Guidelines for topical photodynamic therapy: update

Predominant Binding Mode of Palmatine to DNA

Palmatine is a protoberberine alkaloid, which may produce singlet oxygen under visible light irradiation and binds to DNA. The fact that singlet oxygen activation in palmatine may be triggered by environmental conditions, and in particular its interaction with nucleic acids, makes it a most suitable candidate for photodynamic therapy and DNA-targeted noninvasive anticancer strategies. Despite these remarkable properties, the actual binding mode between palmatine and DNA has not been resolved, yet. Its elucidation has indeed led to contrasting hypotheses. In this contribution, by using long-range molecular dynamic simulations and enhanced sampling approaches, we unequivocally identify that intercalation is the dominant binding mode of palmatine with DNA, from both a thermodynamic and kinetic point of view.

Clinical trial of two-step photodynamic therapy for reduced pain in the treatment of precancerous squamous lesions (Actinic keratoses)

BACKGROUND

Pain associated with aminolevulinic acid photodynamic therapy (ALA-PDT) for the treatment of facial dermatoses results in low patient compliance. Two-step photodynamic therapy (two-step PDT) may improve comfort by optimizing light amplitude and exposure time.

OBJECTIVE

To investigate the efficacy of two-step PDT in reducing the pain generated during the treatment of facial skin disorders.

METHODS

Twenty-six patients with AK were randomly divided into two groups; the experimental group was treated with two-step photodynamic therapy and the control group was treated with conventional photodynamic therapy. The pain intensity of the patients at different times was assessed using the pain numerical rating scale (NRS).

RESULTS

A total of 26 patients completed three ALA-PDT treatments, 13 and 13 patients in each group, respectively. The mean NRS scores of patients in the experimental group (3.28±1.41, 3.33±1.43, 3.42±1.78) were lower than those of the control group (5.00±1.94, 5.09±1.86, 4.86±1.64) on each occasion. The incidence of certain adverse reactions was lower in the experimental group than in the control group. There was no difference between the two groups in terms of clinical outcome, recurrence rate and patient satisfaction.

CONCLUSION

Two-step photodynamic therapy can reduce pain and the incidence of some adverse reactions, but does not affect clinical efficacy, recurrence rate and patient satisfaction.

Jet-injection assisted photodynamic therapy for superficial and nodular basal cell carcinoma: A pilot study

BACKGROUND

Photodynamic therapy (PDT) with topical δ-Aminolevulinic acid (ALA) has efficacy in treating basal cell carcinoma (BCC) but is limited by incomplete penetration of ALA into the deeper dermis. This prospective open-label pilot trial investigated the safety and efficacy of photosensitizer jet injection for PDT (JI-PDT) for BCC treatment. It was performed with 15 patients (n = 15) with histologically confirmed, untreated, low-risk nodular BCCs at a single institution.

METHODS

For the intervention, JI-PDT patients (n = 11) received two sessions of jet-injected ALA with PDT separated by four to 6 weeks. To further understand treatment technique, another group of patients (n = 4) received jet-injected ALA followed by tumor excision and fluorescence microscopy (JI-E). Treatment tolerability was assessed by local skin responses (LSR) score at five distinct time intervals. Fluorescence microscopy assessed protoporphyrin IX penetration depth and biodistribution within the tumor. At the primary endpoint, tumor clearance was evaluated via visual inspection, dermoscopy and reflectance confocal microscopy. Postinjection and postillumination pain levels, and patient satisfaction, were scored on a 0-10 scale.

RESULTS

Fifteen participants with mean age of 58.3, who were 15/15 White, non-Hispanic enrolled. The median composite LSR score immediately after JI-PDT was 5 (interquartile range [IQR] = 3) which decreased to 0.5 (IQR = 1) at primary endpoint (p < 0.01). Immunofluorescence of excised BCC tumors with jet-injected ALA showed photosensitizer penetration into papillary and reticular dermis. Of the 13 JI-PDT tumors, 11 had tumor clearance confirmed, 1 recurred, and 1 was lost to follow-up. 1/11 patients experienced a serious adverse event of cellulitis. 70% of patients had local scarring at 3 months. Patients reported an average pain level of 5.6 (standard deviation [SD] = 2.3) during jet injection and 3.7 (SD = 1.8) during light illumination.

CONCLUSIONS

Jet injection of ALA for PDT treatment of nodular low-risk BCC is tolerable and feasible and may represent a novel modality to improve PDT.

Nanocarriers in topical photodynamic therapy

INTRODUCTION

Photodynamic therapy (PDT) has gained significant attention due to its superiority over conventional treatments. In the context of skin cancers and nonmalignant skin diseases, topical application of photosensitizer formulations onto affected skin, followed by illumination, offers distinct advantages. Topical PDT simplifies therapy by providing easy access to the skin, increasing drug concentration within the target area, and confining residual photosensitivity to the treated skin. However, the effectiveness of topical PDT is often hindered by challenges such as limited skin penetration or photosensitizer instability. Additionally, the hypoxic tumor environment poses further limitations. Nanocarriers present a promising solution to address these challenges.

AREAS COVERED

The objective of this review is to comprehensively explore and highlight the role of various nanocarriers in advancing topical PDT for the treatment of skin diseases. The primary focus is to address the challenges associated with conventional topical PDT approaches and demonstrate how nanotechnology-based strategies can overcome these challenges, thereby improving the overall efficiency and efficacy of PDT.

EXPERT OPINION

Nanotechnology has revolutionized the field of PDT, offering innovative tools to combat the unfavorable features of photosensitizers and hurdles in PDT. Nanocarriers enhance skin penetration and stability of photosensitizers, provide controlled drug release, reduce needed dose, increase production of reactive oxygen species, while reducing side effects, thereby improving PDT effectiveness.

Trends in photodynamic therapy for dermatology in recent 20 years: A scientometric review based on CiteSpace

OBJECTIVE

Analyze the research state and development trend of photodynamic therapy for dermatology using visual knowledge graphs derived from the Web of Science Core Collection database.

METHODS

The Web of Science Core Collection database was utilized as the search data source for the bibliometric analysis, and the associated articles published between January 1, 2000, and December 31, 2022, were obtained using the search terms "photodynamic therapy" and "dermatology". CiteSpace, VOSviewer, and additional tools were utilized for bibliometric analysis, and visual knowledge graphs were created.

RESULTS

Eight hundred and thirty two articles were retrieved in total, and 747 were included following de-duplication and transformation. The country with the greatest number of publications is the United States; the primary research institution was University of Copenhagen; and the references with the highest centrality were primarily concerned with the selection of photosensitizers; High frequency keywords primarily comprised 5 aminolevulinic acid and basal cell carcinoma; and the clustering graph revealed that all keywords fell into 11 categories.

CONCLUSION

In numerous areas of dermatology, photodynamic treatment is commonly employed. Current research focuses on nonneoplastic skin diseases and the choice of photosensitizers. Nonetheless, its specific mechanism and other applications merit further investigation.

A Comprehensive Review of Treatment Approaches for Cutaneous and Genital Warts

Cutaneous and genital warts are common in both developed as well as developing countries. Human papillomavirus (HPV), which is a double-stranded DNA virus, is the causative agent of wart infection. Different types of HPV viruses are responsible for the different severity of diseases. Some types are associated with malignancy of the anal region and cervix. HPV is a common sexually transmitted disease in the United States. The incidence is most common in the younger age groups and the elderly population. Our main goal is to describe the different treatment modalities available for warts. Treatment modalities are divided into primary, secondary, and tertiary options. Topical medications, and physical excision of warts via cryotherapy, electrocautery, lasers, or photodynamic therapy are all common forms of treatment. Various clinical trials and randomized control trials have been seen as effective treatment against HPV infection. Higher remission rates are seen irrespective of different treatment options. Warts can be treated but the HPV virus cannot be completely removed. Older age, immunocompromised state, diabetes mellitus, and HIV are the predisposing factors for the disease. There is currently a large variety of medicines in use, all of which can differ significantly in terms of price, side-effect profiles, dosing regimens, length of therapy, and overall effectiveness. The best course of treatment has not yet been identified, and patients are often treated according to their unique needs.

Recommendations for Cost-Conscious Treatment of Basal Cell Carcinoma

BACKGROUND

Basal cell carcinoma (BCC) affects 3.3 million Americans annually. Treatment modalities for BCC include many surgical and nonsurgical options. The cost of BCC treatment can pose a substantial burden to patients and the healthcare system. Cost can be an important consideration in BCC treatment planning.

OBJECTIVE

We present an approach to the management of BCC when cost reduction is a priority.

METHODS

A PubMed literature search identified studies on effectiveness of current BCC therapies. Treatment prices were obtained from the Medicare National Fee Schedule, GoodRx, and pharmaceutical companies. The American Academy of Dermatology's (AAD) guidelines for treating BCC were used to develop recommendations for cost-reductive treatment.

RESULTS

The cost of treating a primary superficial BCC < 0.5 cm arising on Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface) was $143 with curettage and electrodesiccation (C&E), $143 with cryosurgery, $210 with standard excision and simple reconstruction (SE), $1221 with Mohs Micrographic Surgery (MMS) and simple reconstruction, $472 with imiquimod, $186 with 5-fluorouracil (5-FU), and $354-$371 for photodynamic therapy (PDT). The cost of treating a primary nodular BCC 1.1-2 cm arising on Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles) was $183 with C&E, $183 with cryosurgery, $251 with SE and simple reconstruction, $1163-1351 with MMS and simple reconstruction, $472 with imiquimod, $186 with 5-FU, and $354-$371 for photodynamic therapy (PDT). The cost of treating a giant BCC (BCC > 10 cm with aggressive behavior) was $465-3311 with radiation, $139,560 with vismodegib, $144,452 with sonidegib, ~ $44.5 with cisplatin (medication cost only), and at least $184,836 with cemiplimab-rwlc.

CONCLUSIONS

For a primary superficial BCC < 0.5 cm arising on Area M, the cost-conscious algorithm prioritizes C&E or cryosurgery. For a primary nodular BCC 1.1-2 cm arising on Area L, the cost-conscious algorithm prioritizes C&E, cryosurgery, or 5-FU. For a giant BCC, the cost-conscious algorithm identifies superficial radiation therapy as first line.

Improving the efficacy of photodynamic therapy for actinic keratosis: A comprehensive review of pharmacological pretreatment strategies

BACKGROUND

Photodynamic therapy (PDT) is approved for treatment of actinic keratoses (AKs) and field-cancerisation. Pretreatment with pharmacological compounds holds potential to improve PDT efficacy, through direct interaction with PpIX formation or through an independent response, both of which may improve PDT treatment.

OBJECTIVE

To present the currently available clinical evidence of pharmacological pretreatments prior to PDT and to associate potential clinical benefits with the pharmacological mechanisms of action of the individual compounds.

METHODS

A comprehensive search on the Embase, MEDLINE, and Web of Science databases was performed.

RESULTS

In total, 16 studies investigated 6 pretreatment compounds: 5-fluorouracil (5-FU), diclofenac, retinoids, salicylic acid, urea, and vitamin D. Two of these, 5-FU and vitamin D, robustly increased the efficacy of PDT across multiple studies, illustrated by mean increases in clearance rates of 21.88% and 12.4%, respectively. Regarding their mechanisms, 5-FU and vitamin D both increased PpIX accumulation, while 5-FU also induced a separate anticarcinogenic response. Pretreatment with diclofenac for four weeks improved the clearance rate in one study (24.9%), administration of retinoids had a significant effect in one of two studies (16.25%), while salicylic acid and urea did not lead to improved PDT efficacy. Diclofenac and retinoids demonstrated independent cytotoxic responses, whereas salicylic acid and urea acted as penetration enhancers to increase PpIX formation.

CONCLUSION

5-FU and vitamin D are well-tested, promising candidates for pharmacological pretreatment prior to PDT. Both compounds affect the haem biosynthesis, providing a target for potential pretreatment candidates.

KEY WORDS

Photodynamic Therapy, Actinic Keratosis,Pre-tretment,Review,enhancement.

Photodynamic therapy in oral cancer: a review of clinical studies

A significant mortality rate is associated with oral cancer, particularly in cases of late-stage diagnosis. Since the last decades, oral cancer survival rates have only gradually improved despite advances in treatment. This poor success rate is mainly due to the development of secondary tumors, local recurrence, and regional failure. Invasive treatments frequently have a negative impact on the aesthetic and functional outcomes of survivors. Novel approaches are thus needed to manage this deadly disease in light of these statistics. In photodynamic therapy (PDT), a light-sensitive medication called a photosensitizer is given first, followed by exposure to light of the proper wavelength that matches the absorbance band of the photosensitizer. The tissue oxygen-induced cytotoxic free radicals kill tumor cells directly, harm the microvascular structure, and cause inflammatory reactions at the targeted sites. In the case of early lesions, PDT can be used as a stand-alone therapy, and in the case of advanced lesions, it can be used as adjuvant therapy. The current review article discussed the uses of PDT in oral cancer therapy based on recent advances in this field.

Targeted implementation strategies of precise photodynamic therapy based on clinical and technical demands

With the development of materials science, photodynamic-based treatments have gradually entered clinics. Photodynamic therapy is ideal for cancer treatment due to its non-invasive and spatiotemporal properties and is the first to be widely promoted in clinical practice. However, the shortcomings resulting from the gap between technical and clinical demands, such as phototoxicity, low tissue permeability, and tissue hypoxia, limit its wide applications. This article reviews the available data regarding the pharmacological and clinical factors affecting the efficacy of photodynamic therapy, such as photosensitizers and oxygen supply, disease diagnosis, and other aspects of photodynamic therapy. In addition, the synergistic treatment of photodynamic therapy with surgery and nanotechnology is also discussed, which is expected to provide inspiration for the design of photodynamic therapy strategies.

Photodynamic therapy for skin carcinomas: A systematic review and meta-analysis

Background

Photodynamic therapy (PDT) is increasingly used for the treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). However, it is unknown whether photodynamic therapy is more effective than other commonly used treatment modalities for these cancers.

Purpose

The aim of this study was to determine the relative efficacy and safety of PDT compared with placebo or other interventions for the treatment of skin carcinomas.

Methods

Searches were performed in PubMed, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials databases. We included randomized controlled trials comparing the PDT with other interventions in adults skin BCC or SCC that reported on lesion response, recurrence, cosmetic appearance, or safety outcomes.

Results

Seventeen unique randomized controlled trials, representing 22 study arms from 21 publications were included. The included trials included 2,166 participants, comparing methyl aminolevulinic (MAL) PDT (six studies) or aminolevulinic acid (ALA) PDT (two studies). Comparators included placebo, surgery, hexaminolevulinic (HAL) PDT, erbium: yttrium-aluminum-garnet ablative factional laser (YAG-AFL) PDT, fluorouracil, and imiquimod. There were few studies available for each comparison. Mantel-Haenszel fixed effects risk ratios were calculated for response, recurrence, cosmetic outcomes, and adverse events. MAL-PDT had similar response rates to surgery, ALA-PDT, fluorouracil and imiquimod at 3- and 12 months post-intervention. The rate of recurrence was similar, showing few differences at 12 months, but at later time points (24-60 months), fewer lesions recurred with surgery and imiquimod than with PDT. PDT also caused more adverse events and pain than other interventions. However, PDT treatment was more likely to receive a "good" or "excellent" rating for cosmetic appearance than surgery or cryotherapy.

Conclusion

This systematic review and meta-analysis demonstrates that the choice of treatment modality for BCC or SCC is best chosen in the context of the location and size of the lesion, the socioeconomic circumstances of the patient, as well as the patient's preferences. We call for more high quality studies to be done, in order to enable more reliable interpretations of the data.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=368626, identifier CRD42022368626.

The Combination of the Mini-Punch Technique and Photodynamic Therapy for the Treatment of Mandibular Keloids and Hypertrophic Scars

BACKGROUND

Mandibular keloids and hypertrophic scars can exert significant effects on the appearance of a patient. However, current treatments are not effective in all cases. Consequently, it is vital to identify a safe and effective treatment method.

OBJECTIVE

To investigate the therapeutic effect of the mini-punch technique combined with photodynamic therapy (PDT) on mandibular keloids and hypertrophic scars.

PATIENTS AND METHODS

Twenty patients with mandibular keloids and hypertrophic scars were enrolled, including 5 cases of keloids and 15 cases of hypertrophic scars, with a total of 40 lesions. The mini-punch technique was performed first, and then, PDT was conducted, once a week on 3 occasions in total.

RESULTS

After 12 months of follow-up, 30 lesions had improved by more than 50%, thus achieving a good therapeutic effect. The Vancouver Scar Scale score of patients ranged between 8 and 12 points with a mean of 9.60 ± 1.09 points before surgery and between 2 and 9 points with a mean of 4.15 ± 2.05 points at 12 months after surgery. The mean Vancouver Scar Scale score after treatment was significantly lower than that before treatment (t = 11.80, p < .001).

CONCLUSION

A combination of the mini-punch technique and PDT is an effective treatment for mandibular keloids and hypertrophic scars.

The Efficacy of Topical Photodynamic Therapy in Precancerous Lesions of the Skin: A Literature Review

Precancerous skin lesions are associated with high probability of malignant transformation to squamous cell carcinoma. Early detection and management are necessary to improve prognosis and outcomes. Literatures showed that topical photodynamic therapy (PDT) is a promising treatment method which can be successfully applied in several conditions in dermatology. This study aims to review the efficacy of topical PDT for various precancerous lesions in dermatology, such as actinic keratosis, Bowen disease, and Bowenoid papulosis.

The evolution of clinical guidelines for antimicrobial photodynamic therapy of skin

Antimicrobial photodynamic therapy has become an important component in the treatment of human infection. This review considers historical guidelines, and the scientific literature to envisage what future clinical guidelines for treating skin infection might include. Antibiotic resistance, vertical and horizontal infection control strategies and a range of technologies effective in eradicating microbes without building up new resistance are described. The mechanism of action of these treatments and examples of their clinical use are also included. The research recommendations of NICE Guidelines on the dermatological manifestations of microbial infection were also reviewed to identify potential applications for PDT. The resistance of some microbes to antibiotics can be halted, or even reversed through the use of supplementary drugs, and so they are likely to persist as a treatment of infection. Conventional PDT will undoubtedly continue to be used for a range of skin conditions given existing healthcare infrastructure and a large evidence base. Daylight PDT may find broader antimicrobial applications than just Acne and Cutaneous Leishmaniasis, and Ambulatory PDT devices could become popular in regions where resources are limited or daylight exposure is not possible or inappropriate. Nanotheranostics were found to be highly relevant, and often include PDT, however, new treatments and novel applications and combinations of existing treatments will be subject to Clinical Trials.

Penetration of Singlet Oxygen into Films with Oxygen Permeability Coefficient Close to that of Skin

Although its antiviral and antibacterial functions help prevent infection, singlet oxygen (¹ O₂ )-which is generated by the action of light on an endogenous photosensitizer-is cytotoxic. In the present study, we investigated the ability of ¹ O₂ -generated by the action of visible light on a photosensitizer-to penetrate skin. We used two polymer films with oxygen permeability coefficients similar to that of skin-i.e. cellulose acetate (CA) and ethyl cellulose (EC). Both films contained 1,3-diphenylisobenzofuran (DPBF), which was used as an ¹ O₂ probe. ¹ O₂ generated externally did not permeate the films by mere contact. Therefore, we conclude that the potential for ¹ O₂ to penetrate the skin is very low, and films that generate ¹ O₂ are safe and useful for preventing infections by contact. We also proved that ¹ O₂ can move between the layers of integrated polymer films when they are joined together.

Painless Photodynamic Therapy Triggers Innate and Adaptive Immune Responses in a Murine Model of UV-induced Squamous Skin Pre-cancer

Painless photodynamic therapy (p-PDT), which involves application of photosensitizer and immediate exposure to light to treat actinic keratosis (AK) in patients, causes negligible pain on the day of treatment but leads to delayed inflammation and effective lesion clearance (Kaw et al., J Am Acad Dermatol 2020). To better understand how p-PDT works, hairless mice with UV-induced AK were treated with p-PDT and monitored for 2 weeks. Lesion clearance after p-PDT was similar to clearance after conventional PDT (c-PDT). However, lesion biopsies showed minimal cell death and less production of reactive oxygen species (ROS) in p-PDT treated than in c-PDT-treated lesions. Interestingly, p-PDT triggered vigorous recruitment of immune cells associated with innate immunity. Neutrophils (Ly6G+) and macrophages (F4/80+) appeared at 4 h and peaked at 24 h after p-PDT. Damage-associated molecular patterns (DAMPs), including calreticulin, HMGB1, and HSP70, were expressed at maximum levels around 24 h post-p-PDT. Total T cells (CD3+) were increased at 24 h, whereas large increases in cytotoxic (CD8+) and regulatory (Foxp3+) T cells were observed at 1 and 2 weeks post-p-PDT. In summary, the ability of p-PDT to eliminate AK lesions, despite very little overt cellular damage, appears to involve stimulation of a local immune response.

Near Infrared (NIR) Light Therapy of Eye Diseases: A Review

Near infrared (NIR) light therapy, or photobiomodulation therapy (PBMT), has gained persistent worldwide attention in recent years as a new novel scientific approach for therapeutic applications in ophthalmology. This ongoing therapeutic adoption of NIR therapy is largely propelled by significant advances in the fields of photobiology and bioenergetics, such as the discovery of photoneuromodulation by cytochrome c oxidase and the elucidation of therapeutic biochemical processes. Upon transcranial delivery, NIR light has been shown to significantly increase cytochrome oxidase and superoxide dismutase activities which suggests its role in inducing metabolic and antioxidant beneficial effects. Furthermore, NIR light may also boost cerebral blood flow and cognitive functions in humans without adverse effects. In this review, we highlight the value of NIR therapy as a novel paradigm for treatment of visual and neurological conditions, and provide scientific evidence to support the use of NIR therapy with emphasis on molecular and cellular mechanisms in eye diseases.

Photodynamic Therapy for Basal Cell Carcinoma: The Clinical Context for Future Research Priorities

Photodynamic therapy (PDT) is an established treatment option for low-risk basal cell carcinoma (BCC). BCC is the most common human cancer and also a convenient cancer in which to study PDT treatment. This review clarifies challenges to researchers evident from the clinical use of PDT in BCC treatment. It outlines the context of PDT and how PDT treatments for BCC have been developed hitherto. The sections examine the development of systemic and subsequently topical photosensitizers, light delivery regimens, and the use of PDT in different patient populations and subtypes of BCC. The outcomes of topical PDT are discussed in comparison with alternative treatments, and topical PDT applications in combination and adjuvant therapy are considered. The intention is to summarize the clinical relevance and expose areas of research need in the BCC context, ultimately to facilitate improvements in PDT treatment.

Light Sources and Dosimetry Techniques for Photodynamic Therapy

Effective treatment delivery in photodynamic therapy (PDT) requires coordination of the light source, the photosensitizer, and the delivery device appropriate to the target tissue. Lasers, light-emitting diodes (LEDs), and lamps are the main types of light sources utilized for PDT applications. The choice of light source depends on the target location, photosensitizer used, and light dose to be delivered. Geometry of minimally accessible areas also plays a role in deciding light applicator type. Typically, optical fiber-based devices are used to deliver the treatment light close to the target. The optical properties of tissue also affect the distribution of the treatment light. Treatment light undergoes scattering and absorption in tissue. Most tissue will scatter light, but highly pigmented areas will absorb light, especially at short wavelengths. This review will summarize the basic physics of light sources, and describe methods for determining the dose delivered to the patient.

Mechanochemical generation of singlet oxygen

Controlled generation of singlet oxygen is very important due to its involvement in scheduled cellular maintenance processes and therapeutic potential. As a consequence, precise manipulation of singlet oxygen release rates under mild conditions, is crucial. In this work, a cross-linked polyacrylate, and a polydimethylsiloxane elastomer incorporating anthracene-endoperoxide modules with chain extensions at the 9,10-positions were synthesized. We now report that on mechanical agitation in cryogenic ball mill, fluorescence emission due to anthracene units in the PMA (polymethacrylate) polymer is enhanced, with a concomitant generation of singlet oxygen as proved by detection with a selective probe. The PDMS (polydimethylsiloxane) elastomer with the anthracene endoperoxide mechanophore, is also similarly sensitive to mechanical force.

A Comparison of The Effects of Clobetasol 0.05% and Photodynamic Therapy Using Aminolevulinic Acid With Red Light in the Treatment of Severe Nail Psoriasis

Introduction: The treatment of nail psoriasis is often difficult and unsatisfactory due to therapy resistance. This study aimed to compare the efficacy of clobetasol 0.05% ointment and photodynamic therapy (PDT) using aminolevulinic acid (ALA) and red light in the treatment of severe nail psoriasis. Methods: This open-trial study included 69 nails of 8 patients with severe nail psoriasis. Thirty-four nails were treated with clobetasol 0.05% ointment and 35 nails were treated with ALA-PDT. ALAPDT treatment was performed every 3 weeks for 5 cycles; the nails were treated with clobetasol under occlusion every day during the study. All the patients were followed up after 24 weeks. The severity of nail involvement was measured by the Nail Psoriasis Severity Index (NAPSI) scores at the baseline and during the treatment. Results: There were no significant differences in the NAPSI scores between the treatment groups in the baseline and weeks 3, 6 and 9 (all P>0.05), although significant differences were found in weeks 12, 15 and 24 (follow-up) (P<0.001). A significant time-effect improvement was found in all the nailmatrix, nail-bed and total NAPSI scores in both treatment groups (all P<0.001). The patients did not report intense pain and discomfort during irradiation. Conclusion: Clobetasol 0.05% ointment seems to be effective in treating nail psoriasis after a treatment period of 15 weeks. However, the efficacy of ALA-PDT at a 24-week follow-up was greater than that of clobetasol.

Photodynamic therapy for keloids and hypertrophic scars: a review

PURPOSE

Keloid is a poorly understood disease that is unique to humans. Hypertrophic scars are similar to keloids and may transform into keloids over time. The standard treatments for these scars are limited by inconsistent efficacy and long treatment/follow-up times. Therefore, a new treatment that is effective for all abnormal scar cases is needed. One option may be photodynamic therapy (PDT). This review assesses the current evidence regarding the safety and efficacy of PDT for keloids and hypertrophic scars.

METHODS

PubMed, Medline and Web of Science were searched from 1900 onwards for the following terms: 'keloid and photodynamic therapy (PDT)'; 'hypertrophic scar and photodynamic therapy (PDT)'; and 'scar and photodynamic therapy (PDT)'. Articles were included if they reported using topical PDT to treat keloids or hypertrophic scars, the patient(s) had one or more keloids and/or hypertrophic scars, and the effect of PDT on these abnormal scars was described.

RESULTS

In total, 538 articles were identified. Thirteen fulfilled all inclusion criteria. Eight were laboratory studies on keloid/hypertrophic scar explants, fibroblasts or tissue-engineered skin models and five were clinical studies/case reports. The clinical results of PDT on keloids and hypertrophic scars are encouraging.

CONCLUSION

PDT appears to play a promising role in keloid and hypertrophic scar therapy but additional clinical studies, particularly randomised clinical trials, are needed.

Therapeutic evaluation of 5-aminolevulinic acid-mediated photodynamic therapy in Bowenoid papulosis

BACKGROUND

Bowenoid papulosis is a polymorphic papular disease that occurs on the external genital area. We investigated the efficacy of 5-aminolevulinic acid-mediated photodynamic therapyin the treatment of Bowenoid papulosis.

METHODS

We investigated 200 Bowenoid papulosis cases from the Department of Dermatology and Venereology of Nanfang Hospital in 2016-2018. Biopsies were performed from Bowenoid papulosis lesions before treatment. The patients were divided into two groups: 100 patients each in the 5-aminolevulinic acid-mediated photodynamic therapy and control groups(radiofrequency cauterisation, microwave ablation, and surgical resection groups). Differences in lesion clearance, recurrence rate, and patient satisfaction after treatment were evaluated.

RESULTS

Photodynamic therapy sessions for multifocal Bowenoid papulosis were more frequent than those for monofocal lesions. All lesions in the 5-aminolevulinic acid-mediated photodynamic therapy group were cleared after photodynamic therapy, with no recurrence at the 1-year follow-up; however, 20 (20.0 %) patients in the control showed recurrence after 1 year. Only 5patients in the photodynamic group were unsatisfied with the treatment cost and 34 patients in the control group experienced short-term pain and scarring. The recurrence rate was significantly lower (P < 0.05) and patient satisfaction was higher (P < 0.05) in the 5-aminolevulinic acid-mediated photodynamic therapy group than those in the control. The recurrence rate was significantly lower (P < 0.05) and patient satisfaction was higher (P < 0.05) in the 5-aminolevulinic acid-mediated photodynamic therapy group than those in the surgical resection group. The recurrence rate of lesions was significantly lower in the surgical resection group than that in the rest of the control group (P < 0.05). There was no difference in recurrence rate and patient satisfaction between the radiofrequency cauterisation and microwave ablation groups.

CONCLUSIONS

5-aminolevulinic acid-mediated photodynamic therapy for Bowenoid papulosis results in a low recurrence rate and high satisfaction.

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.

Exploiting knowledge on pharmacodynamics-pharmacokinetics for accelerated anti-leishmanial drug discovery/development

Introduction: Being on the top list of neglected tropical diseases, leishmaniasis has been marked for elimination by 2020. In the light of small armamentarium of drugs and their associated drawbacks, the understanding of pharmacodynamics and/or pharmacokinetics becomes a priority to achieve and sustain disease elimination. Areas covered: The authors have looked into pharmacological aspects of existing and emerging drugs for treatment of leishmaniasis. An in-depth understanding of pharmacodynamics and pharmacokinetics (PKPD) provides a rationale for drug designing and optimizing the treatment strategies. It forms a key to prevent drug resistance and avoid drug-associated adverse effects. The authors have compiled the researches on the PKPD of different anti-leishmanial formulations that have the potential for improved and/or effective disease intervention. Expert opinion: Understanding the pharmacological aspects of drugs forms the basis for the clinical application of novel drugs. Tailoring drug dosage and individualized treatment can avoid the adverse events and bridge gap between the in vitro models and their clinical application. An integrated approach, with pragmatic use of technological advances can improve phenotypic screening and physiochemical properties of novel drugs. Concomitantly, this can serve to improve clinical efficacies, reduce the incidence of relapse and accelerate the drug discovery/development process for leishmaniasis elimination.

Evaluating the Noninferiority of a New Photodynamic Therapy (Flexitheralight) Compared With Conventional Treatment for Actinic Keratosis: Protocol for a Phase 2 Study

Background

Actinic keratosis (AK) is characterized by preinvasive, cancerous lesions on sun-exposed skin that negatively affect patient quality of life and may progress to invasive squamous cell carcinoma (SCC). If untreated, AK may either regress or progress to SCC, with significant morbidity and possible lethal outcomes. The most commonly used treatments for AK are cryotherapy, topical chemotherapy and, more recently, photodynamic therapy (PDT). This clinical study is part of a project that aims to create specific light-emitting fabrics (LEFs) that strongly improve the efficiency and reliability of PDT as a treatment for AK.

Objective

This study aims to compare the efficacy and tolerability of a new PDT protocol involving the Flexitheralight device (N-PDT) with the classical protocol involving the Aktilite CL 128 device (C-PDT; Galderma Laboratories) for the treatment of AK. All participants receive both protocols. The primary objective of this study is to compare the lesion response rate after 3 months of N-PDT with C-PDT. Secondary objectives are evaluations of pain and local tolerance during treatment, clinical evolution of the subject's skin, and evaluations of patient quality of life and satisfaction.

Methods

The study is a split-face, intraindividual comparison of two PDT protocols. The total number of patients recruited was 42. Patients were exposed to a continuous red light with the Aktilite CL 128 device on one side of the face and to fractionated red illumination with the new device, Flexitheralight, on the other side of the face. Males or females over the age of 18 years with a clinical diagnosis of at least 10 previously untreated, nonpigmented, nonhyperkeratotic grade I and II AK lesions of the forehead and/or scalp were included and were recruited from the Department of Dermatology of the Centre Hospitalier Universitaire de Lille. The patients came to the investigational center for one treatment session (day 1), and they were followed up after 7 days, 3 months and 6 months. A second treatment session was performed on day 111 in cases in which an incomplete response was observed at the 3-month follow-up. Data will be analyzed using SAS software version 9.4 (SAS Institute Inc). Continuous variables will be reported as means and standard deviations, and categorical variables will be reported as frequencies and percentages. The Shapiro-Wilk test will be used to assess the normality of the distribution.

Results

The clinical investigation was performed by July 2018. Data analysis was performed at the end of 2018, and results are expected to be published in early 2019.

Conclusions

This phase II clinical trial aims to evaluate the noninferior efficacy and superior tolerability of N-PDT compared to that of C-PDT. If N-PDT is both efficacious and tolerable, N-PDT could become the treatment of choice for AK due to its ease of implementation in hospitals.

Trial Registration

ClinicalTrials.gov NCT03076918; https://clinicaltrials.gov/ct2/show/NCT03076918 (archived by WebCite at http://www.webcitation.org/771KA0SSK)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11530

A New Light-Emitting, Fabric-Based Device for Photodynamic Therapy of Actinic Keratosis: Protocol for a Randomized, Controlled, Multicenter, Intra-Individual, Phase II Noninferiority Study (the Phosistos Study)

BACKGROUND

Actinic keratosis (AK) is a common early in situ skin carcinoma caused by long-term sun exposure and usually develops on sun-exposed skin areas. Left untreated, AK may progress to squamous cell carcinoma. To prevent such risk, most clinicians routinely treat AK. Therapy options for AK include cryotherapy, topical treatments, curettage, excision surgery, and photodynamic therapy (PDT).

OBJECTIVE

The aim of this study is to assess the noninferiority, in terms of efficacy at 3 months, of a PDT protocol involving a new light-emitting device (PDT using the Phosistos protocol [P-PDT]) compared with the conventional protocol (PDT using the conventional protocol [C-PDT]) in the treatment of AK.

METHODS

In this randomized, controlled, multicenter, intra-individual, phase II noninferiority clinical study, subjects with AK of the forehead and scalp are treated with P-PDT on one area and with C-PDT on the contralateral area. In both areas, lesions are prepared and methyl aminolevulinate (MAL) is applied. Thirty minutes after MAL application, the P-PDT area is exposed to red light at low irradiance (1.3 mW/cm²) for 2.5 hours so that a light dose of 12 J/cm² is achieved. In the control area (C-PDT area), a 37 J/cm² red light irradiation is performed 3 hours after MAL application. Recurrent AK at 3 months is retreated. The primary end point is the lesion complete response rate at 3 months. Secondary end points include pain scores at 1 day, local tolerance at 7 days, lesion complete response rate at 6 months, cosmetic outcome at 3 and 6 months, and patient-reported quality of life and satisfaction throughout the study. A total of 45 patients needs to be recruited.

RESULTS

Clinical investigations are complete: 46 patients were treated with P-PDT on one area (n=285 AK) and with C-PDT on the contralateral area (n=285 AK). Data analysis is ongoing, and statistical results will be available in the first half of 2019.

CONCLUSIONS

In case of noninferiority in efficacy and superiority in tolerability of P-PDT compared with C-PDT, P-PDT could become the treatment of choice for AK.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03076892; https://clinicaltrials.gov/ct2/show/NCT03076892 (Archived by WebCite at http://www.webcitation.org/779qqVKek).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12990.

Nanoparticles in dermatologic surgery

Nanotechnology is an emerging branch of science that involves the engineering of functional systems on the nanoscale (1-100 nm). Nanotechnology has been used in biomedical and therapeutic agents with the aim of providing novel treatment solutions where small molecule size may be beneficial for modulation of biologic function. Recent investigation in nanomedicine has become increasingly important to cutaneous pathophysiology, such as functional designs directed towards skin cancers and wound healing. This review outlines the application of nanoparticles relevant to dermatologic surgery.

Giant Basal Cell Carcinoma – a Case Report

Basal cell carcinoma is the most common form of cutaneous cancer. In majority of cases it is locally invasive with slow growth, ranging in size from a couple of milimeters to a couple of centimeters and located primarily on sun-exposed regions. Giant basal cell carcinoma, defined as a tumor that is larger than 5 cm in diameter, is a very rare type of cutaneous malignancy accounting for 0.5-1% of all basal cell carcinomas. We present a case of a 74-year-old man with a 17 x 14 cm giant basal cell carcinoma in the right supraclavicular region. Detailed history revealed that the lesion had started as a papule 15 years before presentation. Despite its growth, the lesion was neglected until admission. Histological examination of skin lesion confirmed superficial and focally infiltrative types of basal cell carcinoma. Electron radiotherapy was administered with 54 Gy total dose delivered in 20 daily fractions which resulted in healing of lesions and adequate response. Thus, definitive radiotherapy can be just as effective as excision when the criteria are met.

Current Basal and Squamous Cell Skin Cancer Management

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Characterize basal and squamous cell carcinomas as low or high risk based on size, location, histology, and clinical features. 2. Understand appropriate surgical margins in low- and high-risk lesions, and other management options, including Mohs micrographic surgery, electrodissection and curettage, topical agents, cryotherapy, photodynamic therapy, and radiation therapy. 3. Discuss adjuvant therapies for locally advanced and metastatic disease, including radiation therapy, chemotherapy, and targeted therapies such as hedgehog pathway inhibitors. 4. Educate patients on preventive measures such as skin examinations, sun protection, oral retinoids, and oral nicotinamide (vitamin B3). 5. Devise a reconstructive plan once clear oncologic margins are obtained.

SUMMARY

With the growing incidence of basal and squamous cell carcinoma, there is an increasing demand for appropriate oncologic management and aesthetic reconstruction. The goal of this CME article is to provide a foundation of knowledge to accurately diagnose, stage, and treat nonmelanoma skin cancers. In addition, it provides the practicing plastic surgeon alternate tools for managing these skin lesions, including topical agents, destructive therapies, and radiation therapy. Lastly, reconstructive plans for selected soft-tissue defects are discussed.

Drug and chemical induced photosensitivity from a clinical perspective

Drug photosensitivity is a relatively common occurrence and a range of mechanisms may be involved. Some of these mechanisms will be discussed, including the most common, that of drug phototoxicity. Different types of photosensitivity are addressed with respect to clinical presentation, mechanisms and additionally the contribution to our understanding through clinically directed investigations and regulatory requirements. Repeated controlled therapeutic use of drug phototoxicity, with psoralen-UVA (PUVA) photochemotherapy and photodynamic therapy (PDT) will also be discussed. Finally, the potential for drug-induced photocarcinogenesis will also be covered.

Improving in vitro photodynamic therapy through the development of a novel iron chelating aminolaevulinic acid prodrug

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A new combined iron chelating prodrug (AP2-18) has been synthesised and evaluated.

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AP2-18 significantly increased protoporphyrin IX accumulation in human skin cells.

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This enhancement translated into greater cytotoxicity on irradiation.

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Clinical AP2-18 application may improve future dermatological photodynamic therapy.

Background

Photodynamic therapy (PDT) is a light activated drug therapy that can be used to treat a number of cancers and precancers. It is particularly useful in its topical form in dermatology but improvement of efficacy is required to widen its application.

Methods

An ester between aminolaevulinic acid (ALA) and CP94 was synthesised (AP2-18) and experimentally evaluated to determine whether protoporphyrin IX (PpIX)-induced PDT effectiveness could be improved. A biological evaluation of AP2-18 was conducted in cultured human primary cells with both PpIX fluorescence and cell viability (as determined via the neutral red assay) being assessed in comparison to the PpIX prodrugs normally utilised in clinical practice (aminolaevulinic acid (ALA) or its methyl ester (MAL)) either administered alone or with the comparator iron chelator, CP94.

Results

No significant dark toxicity was observed in human lung fibroblasts but AP2-18 significantly increased PpIX accumulation above and beyond that achieved with ALA or MAL administration +/- CP94 in both human dermal fibroblasts and epithelial squamous carcinoma cells. On light exposure, the combined hydroxypyridinone iron chelating ALA prodrug AP2-18 generated significantly greater cytotoxicity than any of the other treatment parameters investigated when the lowest concentration (250 μM) was employed.

Conclusions

Newly synthesised AP2-18 is therefore concluded to be an efficacious prodrug for PpIX-induced PDT in these dermatologically relevant human cells, achieving enhanced effects at lower concentrations than currently possible with existing pharmaceuticals.

The good, the bad, and the ugly - controlling singlet oxygen through design of photosensitizers and delivery systems for photodynamic therapy

Singlet oxygen, although integral to photodynamic therapy, is notoriously uncontrollable, suffers from poor selectivity and has fast decomposition rates in biological media. Across the scientific community, there is a conscious effort to refine singlet oxygen interactions and initiate selective and controlled release to produce a consistent and reproducible therapeutic effect in target tissue. This perspective aims to provide an insight into the contemporary design principles behind photosensitizers and drug delivery systems that depend on a singlet oxygen response or controlled release. The discussion will be accompanied by in vitro and in vivo examples, in an attempt to highlight advancements in the field and future prospects for the more widespread application of photodynamic therapy.

Daylight Photodynamic Therapy for Actinic Keratoses

Topical photodynamic therapy (PDT) using daylight is effective in the treatment of actinic keratoses (AKs), offering the potential for treatment of large fields such as full face and balding scalp, but with minimal therapy-associated pain. Comparison with conventional PDT indicates similar efficacy for thin and moderate-thickness AKs, but with significantly less discomfort/pain, driving a patient preference for daylight-mediated PDT (DL-PDT) compared with conventional PDT using high-intensity office/hospital-based light sources. Treatment protocol involves the application of a photosensitizing agent without occlusion and subsequent exposure to ambient daylight within 30 min, with patients exposed to daylight for 1.5-2.0 h. Pivotal randomized controlled trials in Europe and Australia have confirmed the efficacy of methyl aminolevulinic acid (MAL) DL-PDT in comparison with conventional MAL-PDT for mild and moderate-thickness lesions on the face and scalp. Initial clearance rates of 70-89% are reported. DL-PDT using a nanoemulsion aminolevulinic acid (ALA) has recently been shown to be at least as effective as MAL DL-PDT in treating mild and moderate-thickness AKs. DL-PDT may offer a better-tolerated method for treating patients with extensive AK disease. There is emerging literature on the potential for field PDT to reduce the number of new AKs developing, potentially preventing/slowing skin cancer development. Conventional PDT remains established as a therapy for Bowen's disease (squamous cell carcinoma in situ), superficial and certain thin basal cell carcinomas (BCCs), and AKs. The evidence for the use of DL-PDT beyond AK is limited, although has been reported in actinic cheilitis, superficial BCC, and acne and cutaneous leishmaniasis. There is emerging interest in combination therapy for AK, using one or more field therapies such as DL-PDT as an option to complement with localized treatment for residual lesions. We review current recommendations and consider the appropriate place for DL-PDT in our treatment armamentarium.