The subsequent experiments demonstrated that ALA-PDT could trigger pro-inflammatory M1 polarization of macrophages in vitro and in vivo. Additionally, the crosstalk between keratinocytes and macrophages studied by a transwell co-culture system indicated that PGE2 secreted by ALA-PDT treated HaCaT cells could promote THP-1 macrophages M1 polarization by COX2/PGE2/TLR4/TREM1 axis to augment inflammation. Our study provides a novel insight that ALA-PDT could amplify inflammation by COX2/TREM1 mediated macrophages M1 polarization for the treatment of acne. It is hoped that this research will decipher the mechanism of ALA-PDT for the treatment of acne and provide a theoretical basis for optimizing the clinical ALA-PDT management.

Clinical practice Guidelines for 5-Aminolevulinic acid photodynamic therapy for acne vulgaris in China

A variety of evidence suggest that 5-Aminolevulinic acid-based photodynamic therapy (ALA-PDT) is clinically effective in management of acne vulgaris. Several clinical guidelines for acne recommend PDT as an alternative treatment modality for severe acne. However, there is a lack of detailed clinical guideline for PDT in acne treatment. To propose up-to-date, evidence-based and practical recommendations on application of ALA-PDT for acne vulgaris, dermatologists and PDT experts from the Photodynamic Therapy Research Center of the CMA and Photodynamic Therapy Rehabilitation Training Center of CARD achieved consensus and guidelines based on careful evaluation of published literature, expert opinions and experience. ALA-PDT plays a therapeutic role in all four major pathogenesis of acne, and is suitable for moderate to severe acne and scar-prone acne, especially for patients who cannot tolerate or refused systemic antibiotics and isotretinoin. The efficacy and adverse reactions of ALA-PDT are closely related to therapeutic parameters including ALA concentration, incubation time, light source and dosage. Proper pretreatment helps to improve transdermal absorption of ALA and enhances its efficacy. We reviewed and proposed recommended protocols for four PDT procedures including conventional PDT (C-PDT), modified painless PDT (M-PDT), intense pulsed light PDT (IPL-PDT) and daylight PDT (DL-PDT). M-PDT with lower ALA concentration (3-5%), shorter incubation time (30 mins), and lower dose but prolonged illumination (630nm, 40-60 mW/cm², 150 J/cm²) can improve lesions of moderate to severe acne vulgaris effectively with minimal pain and easier manipulation, and thus was recommended by Chinese dermatologists. Lastly, management of adverse reactions were addressed.

ALA-PDT regulates macrophage M1 polarization via ERK/MAPK-NLRP3 pathway to promote the early inflammatory response

BACKGROUND

Photodynamic therapy (PDT) is a promising new approach to promote wound healing and its effectiveness has been demonstrated in both clinical and animal studies. Macrophages are the key cells in wound healing and inflammatory response. However, the mechanism of action of PDT on macrophages in promoting wound healing is still unclear.

METHODS

In this study, RAW264.7 cells were used. We analyzed the expression levels of macrophage markers arginase 1 (Arg-1), CD206, iNOS, CD86, and inflammatory factors IL-6, TNF-α, and IL-1β by reverse transcription-polymerase chain reaction and Western blot, Milliplex microtubule-associated protein multiplex assay was performed to analyze the expression of inflammatory factors in the supernatant. Live cell Imaging System to observe the dynamic process of macrophage phagocytosis. Western blot was performed to observe the activation of extracellular signal-regulated kinase/mitogen-activated protein kinase (ERK/MAPK) and NOD-like receptor protein 3 (NLRP3) inflammasome.

RESULTS

5-Aminolevulinic acid (ALA)-PDT increased the expression of M1 marker iNOS/CD86 and decreased the expression of Arg-1/CD206 in RAW264.7 cells, while, proinflammatory factors IL-6, TNF-α, and IL-1β expression was enhanced and macrophage phagocytosis was increased. We also found that these phenomena were associated with activation of the ERK/MAPK-NLRP3 pathway.

CONCLUSION

ALA-PDT promotes early inflammatory responses by regulating macrophage M1 polarization through the ERK/MAPK-NLRP3 pathway. It also promotes macrophage phagocytosis.

An insight into photodynamic therapy towards treating major dermatological conditions

Photodynamic therapy (PDT), as the name suggests is a light-based, non-invasive therapeutic treatment method that has garnered immense interest in the recent past for its efficacy in treating several pathological conditions. PDT has prominent use in the treatment of several dermatological conditions, which consequently have cosmetic benefits associated with it as PDT improves the overall appearance of the affected area. PDT is commonly used for repairing sun-damaged skin, providing skin rejuvenation, curbing pre-cancerous cells, treating conditions like acne, keratosis, skin-microbial infections, and cutaneous warts, etc. PDT mediates its action by generating oxygen species that are involved in bringing about immunomodulation, suppression of microbial load, wound-healing, lightening of scarring, etc. Although there are several challenges associated with PDT, the prominent ones being pain, erythema, insufficient delivery of the photosensitizing agent, and poor clinical outcomes, still PDT stands to be a promising approach with continuous efforts towards maximizing clinical efficacy while being cautious of the side effects and working towards lessening them. This article discusses the major skin-related conditions which can be treated or managed by employing PDT as a better or comparable alternative to conventional treatment approaches such that it also brings about aesthetic improvements thereof.

Photodynamic therapy in pediatric age: Current applications and future trends

Photodynamic therapy (PDT) is a photochemotherapy based on local application of a photosensitive compound and subsequent exposure to a light source of adequate wavelength. It is a non-invasive therapeutic procedure widely used in oncodermatology for treatment of numerous skin cancers, but in the last years its use has been gradually extended to an increasing list of skin diseases of both infectious and inflammatory nature. Although PDT is proven as a safe and effective therapeutic option in adults, its use is not well standardized in the pediatric population. In this review, we will focus on clinical applications, mechanisms of action, protocols, and adverse events in children and adolescents. Most of pediatric experiences concerned treatment of skin cancers in Gorlin syndrome and xeroderma pigmentosum, acne vulgaris, and viral warts, but other applications emerged, such as cutaneous lymphoma and pseudo-lymphomas, necrobiosis lipoidica, hidradenitis suppurativa, dissecting cellulitis, leishmaniasis, angiofibromas, verrucous epidermal nevus, and linear porokeratosis. In these pediatric diseases, PDT appeared as an effective therapeutic alternative. The results on vitiligo were limited and not fully encouraging. Although highly versatile, PDT is not a therapy for all skin diseases, and a deeper knowledge of its mechanisms of action is required to better define its spectrum of action and safety in pediatric patients.

Efficacy and therapeutic reactions of tri-needle-pretreatment combined with painless ALA-PDT for the treatment of moderate-to-severe acne vulgaris: A randomized controlled trial

BACKGROUND

Our clinical experience suggests that pretreatment of the original lesions may be crucial for enhancing the efficacy of 5-aminolevulinic acid-photodynamic therapy (ALA-PDT) in moderate-to-severe acne vulgaris. We performed this randomized controlled trial (RCT) to validate this observation.

METHODS

Efficacy and therapeutic reactions between tri-needle-pretreatment with ALA-PDT (TP-PDT) and conventional ALA-PDT without pretreatment (NP-PDT) were compared. In TP-PDT group, tri-needle-pretreatment was performed using comedone extractors, fire needles, or plum-blossom needles, according to the lesion type. In the TP-PDT group, 5% ALA cream was applied to lesions 30 min before illumination (LED red light: 633±10 nm, 40 mW/cm², 150 J/cm²). In the NP-PDT group, 5% ALA cream was applied 1 h before illumination (60 mW/cm², 72 J/cm²). Patients underwent four sessions, at 1-week intervals. The efficacy was evaluated as the proportion of patients achieving a remarkable effective rate, based on the reduction in the number of lesions. A numeric rating scale was used to assess the severity of pain, erythema, and edema.

RESULTS

Forty-eight patients completed the trial. The proportion of remarkable effective rate was significantly greater and the pain score was significantly lower for the TP-PDT than NP-PDT group. The edema score was significantly higher for the TP-PDT than NP-PDT group. There was no difference in erythema scores between the two groups.

CONCLUSION

The tri-needle-pretreatment can improve the efficacy of ALA-PDT, without an increase in pain, for the treatment of moderate-to-severe acne vulgaris. These qualities make the TP-PDT a promising gold standard pretreatment for ALA-PDT for acne vulgaris.

A Randomized Cohort Study: Is It Worth the Time to Receive Antiandrogenic Pretreatment Before Ovulation Induction for Women With Polycystic Ovary Syndrome?

Objective

To assess the effect of antiandrogenic pretreatment using combined oral contraceptives (COCs) before ovulation induction in infertile patients with polycystic ovary syndrome (PCOS) with hyperandrogenism.

Design

Prospective, randomized open-labeled cohort study.

Setting

Multicenter.

Patients

PCOS patients with hyperandrogenism and requiring infertility treatments.

Interventions

Randomization to direct ovulation induction of letrozole (letrozole group) or ethinylestradiol/cyproterone acetate (EE/CPA) for 3 months and subsequent letrozole-induced ovulation (EE/CPA+ letrozole group). The maximum number of ovulation induction cycle was three to four.

Main Outcome Measures

Ovulation rate, conception rate, ongoing pregnancy rate, and live birth rate were the main outcomes of the study.

Results

There were no significant differences in the cumulative ovulation, conception, ongoing pregnancy, and live birth rates between the letrozole and EE/CPA+ letrozole groups (cumulative ovulation: 206/254 [81.10%] vs. 169/205 [82.44%], risk ratio [RR]= 1.09 [0.68,1.76], P=0.713; conception: 44/90 [48.89%] vs. 42/76 [55.26%], RR= 1.29 [0.70,2.38], P=0.413; ongoing pregnancy: 33/90 [36.67%] vs. 33/76 [43.42%], RR=1.33 [0.71,2.47], P=0.376; and live birth: 32/90 [35.56%] vs. 31/76 [40.79%], RR=1.25 [0.67, 2.34], P=0.489).

Conclusions

The results of this study showed that COC pretreatment was not superior to direct letrozole-induced ovulation therapy in improving ovulation and pregnancy results in women with PCOS. There is no benefit to perform antiandrogenic therapy before ovulation induction in patients with PCOS in clinical practice.

Clinical Trial Registration

www.clinicaltrials.gov, identifier ChiCTR1900022839.

The Use of Lasers and Light Devices in Acne Management: An Update

Acne vulgaris is a disease of the pilosebaceous unit and the most common inflammatory dermatosis worldwide. It is also associated with significant economic burden. Limitations of conventional topical and systemic treatments include long treatment course, intolerable adverse effects, antibiotic resistance, and patient compliance. Therefore, laser and light-based interventions present as alternative options over the past decade and have been used in combination with conventional pharmacological therapies and other physical modalities. An updated overview on the use of lasers and light-based devices in acne management is presented to help clinicians understand the safety and efficacy of these treatment options. The effectiveness of neodymium:yttrium aluminum garnet (Nd:YAG) for treating acne is supported by more high-level studies compared with other laser devices. There is limited evidence to support the use of CO₂ lasers, potassium titanyl phosphate lasers, and 1565-nm non-ablative fractional lasers for treating acne. Among light devices, photodynamic therapy is the most studied, showing higher efficacies than some of the conventional topical and oral acne therapies. Intense-pulsed light and blue light therapies also show favorable outcomes. A limitation is that most studies are non-randomized and lack a control group, and report on a variety of device settings, treatment regimens, and outcome measures, making it challenging to summarize and generalize findings. Although the use of laser and light devices to treat acne is promising, further work with randomized controlled study designs and larger sample sizes will provide improved guidance on the application of these modalities.

5-Aminolaevulinic acid photodynamic therapy amplifies intense inflammatory response in the treatment of acne vulgaris via CXCL8

Acne vulgaris is a chronic inflammatory cutaneous disease. 5-Aminolaevulinic acid photodynamic therapy (ALA-PDT) is a novel and effective approach for severe acne vulgaris treatment. However, its specific treatment mechanism still remains unclear. In the present study, we investigated the potential mechanism of how ALA-PDT regulated intense inflammatory response in acne vulgaris. It appeared that ALA-PDT suppresses proliferation and lipid secretion of primary human sebocytes. Besides, ALA-PDT could up-regulate the expression of CXCL8 in vivo and in vitro, amplifying the inflammatory response by recruiting T cells, B cells, neutrophils and macrophages. We also found that ALA-PDT elevated the expression of CXCL8 via p38 pathway. SB203580, a p38 pathway inhibitor, decreased the expression of CXCL8 in sebocytes after ALA-PDT. These findings indicate that ALA-PDT amplifies the intense inflammatory response in the treatment of acne vulgaris via CXCL8. Our data decipher the mechanism of intense inflammatory response after ALA-PDT for acne vulgaris.

A comparison of the effects of oral contraceptives on the clinical and biochemical manifestations of polycystic ovary syndrome: a crossover randomized controlled trial

STUDY QUESTION

Do oral contraceptives (OCs) containing progestins with low androgenic or antiandrogenic activities have different effects to those containing levonorgestrel (LNG) on clinical, androgenic and metabolic manifestations of polycystic ovarian syndrome (PCOS)?

SUMMARY ANSWER

The three OCs tested had similar effects on clinical findings of hyperandrogenism (HA), whereas products containing LNG were less effective on androgenic profiles and had detrimental effects on lipid profiles.

WHAT IS KNOWN ALREADY

Despite data available on the effects of OCs, the superiority of products with low androgenic or antiandrogenic progesterone components in comparison with older products used in women with PCOS has not been clarified.

STUDY DESIGN, SIZE, DURATION

This study is a crossover randomized controlled six-arm trial, with all six arms including two 6-month treatment periods, one period with OCs containing LNG, and the other with one of three OCs containing desogestrel (DSG), cyproterone acetate (CPA) or drospirenone (DRSP). The trial was conducted between February 2016 and January 2018 and enrolled 200 patients with PCOS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two hundred women with PCOS (ages 18-45 years) were recruited at the endocrine outpatient clinic of the Research Institute for Endocrine Sciences (RIES) of the Shahid Beheshti University of Medical Sciences, Tehran, Iran. A blocking or stratification random allocation (block size = 6) using a computer-based random number generator was prepared to assign participants to treatment groups. Both the clinical examiner and data analyst were blinded to participants during the trial. Outcomes of interest, including anthropometric and clinical manifestations and hormonal, and biochemical parameters were assessed at baseline, after 3 and 6 months of each treatment and after the washout period.

MAIN RESULTS AND THE ROLE OF CHANCE

This study detected a higher decrease in free-androgen index (FAI) levels after 3 months of treatment with OCs containing DSG (95% CI: -2.3, -1.0), CPA (95% CI: -2.4, -1.1) and DRSP (95% CI: -2.6, -1.4), compared with products containing LNG (P < 0.001). Use of OCs containing DSG (95% CI: -3.6, -1.5), CPA (95% CI: -3.1, -0.8) and DRSP (95% CI: -3.4, -1.1) for 6 months was associated with more decrease in FAI, compared with products containing LNG (P < 0.001). The study showed that use of OCs containing DSG, CPA and DRSP for 3-6 months was associated with a higher increase of sex hormone-binding globulin (SHBG), compared with products containing LNG (P < 0.001). We also observed more decrease in dehydroepiandrosterone sulfate levels after use of OCs containing DSG (P = 0.003), CPA (P = 0.012) and DRSP (P < 0.001) for 6 months, compared with products containing LNG. Our results showed that the use of OCs containing DRSP for 6 months was associated with more improvement in acne, compared with products containing LNG (P = 0.007). Women treated with OCs containing CPA, and DRSP for 3 months had higher TG and HDL levels and lower LDL levels, compared with those treated with products containing LNG (P < 0.05). After 6 months of treatment, patients treated with OCs containing DRSP had a sharper decline in LDL levels and more increase in HDL levels, compared to those treated with products containing LNG (P = 0.001).

LIMITATIONS, REASONS FOR CAUTION

Considering this trial was conducted in women diagnosed with Androgen Excess Society criteria, the results may not be generalizable for mild phenotypes diagnosed using Rotterdam criteria. Other limitations of the study include the high dropout rate, the lack of a gold standard androgen assay and the multiple end points.

WIDER IMPLICATIONS OF THE FINDINGS

Our results support the views of clinicians, who suggest an OC with a low androgenic or antiandrogenic progestin, if available, to treat PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the RIES, Shahid Beheshti University of Medical Sciences, Tehran, Iran. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

IRCT201702071281N2.

TRIAL REGISTRATION DATE

21 February 2017.

DATE OF FIRST PATIENT’S ENROLMENT

21 March 2017.

Effects of oral contraceptives on serum concentrations of adipokines and adiposity indices of women with polycystic ovary syndrome: a randomized controlled trial

PURPOSE

To compare the effects of oral contraceptives (OCs) with different progestins, including Levonorgestrel (LNG), Desogestrel (DSG), Cyproterone Acetate (CPA), and Drospirenone (DRSP) on adipokines levels and adiposity indices in women with polycystic ovary syndrome (PCOS).

METHODS

In this parallel randomized clinical trial, 120 women with PCOS randomly assigned to intervention with OCs containing LNG, DSG, CPA, or DRSP. Outcomes of interest, including serum concentrations of adiponectin, leptin, and resistin, and adiposity indices, i.e., body mass index (BMI), waist circumference (WC), obesity, central obesity, waist to hip ratio (WHR), waist to height ratio (WHtR), lipid accumulation product (LAP), a body shape index (ABSI), body roundness index (BRI), and visceral adiposity index (VAI), and lipid profiles were assessed at baseline, and 6 months of treatment.

RESULTS

This study showed no significant differences in serum concentrations of adipokines between the four study groups after 6 months of treatment. Our results also showed that patients treated with various compounds of OC for 6 months had no significant differences in their adiposity indices, except for LAP (p = 0.04), and VAI (p = 0.03). PCOS patients treated with OCs containing CPA had significantly a higher mean LAP, compared to those using products containing LNG. Besides, patients treated with OCs containing CPA had significantly a higher mean VAI, compared to those treated with OCs containing DRSP.

CONCLUSION

This study demonstrated that OCs with low androgenic and antiandrogenic activities had identical effects on serum concentrations of adipokines, and adiposity indices, except LAP, and VAI parameters.

REGISTRATION NUMBER

IRCT20080929001281N3.

Effects of oral contraceptives on the quality of life of women with polycystic ovary syndrome: a crossover randomized controlled trial

BACKGROUND AND OBJECTIVE

A limited number of studies have evaluated the effects of oral contraceptives (OCs) on the quality of life (QOL) of polycystic ovary syndrome (PCOS) patients. This study aimed to compare the effects of using OCs containing levonorgestrel (LNG) and those containing desogestrel (DSG), cyproterone acetate (CPA) or drospirenone (DRSP) for 6 months on the QOL with PCOS.

METHODS

In this crossover randomized controlled 6-arm trial, 200 eligible patients with PCOS scheduled for OC therapy were randomly assigned to one of the 6 study arms. All 6 arms include two 6-month treatment periods, one period with OCs containing LNG, and the other with each of the 3 OCs containing DSG, CPA, or DRSP. Outcomes of interest were the total score of QOL and its domains, which were assessed using a specific and valid health-related quality of life questionnaire for PCOS, which is consisted of six domains, including psychosocial-emotional, self-image, fertility, sexual function, hirsutism, and obesity- menstrual disorders.

RESULTS

Finally, a total of 88 patients were analyzed for this study. The results showed that use of OCs containing DSG, CPA, and DRSP for 3 months was not associated with significant differences in the total scores of QOL compared to those OCs containing LNG, whereas, after 6 months of treatment, patients treated with OCs containing CPA had more improvements in their total scores of QOL, in comparison to OCs containing LNG (P < 0.042). We found no significant differences in QoL domains, including psychosocial-emotional, self-image, fertility, sexual function, hirsutism, and obesity-menstrual disorders after 3-6 months of treatment with DSG, CPA, or DRSP, compared to LNG. The sequence and period effects were not significant in any of the analyses at 3 and 6 months of treatment. The carry-over effect was not significant for most outcomes assessed.

CONCLUSIONS

This crossover study demonstrated non-inferiority of OCs with newer generation progestins on different domains of QOL, in comparison with older compounds, although usage of products containing CPA was significantly associated with more improvement in total QOL of PCOS patients, compared to those containing LNG after 6-month of treatment.

TRIAL REGISTRATION

IRCT201702071281N2 .

Photodynamic therapy for severe facial acne vulgaris with 5% 5-aminolevulinic acid vs 10% 5-aminolevulinic acid: A split-face randomized controlled study

BACKGROUND

Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) has been described as an effective treatment for severe acne. However, very little evidence exists on the optimal concentration of ALA used in PDT for severe acne.

OBJECTIVES

To compare the efficacy and safety of PDT with 5% ALA vs 10% ALA in severe acne.

METHODS

Twenty-three patients with severe facial acne were randomly assigned to receive PDT with 5% ALA or 10% ALA on the left or right side of the face. Four PDT sessions were conducted with a light dose of 96 J/cm2 . The reduction rates of lesion counts between the two groups were compared at the week-4 and week-12 follow-up visits. Effective rate at the week-12 visit was the primary clinical outcome. Pain and other side effects were evaluated at each visit.

RESULTS

The decrease in inflammatory lesions in the 10% ALA group was greater than that in the 5% ALA group at both week-4 (79.2% vs 62.5%, P = 0.009) and week-12 follow-up visits (88.5% vs 78.3%, P = 0.018), while the decrease in noninflammatory lesion counts between the two groups was not statistically significant at each follow-up visit. The effective rate in the 10% ALA group was significantly higher than that in the 5% ALA group (95.7% vs 69.6%, P = 0.02). No significant difference was observed in pain scores between the two groups except in the first treatment session.

CONCLUSIONS

Photodynamic therapy using 10% ALA was more effective for severe acne than PDT using 5% ALA.

Porphyrinoid photosensitizers mediated photodynamic inactivation against bacteria

The multi-drug resistant bacteria have become a serious problem complicating therapies to such a degree that often the term "post-antibiotic era" is applied to describe the situation. The infections with methicillin-resistant S. aureus, vancomycin-resistant E. faecium, third generation cephalosporin-resistant E. coli, third generation cephalosporin-resistant K. pneumoniae and carbapenem-resistant P. aeruginosa have become commonplace. Thus, the new strategies of infection treatment have been searched for, and one of the approaches is based on photodynamic antimicrobial chemotherapy. Photodynamic protocols require the interaction of photosensitizer, molecular oxygen and light. The aim of this review is to provide a comprehensive overview of photodynamic antimicrobial chemotherapy by porphyrinoid photosensitizers. In the first part of the review information on the mechanism of photodynamic action and the mechanism of the bacteria resistance to the photodynamic technique were described. In the second one, it was described porphyrinoids photosensitizers like: porphyrins, chlorins and phthalocyanines useable in photodynamic bacteria inactivation.

[Light-based inflammatory acne treatments]

Light-based acne treatments may represent a new emerging treatment for acne that does not increase the risk of bacterial resistance and they may be potentially effective with a favorable safety profile. Current data show that photodynamic therapy reduces inflammatory lesions and significantly improves acne. However, there is no consensus on the optimal implementation in the treatment of acne. In addition to topically applied photodynamic therapy, intense pulsed light, pulsed dye lasers, potassium-titanyl-phosphate lasers, infrared diode lasers, broad-spectrum continuous-wave light sources (red light, blue-red light) have been introduced as alternative treatments. Since well-designed studies to evaluate their efficacy versus traditional medical therapies are lacking and standardized regimens have not been agreed upon, procedures including laser, intense pulsed light, and photodynamic therapy should currently not be considered first-line treatment for inflammatory acne.

The relationship between clinical and biochemical characteristics and quality of life in patients with polycystic ovary syndrome

BACKGROUND AND OBJECTIVE

While has been well demonstrated that clinical characteristics of polycystic ovary syndrome (PCOS) are associated with an impaired quality of life (QoL) in patients, it is unclear that whether the biochemical aspects of PCOS can influence their QoL. We aimed to investigate the relationship between clinical and biochemical characteristics, and various domains of QoL in patients with PCOS.

DESIGN

A cross-sectional study.

PATIENTS AND MEASUREMENTS

We assessed the association between clinical and biochemical characteristics and QoL domains (psychosocial-emotional, fertility, sexual function, and obesity-menstrual) in a total of 211 women with PCOS using a specific health-related quality-of-life questionnaire for PCOS patients.

RESULTS

Our findings showed positive significant association of QoL with age, and its negative significant associations with BMI, hirsutism and infertility (P < 0.05). We also found a negative association between FAI and total QoL (r = -0.14; P = 0.042) and domains of hirsutism (r = -0.14; P = 0.045) and obesity-menstrual (r = -0.23; P = 0.001). DHEAS was positively associated with the sexual function aspect of QoL (r = 0.20; P = 0.043). There were no significant associations between QoL and other hormonal parameters including LH to FSH ratio and total testosterone (tT). Significant associations were found between triglycerides (TG), total cholesterol (TC), LDL and HDL cholesterol, and domain of obesity-menstrual of QoL. HOMA-IR was significantly related to all QoL domains except self-image and hirsutism.

CONCLUSION

Although biochemical markers can influence QoL in patients with PCOS, clinical manifestations of this syndrome such as obesity, infertility and hirsutism seem to play roles in worsening QoL, in particular for psychosocial domains. Hence, clinicians should regularly assess the clinical and psychosocial dimensions of PCOS as well as biochemical aspects.

Severe acne in monozygotic twins treated with photodynamic therapy

Acne is a common skin disease in adolescence. It is a chronic inflammatory disease of the pilosebaceous units, which mainly occurs on the face and upper parts of the trunk. Based on severity of the lesions, acne can be mild, moderate or severe. Severe acne is usually featured with a protracted course and residual scars. Photodynamic therapy (PDT) has been demonstrated to be effective in severe acne recently. We report a case of monozygotic twins with severe acne who were successfully treated with PDT.

A new optical intra-tissue fiber irradiation ALA-PDT in the treatment of acne vulgaris in rabbit model: improved safety and tolerability

Background

Photodynamic therapy with topical aminolevulinic acid (ALA-PDT) has been suggested to be effective in treatment of acne vulgaris. However, adverse events occur during and after treatment.

Objectives

To compare the efficacy and tolerability of optical intra-tissue fiber irradiation (OFI) ALA-PDT versus traditional ALA-PDT in treatment of acne vulgaris in rabbit models.

Methods

Twenty-five rabbits of clean grade were used. Twenty rabbits were randomly selected to establish acne model and the other five were used as control. Rabbits in model group (40 ears) were further divided into four groups (10 ears/group): I, OFI-ALA-PDT with the head of optical fiber inserted into the target lesion (intra-tissue); II, traditional ALA-PDT group; III, OFI group; IV, blank control group without any treatment. Uncomfortable symptoms, adverse events, and effectiveness rates were recorded on post-treatment day 14, 30, and 45.

Results

On post-treatment day 14, the effectiveness rate in OFI-ALA-PDT group was obviously higher than that of the other three groups (P<0.05). However, no improved effects were observed in OFI-ALA-PDT group on day 30 and 45. During the period of treatment, the frequencies of uncomfortable symptoms in ALA-PDT group were obviously higher than those in the other three groups (P<0.05). The adverse event rate in OFI-ALA-PDT group was obviously lower than that of the ALA-PDT group (P<0.05).

Study limitations

The unblindness of the study and temporary animal models of acne induced may hamper the assessment and monitoring of the results, and future studies are still needed to clarify it further.

Conclusion

The OFI-ALA-PDT group (intra-tissue irradiation) showed no improved efficacy on treating rabbit ear acne but had higher safety and better tolerability.

A review of diagnosis and treatment of acne in adult female patients

This review focuses on the treatment options for adult female patients with acne. Acne in adult female patients may start during adolescence and persist or have an onset in adulthood. Acne has various psychosocial effects that impact patients’ quality of life. Treatment of acne in adult women specifically has its challenges due to the considerations of patient preferences, pregnancy, and lactation. Treatments vary widely and treatment should be tailored specifically for each individual woman. We review conventional therapies with high levels of evidence, additional treatments with support from cohort studies and case reports, complementary and/or alternative therapies, and new agents under development for the treatment of patients with acne.

Efficacy of photodynamic therapy combined with minocycline for treatment of moderate to severe facial acne vulgaris and influence on quality of life

BACKGROUND

Acne vulgaris is a prevalent skin disorder impairing both physical and psychosocial health. This study was designed to investigate the effectiveness of photodynamic therapy (PDT) combined with minocycline in moderate to severe facial acne and influence on quality of life (QOL).

METHODS

Ninety-five patients with moderate to severe facial acne (Investigator Global Assessment [IGA] score 3-4) were randomly treated with PDT and minocycline (n = 48) or minocycline alone (n = 47). All patients took minocycline hydrochloride 100 mg/d for 4 weeks, whereas patients in the minocycline plus PDT group also received 4 times PDT treatment 1 week apart. IGA score, lesion counts, Dermatology Life Quality Index (DLQI), and safety evaluation were performed before treatment and at 2, 4, 6, and 8 weeks after enrolment.

RESULTS

There were no statistically significant differences in characteristics between 2 treatment groups at baseline. Minocycline plus PDT treatment led to a greater mean percentage reduction from baseline in lesion counts versus minocycline alone at 8 weeks for both inflammatory (-74.4% vs -53.3%; P < .001) and noninflammatory lesions (-61.7% vs -42.4%; P < .001). More patients treated with minocycline plus PDT achieved IGA score <2 at study end (week 8: 30/48 vs 20/47; P < .05). Patients treated with minocycline plus PDT got significant lower DLQI at 8 weeks (4.4 vs 6.3; P < .001). Adverse events were mild and manageable.

CONCLUSIONS

Compared with minocycline alone, the combination of PDT with minocycline significantly improved clinical efficacy and QOL in moderate to severe facial acne patients.

Topical 5-aminolevulinic photodynamic therapy with red light vs intense pulsed light for the treatment of acne vulgaris: A spilit face, randomized, prospective study

5-Aminolevulinic acid photodynamic therapy (ALA-PDT) has been an effective method for treating acne vulgaris. Red light is the most widely used light source while Intense pulsed lights (IPL) is reported effective and well-tolerated. The purpose of this study was to evaluate the efficacy and adverse reactions of ALA-PDT with red light on acne compared with ALA-PDT with IPL.12 patients were recruited in the randomized, prospective and split-face study. 5% ALA cream were applied on the whole face with 2 hours' incubation before narrow band LED(633 ± 10 nm, 36 ∼ 108J/cm²) on one side of face and IPL(590∼1200 nm, 15∼17J/cm²) on the other side. Three treatment sessions were administered with 2-week interval each time and 8 weeks' follow up. The number of the total acne lesions and inflammatory lesions of the side treated by red light-PDT showed a relatively higher reduction rate that that by IPL-PDT (P < 0.05). Significant PpIX fluorescence decrease was observed only for the group of red light (P < 0.05). Lower pain intensity numeric rating scale values and Investigator's Global Severity Assessment (IGA) grading for erythema of the IPL side were observed (P<0.05).The results suggested that both red light and IPL are effective for ALA-PDT on acne vulgaris. ALA-PDT with red light may achieve better efficacy by more effective photobleaching of protoporphyrin IX (PpIX), whereas IPL may accomplish less adverse reactions and better tolerance.

Low-Dose Topical 5-Aminolevulinic Acid Photodynamic Therapy in the Treatment of Different Severity of Acne Vulgaris

The objective of this article is to investigate the effectiveness and safety of photodynamic therapy (PDT) with 3.6 % topical aminolevulinic acid (ALA) and a short incubation time with red light in moderate to severe acne. One hundred and thirty-six patients with moderate to severe acne were treated with 3.6 % topical ALA-PDT for three sessions with an interval of 2 weeks. Patients were evaluated for efficacy and safety on week 2, 4, 6, 8, and 12 after the initial treatment. Most patients showed apparent clearance of acne lesions at the treated site after three sessions. The effective treatment rates were increased after the multiple therapies. The clinical outcomes are the best at 4 weeks after the final treatment. The total effectiveness rate and cure rate of the low-dose ALA-PDT procedure is 92.65 and 47.06 %, respectively. Thirty-one patients and nineteen patients showed apparent exacerbation of acne lesions before the 2nd and 3rd treatment, respectively, but all of them showed good or excellent improvement after a three-course treatment. A few patients showed mild relapse including papules and comedos at 8 weeks after the final treatment. No significant differences are found in the effects of different acne severity and different genders. Adverse reactions are mild and transient. A 3.6 % topical ALA-PDT with a short time incubation with red light is a simple and an effective treatment option for moderate to severe acne with mild side effects in Chinese people.

Guidelines of care for the management of acne vulgaris

Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

Clinical efficacy of 5-aminolevulinic acid photodynamic therapy in the treatment of moderate to severe facial acne vulgaris

Acne vulgaris is considered as a therapeutic challenge in terms of managing ongoing symptoms and preventing scar formation. Although there are many available treatments for alleviating acne, therapies for resistant or moderate-to-severe forms have been limited to systemic agents that are accompanied by potentially severe side-effects. While, aminolevulinic acid (ALA) photodynamic therapy (PDT) has increasingly been used as a simple and safe therapeutic option of acne vulgaris, the clinical efficacy requires confirmation in further studies. The aim of this study was to investigate the efficacy and safety of 5-ALA-PDT in the treatment of moderate-to-severe facial acne vulgaris. A total of 50 patients with moderate-to-severe facial acne were enrolled in the study and randomly divided equally into a therapy group and a control group. In the therapy group, the patients were treated with 5% 5-ALA for 1.5 h, followed by three 20-min doses of infrared radiation once a week; in the control group, the patients were treated with three 20 min doses of infrared radiation without 5-ALA once a week. Both treatments lasted for 3 weeks. The clinical efficacy was determined by evaluating acne lesion counts at weeks 0, 2, 4 and 6. Total efficacy rate (TER) was the primary endpoint of the study, and was defined as the proportion of the patients whose treatment effectiveness evaluation was cured (≥90% of skin lesions improved) and excellent (60-89% improvement). Adverse effects were recorded throughout the study. The study was completed by 24 patients in the therapy group and 23 patients in the control group. The numbers of acne lesions significantly decreased. The TER of the therapy group was significantly higher than that of the control group at weeks 4 and 6. Adverse effects were observed in 12 patients of the therapy group and 2 patients of the control group. In the therapy group the most common adverse effect was a burning sensation (n=7), followed by transient hyperpigmentation (n=3) and acute acneform lesions (n=2), while in control group, the 2 patients experienced flushing and dryness. The adverse effects were all cured by a symptomatic approach prior to the end of the study. 5-ALA-PDT combined with infrared radiation is an effective and safe therapy for moderate-to-severe facial acne.

Light based anti-infectives: ultraviolet C irradiation, photodynamic therapy, blue light, and beyond

Owing to the worldwide increase in antibiotic resistance, researchers are investigating alternative anti-infective strategies to which it is supposed microorganisms will be unable to develop resistance. Prominent among these strategies, is a group of approaches which rely on light to deliver the killing blow. As is well known, ultraviolet light, particularly UVC (200-280 nm), is germicidal, but it has not been much developed as an anti-infective approach until recently, when it was realized that the possible adverse effects to host tissue were relatively minor compared to its high activity in killing pathogens. Photodynamic therapy is the combination of non-toxic photosensitizing dyes with harmless visible light that together produce abundant destructive reactive oxygen species (ROS). Certain cationic dyes or photosensitizers have good specificity for binding to microbial cells while sparing host mammalian cells and can be used for treating many localized infections, both superficial and even deep-seated by using fiber optic delivered light. Many microbial cells are highly sensitive to killing by blue light (400-470 nm) due to accumulation of naturally occurring photosensitizers such as porphyrins and flavins. Near infrared light has also been shown to have antimicrobial effects against certain species. Clinical applications of these technologies include skin, dental, wound, stomach, nasal, toenail and other infections which are amenable to effective light delivery.

Prospective study of topical 5-aminolevulinic acid photodynamic therapy for the treatment of moderate to severe acne vulgaris in Chinese patients

BACKGROUND

Topical photodynamic therapy (PDT) mediated with 5-aminolevulinic acid (ALA) offers an alternative option for the treatment of acne vulgaris.

OBJECTIVE

To study the effects of ALA dose, incubation time, and lesion type on protoporphyrin IX (PpIX) production and treatment outcomes.

METHODS

To examine the time course of PpIX production, 10% ALA was applied to inflammatory papules for 1 to 5 hours and followed by in situ fluorescence examination. To determine the effects of ALA dose and lesion type, 3, 5, and 10% ALA was applied to acne lesions in split-face fashion for 3 hours followed by whole-face light irradiation at 633 nm and 30 to 70 J/cm2. Treatment was repeated twice at 2-week intervals.

RESULTS

PpIX reached a stable level after 3 hours of incubation. Similar PpIX levels were seen in areas receiving 3, 5, and 10% ALA. Poisson regression analyses indicated that lesion counts decreased by 0.791 times for a one-unit increase in treatment times (95% CI 0.782-0.799 < .0001) but only by 0.999 times for a one-unit increase in ALA dose (95% CI 0.998-1.000  =  .22).

CONCLUSION

The combination of low-dose ALA and a red light is a safe and effective option for the treatment of moderate to severe acne.

Liposomes in topical photodynamic therapy

INTRODUCTION

Topical photodynamic therapy (PDT) refers to topical application of a photosensitizer onto the site of skin disease which is followed by illumination and results in death of selected cells. The main problem in topical PDT is insufficient penetration of the photosensitizer into the skin, which limits its use to superficial skin lesions. In order to overcome this problem, recent studies tested liposomes as delivery systems for photosensitizers.

AREAS COVERED

This paper reviews the use of different types of liposomes for encapsulating photosensitizers for topical PDT. Liposomes should enhance the photosensitizers' penetration into the skin, while decreasing its absorption into systemic circulation. Only few photosensitizers have currently been encapsulated in liposomes for topical PDT: 5-aminolevulinic acid (5-ALA), temoporfin (mTHPC) and methylene blue.

EXPERT OPINION

Investigated liposomes enhanced the skin penetration of 5-ALA and mTHPC, reduced their systemic absorption and reduced their cytotoxicity compared with free drugs. Their high tissue penetration should enable the treatment of deep and hyperkeratotic skin lesions, which is the main goal of using liposomes. However, liposomes still do not attract enough attention as drug carriers in topical PDT. In vivo studies of their therapeutic effectiveness are needed in order to obtain enough evidence for their potential clinical use as carriers for photosensitizers in topical PDT.

Combination of photodynamic therapy and immunomodulation for skin diseases--update of clinical aspects

In dermatology, photodynamic therapy (PDT) has become a well established treatment modality which has been shown to be effective and safe for many skin and mucosal disorders. Pre-clinical and clinical studies demonstrate that, in addition to the direct local cytotoxicity and vascular effects, PDT can induce various host immune responses. Recent clinical data also show that improved clinical outcomes can be obtained through the sequential use of PDT and immunomodulation. This article will provide an update on the current status of such a combination in dermatological applications.