Photodiagnosis and Photodynamic Therapy (2006) 3, 112—115
EDITORIAL
How to optimise topical photodynamic therapy in dermatology C.A. Morton MD, FRCP ∗ Forth Valley Dermatology Centre, Stirling Royal Infirmary, Stirling FK8 2AU, UK
In this edition of PDPDT, three papers describe current practice in the delivery of topical photodynamic therapy (PDT) in non-melanoma skin cancer (NMSC) [1—3]. PDT has moved from being a research therapy with limited availability to a standard modality for NMSC in many dermatology departments. The evidence base for the use of PDT was assessed by the British Photodermatology Group in 2000 with a recent review of its use in NMSC by Szeimies and co-workers [4,5]. The FDA approved the use of topical PDT in actinic keratosis (AK) in 1999 using the Levulan formulation of 5-aminolaevulinic acid (5-ALA) (DUSA Pharmaceuticals, Wilmington, MA, USA), but there remain no other approvals of this formulation to date. Subsequent approval of the methyl ester of 5-ALA (Galderma, Paris, France and PhotoCure AS, Oslo, Norway) in most European countries, Australia and across Scandinavia, for actinic keratoses, superficial and nodular basal cell carcinoma (BCC), and recently also for Bowen’s disease (squamous cell carcinoma in situ), has permitted the much wider use of topical PDT. The current focus of PDPDT, on how we should best deliver PDT, is therefore timely as many dermatologists introduce PDT into their practice. Although PDT is a relatively simple therapy to perform, choice of photosensitizers, light sources,
∗ Corresponding
author. E-mail address: [email protected].
1572-1000/$ — see front matter © 2006 Published by Elsevier B.V. doi:10.1016/j.pdpdt.2006.05.001
dosage and preparation protocols, as well as a variety of approaches to minimise side effects, combine now with several skin cancer applications, to risk sub-optimal therapy due to failure to use protocols most appropriate for the cream and light used in that given indication. Recently we have seen the increase in off-label use of PDT in certain non-cancer dermatological indications, where individual treatments may be less intense, but where multiple visits are typically required. This edition of PDPDT also carries an updated assessment of the potential of topical PDT in non-cancer indications [6]. Ibbotson [1] reports on specific issues concerning the delivery of topical PDT in superficial BCC, arguably one of the strongest indications for PDT, where the alternative of extensive surgery may now be avoided. The Dundee team recommend that BCC with a histological thickness not exceeding 2 mm and of superficial subtype are most appropriate for the ALA-PDT described. Multiple methods of lesion preparation are described in the literature on topical PDT [4] and the team advise the application of vaseline to the tumour for 3 days prior treatment to loosen surface crust. There has been no specific study of the importance of lesion preparation but as we presume overlying crust or debris may limit efficacy, some form of preparation is advisable. In addition, some form of gentle debulking curettage prior to cream application may help to extend the range of effective PDT by reducing lesion thickness to 2 mm or less.
How to optimise topical photodynamic therapy in dermatology Following lesion preparation and photosensitizer application, an occlusive dressing is usually applied which is useful in helping to spread the applied agent before a further light-opaque dressing is applied. Siero´ n et al. [2] have also described how they perform ALA-PDT in their department and point out that when applying photosensitiser it is advisable to ensure that a margin of skin around clinically obvious lesions is included. I would suggest a margin of at least 5 mm in order to hopefully ensure that the full extent of the individual lesions are treated. This group also applied a formulation of 20% ALA for 10 h, a duration that is now unusual, with patients hospitilized for 2 days. High efficacy is recorded for sBCC, AK and Bowen’s disease, but 90% of patients received local anaesthesia and 30% additional oral analgesics, suggesting greater non-specific photosensitivity leading perhaps to a greater level of pain. For ALA-PDT an application time of 6 h photosensitiser appears optimal for BCC and 4 h for AK and Bowen’s disease (short duration, e.g. 1 h application times are employed in the US, along with blue light, which is little used in Europe). MAL PDT requires only a three-hour period of application to achieve the results described above, typically without anaesthesia required. What light sources should we use? Illumination of lesions was initially provided by laser sources, but several alternative non-laser sources can be used in topical PDT [4]. New red LED light sources that are relatively cheap, convenient and much easier to use, are fast becoming the most popular devices used for topical PDT. Indeed, a recent comparison of a broadband halogen source with such an LED system showed no difference in in vitro nor in vivo effect [7]. Using ALA-PDT, treatment typically has been repeated after 6—8 weeks. The current licence for topical MAL-PDT in Bowen’s disease and basal cell carcinoma is to undertake two treatments 1 week apart. A recent compassion study of two protocols for actinic keratoses has shown that a protocol repeating MAL-PDT using a narrowband red LED device was as effective when a second treatment was administered after 3 months, if required, as the conventional protocol for AK of routine double treatments 7 days apart, thus saving on unnecessary treatments [8]. For AK in many countries now, the current licence for MAL-PDT has changed to reflect this study. Can all NMSC lesions be treated by topical PDT? High clearance rates for superficial lesions such as AK and Bowen’s disease of around 90% are typically reported with depth of light penetration shown to be important—–green light inferior to red for Bowen’s disease, although red and green light appear equivalent for thin actinic keratoses [4].
113
Broadband light sources that include red and more recently narrowband red light devices are used in treating BCC to maximize depth of light penetration in these thicker lesions. Previous observations with ALA-PDT, suggested a reduction in efficacy for lesions more than 2 mm thick, as described here by Ibbotson [1], with generally lower clearance rates for nodular than superficial BCC [4,9]. MALPDT has been shown to be as effective as surgery (excisions with at least a 5 mm margin) in clearing nodular BCCs in a multicentre randomized study of 105 lesions (CR at 3 months: PDT 91%, surgery 98%) [10]. After 36 months of follow-up, 10% of the PDT treated lesions had recurred against 2% in the surgery group [11]. Another study of MAL-PDT for primary nodular BCC cleared 89% of 168 lesions with 12 thick and 6 thin lesions (14% and 7%, respectively) recurring over 35 months [12]. The former study saw lesions prepared by crust removal with a curette or scalpel, whilst in the latter study, a gentle de-bulking curettage was performed. Clinical clearance at 3 months of 97% of 102 superficial BCC treated by MAL-PDT compared favourably with 95% of 98 lesions that received cryotherapy in a further randomized multi-centre study [13]. During 36 months of follow-up, 22% of PDT treated lesions recurred (cryotherapy: 19%) although treatment may have been sub-optimal with the majority of lesions receiving only one initial treatment, rather than the currently recommended protocol of two treatments, 1 week apart. Evidence therefore currently points to the potential of PDT in treating superficial as well as nodular BCC, although preparation style as well as photosensitizer choice probably influences efficacy via influencing the thickness of the lesion being treated. Limited experience of topical ALA-PDT in invasive squamous cell carcinoma suggests that it should currently not be recommended due to potentially high recurrence rates, given the potential of metastatic disease [4]. Loncaster and Allan [3] report in this edition of PDPDT that PDT is a potentially useful indication for Gorlin syndrome where there is a genetic predisposition to the development of multiple basal cell carcinomas throughout life. The authors describe how to optimise the use of ultrasound in order to try to gauge the thickness of basal cell carcinomas. They propose that in view of its non-invasive nature, efficacy and good cosmesis, PDT is a viable option in this patient group, where radiotherapy is contra-indicated and multiple surgical procedures are typically required. The use of topical PDT is used predominantly, except for thick lesions >3 mm when the intravenous photosensitiser in the form of porfirmer sodium (Photofrin, Axcan Pharma Inc., Quebec, Canada) can be used, at a concentration
114 of 1 mg/kg. The patient receives illumination 48 h after injection but prolonged photosensitivity is an issue with the patient given strict instructions on avoiding exposure to bright ambient light for the following 4 weeks. The practical management of patients with Gorlin syndrome, although a rare group, has been significantly improved by PDT. This is an area requiring further study, preferably multicentre so a larger body of evidence can be accumulated on the potential of PDT in this patient group. How can we maximize tolerance of topical PDT? Pain is often described in association with topical PDT. An audit of patients in my own department indicated that around 20% of patients with NMSC requested local anaesthesia. However, it was completed before the introduction in our unit of an air cooling device that has further significantly reduced discomfort, an observation also noted by others [14]. In my experience, having a member of the nursing team to coordinate and deliver topical PDT and be physically present during treatment, not only helps optimize therapy, but offers patient reassurance, reducing the need for additional methods of pain relief. Several methods of pain relief are described [1,4], including simple fans, topical anaesthetic agents, and oral analgesia/injection anaesthesia. There may be a reduction in pain associated with the use of MAL rather than ALA-PDT, but a study that directly compared pain with these agents utilised normal skin and direct extrapolation to the clinical situation cannot be assumed [15]. Mitra and Stables, describe the status of topical PDT for many non-cancer cutaneous indications, some which have been the focus of prospective studies (viral warts, acne, psoriasis, alopecia areata, photo-ageing) and others that have featured in case reports and series (hidradenitis suppurativa, lichen sclerosus, scleroderma, Darier’s disease, Hailey—Hailey disease, hirsutism, molluscum contagiosum, naevus sebaceous, penile lichen planus, sarcoidosis, leishmaniasis, interdigital mycoses, disseminated superficial actinic porokeratosis) [3]. Accumulating evidence suggests the potential of PDT in recalcitrant warts although careful paring and prior use of keratolytics appears important in securing success, with pain management also a greater challenge in this, typically young, patient group. It remains uncertain that we will see topical PDT emerge as a useful therapy for psoriasis in view of the variable uptake of topical photosensitiser between plaques within a patient and certainly between patients, causing difficulty in dosimetry. The responsiveness of acne to phototherapy, which is essentially an endogenous PDT, utilising the coproporphyrin and protoporphyrin IX produced by P. acnes, suggest that enhancing this
Editorial reaction with an exogenous photosensitiser should be expected to achieve further clinical improvement. A recent study using MAL PDT describes a 68% reduction in inflammatory lesions 12 weeks (compared with no change in the control group) after two treatments, 2 weeks apart [16]. Pain, erythema and pustular eruptions post-treatment confirms the need to undertake further studies to refine treatment protocol as well as identify the most appropriate treatment group for a therapy that will likely cause greater short term adverse events compared with most current acne therapies. The potential of topical PDT in treating photoageing is provoking considerable interest across the world and may stimulate more widespread use of topical PDT [17,18]. For practitioners new to PDT, it is important to appreciate that while treatment protocols for its use in NMSC are now well established, those for use in non-cancer indications remain to be optimized. Topical PDT can be a highly effective therapy and once protocols have been mastered, is a relatively easy treatment to perform. Regular audit of a departments’ PDT practice is encouraged to highlight issues that may be contributing to lower efficacy or greater adverse events than reported efficacy, tolerance and safety rates of this therapy.
References [1] Ibbotson SH. How we treat a superficial basal cell carcinoma with topical photodynamic therapy in Dundee. Photodiag Photodyn Therapy 2006;3:128—31. [2] Siero´ n A, et al. Photodynamic diagnosis (PDD) and photodynamic therapy in dermatology. Photodiag Photodyn Therapy 2006;3:132—3. [3] Loncaster JA, Allan E. How to do it: photodynamic therapy in the management of a patient with Gorlin Syndrome. Photodiag Photodyn Therapy 2006;3:134—7. [4] Morton CA, Brown SB, Collin S, et al. Guidelines for photodynamic therapy: report of a workshop of the British Photodermatology Group. Br J Dermatol 2002;146(4): 552—67. [5] Szeimies RM, Morton CA, Sidoroff A, Braathen LR. Photodynamic therapy for non-melanoma skin cancer. Acta Derm Verereol 2005;85:483—90. [6] Mitra A, Stables GI. Topical photodynamic therapy for non-melanoma skin cancer. Photodiag Photodyn Therapy 2006;3:116—27. [7] Babilas P, Kohl E, Maisch T, et al. In vitro and in vivo comparison of two different light sources for topical photodynamic therapy. Br J Dermatol 2006;154:712—8. [8] Tarstedt M, Rosdahl I, Berne B, et al. A randomized multicenter study to compare two treatment regimens of topical methyl aminolevulinate (Metvix)-PDT in actinic keratosis of the face and scalp. Acta Dermato-Venereologica 2005;85:424—8. [9] Morton CA, MacKie RM, Whitehurst C, et al. Photodynamic therapy for basal cell carcinoma: effect of tumor thickness
How to optimise topical photodynamic therapy in dermatology
[10]
[11]
[12]
[13]
and duration of photosensitizer application on response. Arch Dermatol 1998;134:248—9. Rhodes LE, de Rie M, Enstrom Y, et al. Photodynamic therapy using topical methyl aminolaevulinate vs surgery for nodular basal cell carcinoma. Results of a multicentre randomised prospective trial. Arch Dermatol 2004;140:17—23. Rhodes LE, de Rie M, Enstr¨ om Y, et al. A randomized European comparison of excision surgery and MAL-PDT in nodular basal cell carcinoma: results from a 36-month follow-up. J Eur Acad Dermatol Venereol 2005;19(S2). P08.69. Soler AM, Warloe T, Berner A, et al. A follow-up study of recurrence and cosmesis in completely responding superficial and nodular basal cell carcinomas treated with methyl-5-aminlevulinate-based photodynamic therapy alone and with prior curettage. Br J Dermatol 2001;145: 467—71. Basset-Seguin N, Ibbotson S, Emtestam L, et al. MAL-PDT versus cryotherapy in primary sBCC: results of a 36 month follow-up. Poster presented to the 13th Congress of the
[14]
[15]
[16]
[17]
[18]
115
European Academy of Dermatology and Venereology, Florence, November, 2004. Pagliaro J, Elliott T, Bulsara M, King C, Vinciullo C. Cold air analgesia in photodynamic therapy of basal cell carcinomas and Bowen‘s disease: an effective addition to treatment: a pilot study. Dermatol Surg 2004;30:63—6. Wiegell SR, Stender IM, Na R, Wulf HC. Pain associated with photodynamic therapy using 5-aminolevulinic acid or 5-aminolevulinic acid methylester on tape stripped normal skin. Arch Dermatol 2003;139(9):1173—7. Wiegell SR, Wulf HC. Photodynamic therapy of acne vulgaris using methyl aminolaevulinate: a blinded, randomized, controlled trial. Br J Dermatol 2006;154:969—76. Gold MH. The evolving role aminolaevulinic acid hydrochloride with photodynamic therapy in photoageing. Cutis 2002;69:8—13. Goldman MP, Atkin D, Kincad S. PDT/ALA in the treatment of actinic damage: real world experience. J Lasers Surg Med 2002;14(Suppl.):24.
EDITORIAL
How to optimise topical photodynamic therapy in dermatology C.A. Morton MD, FRCP ∗ Forth Valley Dermatology Centre, Stirling Royal Infirmary, Stirling FK8 2AU, UK
In this edition of PDPDT, three papers describe current practice in the delivery of topical photodynamic therapy (PDT) in non-melanoma skin cancer (NMSC) [1—3]. PDT has moved from being a research therapy with limited availability to a standard modality for NMSC in many dermatology departments. The evidence base for the use of PDT was assessed by the British Photodermatology Group in 2000 with a recent review of its use in NMSC by Szeimies and co-workers [4,5]. The FDA approved the use of topical PDT in actinic keratosis (AK) in 1999 using the Levulan formulation of 5-aminolaevulinic acid (5-ALA) (DUSA Pharmaceuticals, Wilmington, MA, USA), but there remain no other approvals of this formulation to date. Subsequent approval of the methyl ester of 5-ALA (Galderma, Paris, France and PhotoCure AS, Oslo, Norway) in most European countries, Australia and across Scandinavia, for actinic keratoses, superficial and nodular basal cell carcinoma (BCC), and recently also for Bowen’s disease (squamous cell carcinoma in situ), has permitted the much wider use of topical PDT. The current focus of PDPDT, on how we should best deliver PDT, is therefore timely as many dermatologists introduce PDT into their practice. Although PDT is a relatively simple therapy to perform, choice of photosensitizers, light sources,
∗ Corresponding
author. E-mail address: [email protected].
1572-1000/$ — see front matter © 2006 Published by Elsevier B.V. doi:10.1016/j.pdpdt.2006.05.001
dosage and preparation protocols, as well as a variety of approaches to minimise side effects, combine now with several skin cancer applications, to risk sub-optimal therapy due to failure to use protocols most appropriate for the cream and light used in that given indication. Recently we have seen the increase in off-label use of PDT in certain non-cancer dermatological indications, where individual treatments may be less intense, but where multiple visits are typically required. This edition of PDPDT also carries an updated assessment of the potential of topical PDT in non-cancer indications [6]. Ibbotson [1] reports on specific issues concerning the delivery of topical PDT in superficial BCC, arguably one of the strongest indications for PDT, where the alternative of extensive surgery may now be avoided. The Dundee team recommend that BCC with a histological thickness not exceeding 2 mm and of superficial subtype are most appropriate for the ALA-PDT described. Multiple methods of lesion preparation are described in the literature on topical PDT [4] and the team advise the application of vaseline to the tumour for 3 days prior treatment to loosen surface crust. There has been no specific study of the importance of lesion preparation but as we presume overlying crust or debris may limit efficacy, some form of preparation is advisable. In addition, some form of gentle debulking curettage prior to cream application may help to extend the range of effective PDT by reducing lesion thickness to 2 mm or less.
How to optimise topical photodynamic therapy in dermatology Following lesion preparation and photosensitizer application, an occlusive dressing is usually applied which is useful in helping to spread the applied agent before a further light-opaque dressing is applied. Siero´ n et al. [2] have also described how they perform ALA-PDT in their department and point out that when applying photosensitiser it is advisable to ensure that a margin of skin around clinically obvious lesions is included. I would suggest a margin of at least 5 mm in order to hopefully ensure that the full extent of the individual lesions are treated. This group also applied a formulation of 20% ALA for 10 h, a duration that is now unusual, with patients hospitilized for 2 days. High efficacy is recorded for sBCC, AK and Bowen’s disease, but 90% of patients received local anaesthesia and 30% additional oral analgesics, suggesting greater non-specific photosensitivity leading perhaps to a greater level of pain. For ALA-PDT an application time of 6 h photosensitiser appears optimal for BCC and 4 h for AK and Bowen’s disease (short duration, e.g. 1 h application times are employed in the US, along with blue light, which is little used in Europe). MAL PDT requires only a three-hour period of application to achieve the results described above, typically without anaesthesia required. What light sources should we use? Illumination of lesions was initially provided by laser sources, but several alternative non-laser sources can be used in topical PDT [4]. New red LED light sources that are relatively cheap, convenient and much easier to use, are fast becoming the most popular devices used for topical PDT. Indeed, a recent comparison of a broadband halogen source with such an LED system showed no difference in in vitro nor in vivo effect [7]. Using ALA-PDT, treatment typically has been repeated after 6—8 weeks. The current licence for topical MAL-PDT in Bowen’s disease and basal cell carcinoma is to undertake two treatments 1 week apart. A recent compassion study of two protocols for actinic keratoses has shown that a protocol repeating MAL-PDT using a narrowband red LED device was as effective when a second treatment was administered after 3 months, if required, as the conventional protocol for AK of routine double treatments 7 days apart, thus saving on unnecessary treatments [8]. For AK in many countries now, the current licence for MAL-PDT has changed to reflect this study. Can all NMSC lesions be treated by topical PDT? High clearance rates for superficial lesions such as AK and Bowen’s disease of around 90% are typically reported with depth of light penetration shown to be important—–green light inferior to red for Bowen’s disease, although red and green light appear equivalent for thin actinic keratoses [4].
113
Broadband light sources that include red and more recently narrowband red light devices are used in treating BCC to maximize depth of light penetration in these thicker lesions. Previous observations with ALA-PDT, suggested a reduction in efficacy for lesions more than 2 mm thick, as described here by Ibbotson [1], with generally lower clearance rates for nodular than superficial BCC [4,9]. MALPDT has been shown to be as effective as surgery (excisions with at least a 5 mm margin) in clearing nodular BCCs in a multicentre randomized study of 105 lesions (CR at 3 months: PDT 91%, surgery 98%) [10]. After 36 months of follow-up, 10% of the PDT treated lesions had recurred against 2% in the surgery group [11]. Another study of MAL-PDT for primary nodular BCC cleared 89% of 168 lesions with 12 thick and 6 thin lesions (14% and 7%, respectively) recurring over 35 months [12]. The former study saw lesions prepared by crust removal with a curette or scalpel, whilst in the latter study, a gentle de-bulking curettage was performed. Clinical clearance at 3 months of 97% of 102 superficial BCC treated by MAL-PDT compared favourably with 95% of 98 lesions that received cryotherapy in a further randomized multi-centre study [13]. During 36 months of follow-up, 22% of PDT treated lesions recurred (cryotherapy: 19%) although treatment may have been sub-optimal with the majority of lesions receiving only one initial treatment, rather than the currently recommended protocol of two treatments, 1 week apart. Evidence therefore currently points to the potential of PDT in treating superficial as well as nodular BCC, although preparation style as well as photosensitizer choice probably influences efficacy via influencing the thickness of the lesion being treated. Limited experience of topical ALA-PDT in invasive squamous cell carcinoma suggests that it should currently not be recommended due to potentially high recurrence rates, given the potential of metastatic disease [4]. Loncaster and Allan [3] report in this edition of PDPDT that PDT is a potentially useful indication for Gorlin syndrome where there is a genetic predisposition to the development of multiple basal cell carcinomas throughout life. The authors describe how to optimise the use of ultrasound in order to try to gauge the thickness of basal cell carcinomas. They propose that in view of its non-invasive nature, efficacy and good cosmesis, PDT is a viable option in this patient group, where radiotherapy is contra-indicated and multiple surgical procedures are typically required. The use of topical PDT is used predominantly, except for thick lesions >3 mm when the intravenous photosensitiser in the form of porfirmer sodium (Photofrin, Axcan Pharma Inc., Quebec, Canada) can be used, at a concentration
114 of 1 mg/kg. The patient receives illumination 48 h after injection but prolonged photosensitivity is an issue with the patient given strict instructions on avoiding exposure to bright ambient light for the following 4 weeks. The practical management of patients with Gorlin syndrome, although a rare group, has been significantly improved by PDT. This is an area requiring further study, preferably multicentre so a larger body of evidence can be accumulated on the potential of PDT in this patient group. How can we maximize tolerance of topical PDT? Pain is often described in association with topical PDT. An audit of patients in my own department indicated that around 20% of patients with NMSC requested local anaesthesia. However, it was completed before the introduction in our unit of an air cooling device that has further significantly reduced discomfort, an observation also noted by others [14]. In my experience, having a member of the nursing team to coordinate and deliver topical PDT and be physically present during treatment, not only helps optimize therapy, but offers patient reassurance, reducing the need for additional methods of pain relief. Several methods of pain relief are described [1,4], including simple fans, topical anaesthetic agents, and oral analgesia/injection anaesthesia. There may be a reduction in pain associated with the use of MAL rather than ALA-PDT, but a study that directly compared pain with these agents utilised normal skin and direct extrapolation to the clinical situation cannot be assumed [15]. Mitra and Stables, describe the status of topical PDT for many non-cancer cutaneous indications, some which have been the focus of prospective studies (viral warts, acne, psoriasis, alopecia areata, photo-ageing) and others that have featured in case reports and series (hidradenitis suppurativa, lichen sclerosus, scleroderma, Darier’s disease, Hailey—Hailey disease, hirsutism, molluscum contagiosum, naevus sebaceous, penile lichen planus, sarcoidosis, leishmaniasis, interdigital mycoses, disseminated superficial actinic porokeratosis) [3]. Accumulating evidence suggests the potential of PDT in recalcitrant warts although careful paring and prior use of keratolytics appears important in securing success, with pain management also a greater challenge in this, typically young, patient group. It remains uncertain that we will see topical PDT emerge as a useful therapy for psoriasis in view of the variable uptake of topical photosensitiser between plaques within a patient and certainly between patients, causing difficulty in dosimetry. The responsiveness of acne to phototherapy, which is essentially an endogenous PDT, utilising the coproporphyrin and protoporphyrin IX produced by P. acnes, suggest that enhancing this
Editorial reaction with an exogenous photosensitiser should be expected to achieve further clinical improvement. A recent study using MAL PDT describes a 68% reduction in inflammatory lesions 12 weeks (compared with no change in the control group) after two treatments, 2 weeks apart [16]. Pain, erythema and pustular eruptions post-treatment confirms the need to undertake further studies to refine treatment protocol as well as identify the most appropriate treatment group for a therapy that will likely cause greater short term adverse events compared with most current acne therapies. The potential of topical PDT in treating photoageing is provoking considerable interest across the world and may stimulate more widespread use of topical PDT [17,18]. For practitioners new to PDT, it is important to appreciate that while treatment protocols for its use in NMSC are now well established, those for use in non-cancer indications remain to be optimized. Topical PDT can be a highly effective therapy and once protocols have been mastered, is a relatively easy treatment to perform. Regular audit of a departments’ PDT practice is encouraged to highlight issues that may be contributing to lower efficacy or greater adverse events than reported efficacy, tolerance and safety rates of this therapy.
References [1] Ibbotson SH. How we treat a superficial basal cell carcinoma with topical photodynamic therapy in Dundee. Photodiag Photodyn Therapy 2006;3:128—31. [2] Siero´ n A, et al. Photodynamic diagnosis (PDD) and photodynamic therapy in dermatology. Photodiag Photodyn Therapy 2006;3:132—3. [3] Loncaster JA, Allan E. How to do it: photodynamic therapy in the management of a patient with Gorlin Syndrome. Photodiag Photodyn Therapy 2006;3:134—7. [4] Morton CA, Brown SB, Collin S, et al. Guidelines for photodynamic therapy: report of a workshop of the British Photodermatology Group. Br J Dermatol 2002;146(4): 552—67. [5] Szeimies RM, Morton CA, Sidoroff A, Braathen LR. Photodynamic therapy for non-melanoma skin cancer. Acta Derm Verereol 2005;85:483—90. [6] Mitra A, Stables GI. Topical photodynamic therapy for non-melanoma skin cancer. Photodiag Photodyn Therapy 2006;3:116—27. [7] Babilas P, Kohl E, Maisch T, et al. In vitro and in vivo comparison of two different light sources for topical photodynamic therapy. Br J Dermatol 2006;154:712—8. [8] Tarstedt M, Rosdahl I, Berne B, et al. A randomized multicenter study to compare two treatment regimens of topical methyl aminolevulinate (Metvix)-PDT in actinic keratosis of the face and scalp. Acta Dermato-Venereologica 2005;85:424—8. [9] Morton CA, MacKie RM, Whitehurst C, et al. Photodynamic therapy for basal cell carcinoma: effect of tumor thickness
How to optimise topical photodynamic therapy in dermatology
[10]
[11]
[12]
[13]
and duration of photosensitizer application on response. Arch Dermatol 1998;134:248—9. Rhodes LE, de Rie M, Enstrom Y, et al. Photodynamic therapy using topical methyl aminolaevulinate vs surgery for nodular basal cell carcinoma. Results of a multicentre randomised prospective trial. Arch Dermatol 2004;140:17—23. Rhodes LE, de Rie M, Enstr¨ om Y, et al. A randomized European comparison of excision surgery and MAL-PDT in nodular basal cell carcinoma: results from a 36-month follow-up. J Eur Acad Dermatol Venereol 2005;19(S2). P08.69. Soler AM, Warloe T, Berner A, et al. A follow-up study of recurrence and cosmesis in completely responding superficial and nodular basal cell carcinomas treated with methyl-5-aminlevulinate-based photodynamic therapy alone and with prior curettage. Br J Dermatol 2001;145: 467—71. Basset-Seguin N, Ibbotson S, Emtestam L, et al. MAL-PDT versus cryotherapy in primary sBCC: results of a 36 month follow-up. Poster presented to the 13th Congress of the
[14]
[15]
[16]
[17]
[18]
115
European Academy of Dermatology and Venereology, Florence, November, 2004. Pagliaro J, Elliott T, Bulsara M, King C, Vinciullo C. Cold air analgesia in photodynamic therapy of basal cell carcinomas and Bowen‘s disease: an effective addition to treatment: a pilot study. Dermatol Surg 2004;30:63—6. Wiegell SR, Stender IM, Na R, Wulf HC. Pain associated with photodynamic therapy using 5-aminolevulinic acid or 5-aminolevulinic acid methylester on tape stripped normal skin. Arch Dermatol 2003;139(9):1173—7. Wiegell SR, Wulf HC. Photodynamic therapy of acne vulgaris using methyl aminolaevulinate: a blinded, randomized, controlled trial. Br J Dermatol 2006;154:969—76. Gold MH. The evolving role aminolaevulinic acid hydrochloride with photodynamic therapy in photoageing. Cutis 2002;69:8—13. Goldman MP, Atkin D, Kincad S. PDT/ALA in the treatment of actinic damage: real world experience. J Lasers Surg Med 2002;14(Suppl.):24.
