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

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.

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.

Treatment of refractory acne using selective sebaceous gland electro-thermolysis combined with non-thermal plasma

Acne is one of the most common skin diseases whose disfiguring results may cause psychological problems. Despite of the various choices in the treatment of acne, new therapy with fewer complications and lower relapse rate is still in need. In this study, we aim to evaluate the clinical efficacy of a new therapy using selective sebaceous gland electro-thermolysis and non-thermal plasma (NTP) in refractory acne patients. Treatments were given at a monthly interval for three times. The last visit was set at 3 months after the third treatment. Thirty-six moderate to very severe acne patients were enrolled. All the patients got more than 50% clearance after the third treatment. The excellent response rate was 44% at 1 month after the third treatment and 50% at 3 months after the third treatment. Porphyrin and erythema values were significantly reduced after the third treatment. No irreversible complication was reported. Selective sebaceous gland electro-thermolysis combined with NTP can be a safe and effective new option in the treatment of acne.

Photoactivated cell-killing amino-based flavylium compounds

Photodynamic therapy (PDT) is a well-established therapeutic for the treatment of different diseases. The growing interest of this technique required the development of new photosensitizers with better photo-features. This work reports the study of the potential of five nature-inspired amino-based flavylium compounds with different structural features as photosensitizers towards topical PDT. In terms of dark cytotoxicity the five pigments were tested towards confluent skin cells in both fibroblasts and keratinocytes. In the range of concentrations tested (6.3–100 μM), keratinocytes were more prone to growth inhibition and the IC₅₀ values for 5OH4′NMe₂, 7NEt₂st4′NMe₂ and 7NEt₂4′NH₂ were determined to be 47.3 ± 0.3 μM; 91.0 ± 0.8 μM and 29.8 ± 0.8 μM, respectively. 7NEt₂4′NMe₂, 7NEt₂st4′NMe₂ and 7NEt₂4′NH₂ showed significant fluorescence quantum yields (from 3.40 to 20.20%) and production of singlet oxygen (¹O₂). These latter chromophores presented IC₅₀ values of growth inhibition of keratinocytes between 0.9 and 1.5 µM, after 10 min of photoactivation with white light. This cellular damage in keratinocyte cells upon white light activation was accompanied with the production of reactive oxygen species (ROS). It was also found that the compounds can induce damage by either type I (ROS production) or type II (singlet oxygen) PDT mechanism, although a higher cell survival was observed in the presence of ¹O₂ quenchers. Overall, a structure–activity relationship could be established, ranking the most important functional groups for the photoactivation efficiency as follows: C7-diethylamino > C4′-dimethylamino > C2-styryl.

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.

A split-face clinical trial of conventional red-light photodynamic therapy versus daylight photodynamic therapy for acne vulgaris

BACKGROUND

Photodynamic therapy (PDT) is considered an effective treatment for acne vulgaris. A significant drawback is pain during illumination. Daylight PDT (DL-PDT) is more tolerable.

OBJECTIVE

To assess and compare the efficacy and tolerability of DL-PDT and C-PDT for acne vulgaris through a prospective split-face trial.

METHODS AND MATERIALS

Fifteen patients underwent 4 treatment sessions at 3-week intervals. First, 5-aminolevulinic acid (ALA) was applied to the entire face, after which the face was divided into 2 symmetrical areas: The right side was exposed to sunlight, and the left half was illuminated with red light. Photographs were obtained and evaluated by two dermatologists blinded to the study protocol. The patients reported side effects and downtime.

RESULTS

There was a statistically significant decrease in the number and percent change of inflammatory and non-inflammatory lesions on both sides. Adverse effects were markedly decreased on the DL-PDT side compared to the C-PDT side (p < .01). The average downtime duration was longer for the C-PDT side (p < .001).

CONCLUSION

DL-PDT was at least as effective as C-PDT with fewer adverse effects and a shorter downtime duration.

Combination of surgery and photodynamic therapy for the treatment of cystic acne of the scalp

Cystic acne of the scalp is relatively resistant to conventional treatment because of its thick wall and deep cavity. This study was conducted as a comparative analysis of clinical outcomes of single surgery and those of surgery combined with photodynamic therapy for cystic acne of the scalp. Ten patients were treated only with surgical incisions and drainage of pus and necrotic tissues, and another ten patients were treated with photodynamic therapy immediately after surgery, followed by two weekly cycles thereafter. The combination treatment group reported better outcomes than the single surgery group in terms of duration of wound healing, the number of dressing changes, pain score at the time of dressing change, and recurrence rate. Our study demonstrateds that the combination of surgery and photodynamic therapy may have pronounced effects on the treatment for cystic acne of the scalp.

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.

Topical 5-aminolevulinic acid photodynamic therapy for intra anal-rectal warts

Background: Condylomata acuminata (CA) are a common sexually transmitted disease. The recurrence rate of condyloma acuminatum using traditional treatments is higher than that of applying photodynamic therapy, and a variety of adverse reactions after treatment. At the same time, different parts of condyloma acuminatum after treatment recurrence rate is also different, especially for intra anal-rectal warts.Objective: To evaluate whether using photodynamic therapy (PDT) can effectively reduce recurrence of condylomata acuminata for intra anal-rectal warts.Methods: After the confirmation of the diagnosis of intra anal-rectal warts, the patients were treated with PDT with 5-aminolevulinic acid hydrochloride (ALA). PDT was performed with irradiation of 18-36 J/cm² at an irradiance of 20-40 mW/cm² with light-emitting diode (LED) light energy, wavelength 635 nm. We used a special PDT light equipment for intra anal-rectal area warts. PDT was repeated once every week for 4 weeks.Results: After PDT, the complete clearance rate was 76.1% (35 of 46 patients). At the end of the 12 weeks followed, recurrence occurred in five cases. We recorded pain in all 46 patients and the average visual analog scale (VAS) pain score was 6.96 ± 1.41 points.Conclusion: The treatment with PDT is effective in reducing the high rate of recurrence for intra anal-rectal warts. Pain is still a great challenge for the therapy.

Chlorin, Phthalocyanine, and Porphyrin Types Derivatives in Phototreatment of Cutaneous Manifestations: A Review

Recent scientific research has shown the use of chlorin, phthalocyanines, and porphyrins derivatives as photosensitizers in photodynamic therapy in the treatment of various pathologies, including some of the major skin diseases. Thus, the main goal of this critical review is to catalog the papers that used these photosensitizers in the treatment of acne vulgaris, psoriasis, papillomavirus infections, cutaneous leishmaniasis, and skin rejuvenation, and to explore the photodynamic therapy mechanisms against these conditions alongside their clinical benefits.

[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.

What is the most relevent factor causing pain during ALA-PDT? A multi-center, open clinical pain score research trial of actinic keratosis, acne and condylomata acuminata

BACKGROUND

To date, it has been reported that the intrinsic factors(lesions location, lesions area, disease tynpes) and extrinsic factors(fluence rate) contribute to the pain during 5-aminolevulinic acid photodynamic therapy (ALA-PDT). But there are few studies on pain during ALA-PDT and lack of sufficient clinical evidence related to the pain intensity.

OBJECTIVE

To investigate pain intensity and its relative factors during ALA-PDT and to provide clinical implication.

METHODS

The pain numeric rating scale (PNRS) score was used to evaluate the patients' pain intensity at different times during ALA-PDT irradiation from 0 to 10 min during treatment. Gender, age, lesions location, lesions area, ALA concentration and fluence rate were recored.

RESULTS

The trial enrolled 274 patients in total, including 118 acne patients (in face), 30 actinic keratosis(AK)patients(in face), 126 Condylomatata acuminate patients(in genitalia). The average pain score in PDT was highest in the patients with actinic keratosis(7.3 ± 0.7), and that of condylomata acuminata was the lowest (4.5 ± 1.1) (p < 0.05). The highest pain score in patients with AK, acne and condylomata acuminata was 8, 6 and 6 respectively which occurred at 4 min, 4 min and 6 min respectively. The pain score of males was higher compared with females in all of the three diseases (p < 0.05). The pain score of facial diseases (5.6 ± 1.2) was higher than that of the genitalia (4.5 ± 1.1) (p < 0.05). The lesions area was positively correlated with the pain score (p < 0.05). In facial diseases, the pain score of patients with high fluence rate (7.3 ± 0.7) was higher than patients with low fluence rate (5.1 ± 0.9) (p < 0.05).

CONCLUSIONS

Intrinsic and extrinsic factors both correlate with pain during PDT. Intrinsic factors are difficult to change, so extrinsic factors are the key point to control. We can reduce the fluence rate and extend the treatment time, relieving pain intensity while still ensuring equivalent efficacy.

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.

The Role of Photodynamic Therapy in Acne: An Evidence-Based Review

BACKGROUND

Acne vulgaris is a highly prevalent skin disorder that affects almost all adolescents and can persist into adulthood. Photodynamic therapy (PDT) is an emerging treatment for acne that involves the use of a photosensitizer in combination with a light source and oxygen.

METHODS

We performed a systematic review of the literature and critically evaluated the studies. Sixty-nine clinical trials, four case reports, and two retrospective studies met the inclusion criteria, and seven of the studies were high quality.

RESULTS

The most common photosensitizers used were 5-aminolevulinic acid and methyl aminolevulinate, and both showed similar response. Red light was the most frequently used light source, followed by intense pulsed light, and showed comparable results. Inflammatory and non-inflammatory lesions both responded to treatment, with inflammatory lesions showing greater clearance in most studies. Adverse events associated with PDT for acne were mild and included pain on illumination and post-procedural erythema and edema. PDT has been safely used in higher Fitzpatrick skin types (III-IV), although these patients had a higher risk of transient hyperpigmentation.

CONCLUSION

This review supports PDT as an efficacious treatment for acne and a good adjunctive treatment for mild to severe acne, especially in patients who have not responded to topical therapy and oral antibacterials, and are not great candidates for isotretinoin. Further studies are warranted to evaluate the optimal photosensitizers, light sources, incubation times, and number of treatments for PDT use in acne.

Energy-Based Devices in Treatment of Acne Vulgaris

BACKGROUND

Acne vulgaris is a chronic dermatologic complaint with a multifactorial cause. Traditionally, antibiotics and retinoids have been used to manage the condition; patient compliance has been an ongoing issue. A variety of energy-based devices have been reported to be effective in the treatment of acne vulgaris.

OBJECTIVE

To review and summarize the current literature specific to treatment of acne vulgaris with energy-based devices.

METHODS

A review of the current literature of energy-based devices used for the treatment of acne vulgaris.

RESULTS AND CONCLUSIONS

Although limited randomized controlled trials for the treatment of acne have been performed, significant clinical improvement of acne vulgaris, especially of inflammatory lesions, has been demonstrated with a variety of energy-based devices. Newer approaches may lead to even better results.

Optimizing Non-Antibiotic Treatments for Patients with Acne: A Review

Acne is a very common non-infectious skin condition that is frequently treated in dermatological practices. Because acne is often chronic and may persist for years, safe and effective long-term maintenance therapy is often required. Given the increasing frequency of antibiotic-resistant bacteria and the gravity of the consequences of this trend, it behooves dermatologists to maximize use of non-antimicrobial therapy when treating acne. In this review of the literature we present data regarding the efficacy and appropriate use of non-antimicrobial treatments for acne. A variety of topical and oral treatment options exist that can be used in a step-wise manner according to the patients’ severity and therapeutic response. Non-antimicrobial treatments can be highly efficacious at controlling acne, especially when used as maintenance therapy. While antibiotics have a role in acne treatment, they should not be used as monotherapy, and lengthy courses of antibiotic use are discouraged.

Effects of 5-aminolevulinic acid photodynamic therapy on TLRs in acne lesions and keratinocytes co-cultured with P. acnes

OBJECTIVE

To investigate the effect of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) on the expression of Toll like receptors (TLRs) in human keratinocytes and its role in acne treatment.

METHODS

TLR2 and TLR4 expression in acne lesions before and after ALA-PDT were examined by immunohistochemical assay. Primary keratinocytes were obtained from acne lesions, co-cultured with P. acnes and then treated with ALA-PDT using red or blue LED. Cytokines production were examined by ELISA, TLR2 and TLR4 gene expression by real-time PCR, and TLR2 and TLR4 protein expression by Western-blot assay.

RESULTS

The overexpression of TLR2 and TLR4 in acne lesion were detected, which became negative or weaker after ALA-PDT. The infection of P. acnes in keratinocytes could significantly increase the levels of early inflammatory cytokines (e.g. IL-1α, TNF-α and IL-8) (P<0.05). Such responses could be inhibited by ALA-PDT. P. acnes infection could also significantly increase TLR2 and TLR4 expressions in keratinocytes (P<0.05), which could be down-regulated by ALA-PDT.

CONCLUSIONS

ALA-PDT could inhibit innate immune responses in keratinocytes treated with P. acnes via TLRs pathways.

Topical PDT in the Treatment of Benign Skin Diseases: Principles and New Applications

Photodynamic therapy (PDT) uses a photosensitizer, light energy, and molecular oxygen to cause cell damage. Cells exposed to the photosensitizer are susceptible to destruction upon light absorption because excitation of the photosensitizing agents leads to the production of reactive oxygen species and, subsequently, direct cytotoxicity. Using the intrinsic cellular heme biosynthetic pathway, topical PDT selectively targets abnormal cells, while preserving normal surrounding tissues. This selective cytotoxic effect is the basis for the use of PDT in antitumor treatment. Clinically, PDT is a widely used therapeutic regimen for oncologic skin conditions such as actinic keratosis, squamous cell carcinoma in situ, and basal cell carcinoma. PDT has been shown, under certain circumstances, to stimulate the immune system and produce antibacterial, and/or regenerative effects while protecting cell viability. Thus, it may be useful for treating benign skin conditions. An increasing number of studies support the idea that PDT may be effective for treating acne vulgaris and several other inflammatory/infective skin diseases, including psoriasis, rosacea, viral warts, and aging-related changes. This review provides an overview of the clinical investigations of PDT and discusses each of the essential aspects of the sequence: its mechanism of action, common photosensitizers, light sources, and clinical applications in dermatology. Of the numerous clinical trials of PDT in dermatology, this review focuses on those studies that have reported remarkable therapeutic benefits following topical PDT for benign skin conditions such as acne vulgaris, viral warts, and photorejuvenation without causing severe side effects.