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Photodynamic Therapy for Actinic Keratoses: Aren’t We There Yet?

Photodynamic Therapy for Actinic Keratoses: Aren’t We There Yet? Fifteen years ago the US Food and Drug Administration approved the use of photodynamic therapy (PDT) in dermatology for the treatment of actinic keratosis (AK). Photodynamic therapy using topical agents in combination with visible light has been investigated extensively with a general consensus that in cutaneous oncology, PDT is probably best suited for treating patients with multiple or larger superficial lesions. In a meta-analysis, Patel et al1 concluded that PDT resulted in a 14% better probability of complete clearance of AK compared with cryotherapy. Additional potential benefits of PDT such as superior cosmesis and better patient acceptance have not been demonstrated clearly. Although cryotherapy and PDT require the acquisition and use of specialized materials and equipment, only the former is typically a first-line approach for most practicing dermatologists. Notwithstanding the apparent superiority of PDT to cryotherapy, the light-based approach to treating AK has 3 major limitations. The current financial remuneration model is a major disincentive, given the higher costs for PDT in terms of practitioner time and equipment compared with cryotherapy. Although PDT appears to be a simple concept, in practice optimal results may require longer drug incubation times and perhaps light-dose fractionation to generate a sufficient tissue effect. Clinicians aiming to streamline the treatment process by shortening the incubation times may achieve inferior results owing to insufficient in situ generation of local protoporphyrin IX and singlet oxygen. Finally, local pain owing to photosensitizer activation during light exposure is perhaps the most striking adverse effect that clinicians need to anticipate and manage during PDT. Some patients may never be willing to undergo a second treatment after their first painful PDT experience. Patient education and assignment of designated staff to use specific analgesic techniques are highly recommended to manage patient discomfort during PDT. All 3 of these limiting factors necessitate added time and resources compared with the relatively brief outpatient visits for cryotherapy, in which liquid nitrogen is simply and efficiently dispensed to the skin. That PDT yields some cosmetic benefits to patients with photodamaged skin represents one means by which some practitioners are able to make this service economically feasible via private remuneration. Nevertheless AK is still considered a premalignant condition, the treatment of which is medically necessary. Alternate compensation or funding models are needed to commit the proper resources to providing optimal PDT. The future of PDT may rest in the innovation of “daylight” PDT, whereby patients are exposed to ambient outdoor light right after the application of topical aminolevulinic acid or its congener. Although this method is an off-label application, daylight PDT obviates the necessity for a specialized treatment lamp and appears to be a less painful experience for patients.2 Controlled trials will be needed to establish its clinical efficacy and utility clearly. Perhaps the most tantalizing irony of daylight PDT is the specter of treating a solar-induced neoplasm with sunlight itself. Back to top Article Information Corresponding Author: Harvey Lui, MD, FRCPC, Department of Dermatology and Skin Science, University of British Columbia, 835 West 10th Ave, Vancouver, BC V5Z 4E8, Canada. Published Online: August 27, 2014. doi:10.1001/jamadermatol.2014.1869. Conflict of Interest Disclosures: Dr Lui has served as a clinical investigator and consultant for Galderma and LEO Pharma Inc in regard to actinic keratosis; has served on advisory boards for Janssen, Novartis, and Valeant; has equity interest in RepliCel Life Sciences Inc, Lumen Health Technologies, and Verisante Technology; and receives a dermatology textbook publication royalty from Elsevier BV. References 1. Patel G, Armstrong AW, Eisen DB. Efficacy of photodynamic therapy vs other interventions in randomized clinical trials for the treatment of actinic keratoses: a systematic review and meta-analysis [published online August 27, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2014.1253.Google Scholar 2. Rubel DM, Spelman L, Murrell DF, et al. Daylight PDT with methyl aminolevulinate cream as a convenient, similarly effective, nearly painless alternative to conventional PDT in actinic keratosis treatment: a randomised controlled trial [published online May 24, 2014]. Br J Dermatol. doi:10.1111/bjd.13138.PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Photodynamic Therapy for Actinic Keratoses: Aren’t We There Yet?

JAMA Dermatology , Volume 150 (12) – Dec 1, 2014

Photodynamic Therapy for Actinic Keratoses: Aren’t We There Yet?

Abstract

Fifteen years ago the US Food and Drug Administration approved the use of photodynamic therapy (PDT) in dermatology for the treatment of actinic keratosis (AK). Photodynamic therapy using topical agents in combination with visible light has been investigated extensively with a general consensus that in cutaneous oncology, PDT is probably best suited for treating patients with multiple or larger superficial lesions. In a meta-analysis, Patel et al1 concluded that PDT resulted in a 14% better...
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Publisher
American Medical Association
Copyright
Copyright © 2014 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2014.1869
pmid
25162746
Publisher site
See Article on Publisher Site

Abstract

Fifteen years ago the US Food and Drug Administration approved the use of photodynamic therapy (PDT) in dermatology for the treatment of actinic keratosis (AK). Photodynamic therapy using topical agents in combination with visible light has been investigated extensively with a general consensus that in cutaneous oncology, PDT is probably best suited for treating patients with multiple or larger superficial lesions. In a meta-analysis, Patel et al1 concluded that PDT resulted in a 14% better probability of complete clearance of AK compared with cryotherapy. Additional potential benefits of PDT such as superior cosmesis and better patient acceptance have not been demonstrated clearly. Although cryotherapy and PDT require the acquisition and use of specialized materials and equipment, only the former is typically a first-line approach for most practicing dermatologists. Notwithstanding the apparent superiority of PDT to cryotherapy, the light-based approach to treating AK has 3 major limitations. The current financial remuneration model is a major disincentive, given the higher costs for PDT in terms of practitioner time and equipment compared with cryotherapy. Although PDT appears to be a simple concept, in practice optimal results may require longer drug incubation times and perhaps light-dose fractionation to generate a sufficient tissue effect. Clinicians aiming to streamline the treatment process by shortening the incubation times may achieve inferior results owing to insufficient in situ generation of local protoporphyrin IX and singlet oxygen. Finally, local pain owing to photosensitizer activation during light exposure is perhaps the most striking adverse effect that clinicians need to anticipate and manage during PDT. Some patients may never be willing to undergo a second treatment after their first painful PDT experience. Patient education and assignment of designated staff to use specific analgesic techniques are highly recommended to manage patient discomfort during PDT. All 3 of these limiting factors necessitate added time and resources compared with the relatively brief outpatient visits for cryotherapy, in which liquid nitrogen is simply and efficiently dispensed to the skin. That PDT yields some cosmetic benefits to patients with photodamaged skin represents one means by which some practitioners are able to make this service economically feasible via private remuneration. Nevertheless AK is still considered a premalignant condition, the treatment of which is medically necessary. Alternate compensation or funding models are needed to commit the proper resources to providing optimal PDT. The future of PDT may rest in the innovation of “daylight” PDT, whereby patients are exposed to ambient outdoor light right after the application of topical aminolevulinic acid or its congener. Although this method is an off-label application, daylight PDT obviates the necessity for a specialized treatment lamp and appears to be a less painful experience for patients.2 Controlled trials will be needed to establish its clinical efficacy and utility clearly. Perhaps the most tantalizing irony of daylight PDT is the specter of treating a solar-induced neoplasm with sunlight itself. Back to top Article Information Corresponding Author: Harvey Lui, MD, FRCPC, Department of Dermatology and Skin Science, University of British Columbia, 835 West 10th Ave, Vancouver, BC V5Z 4E8, Canada. Published Online: August 27, 2014. doi:10.1001/jamadermatol.2014.1869. Conflict of Interest Disclosures: Dr Lui has served as a clinical investigator and consultant for Galderma and LEO Pharma Inc in regard to actinic keratosis; has served on advisory boards for Janssen, Novartis, and Valeant; has equity interest in RepliCel Life Sciences Inc, Lumen Health Technologies, and Verisante Technology; and receives a dermatology textbook publication royalty from Elsevier BV. References 1. Patel G, Armstrong AW, Eisen DB. Efficacy of photodynamic therapy vs other interventions in randomized clinical trials for the treatment of actinic keratoses: a systematic review and meta-analysis [published online August 27, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2014.1253.Google Scholar 2. Rubel DM, Spelman L, Murrell DF, et al. Daylight PDT with methyl aminolevulinate cream as a convenient, similarly effective, nearly painless alternative to conventional PDT in actinic keratosis treatment: a randomised controlled trial [published online May 24, 2014]. Br J Dermatol. doi:10.1111/bjd.13138.PubMedGoogle Scholar

Journal

JAMA DermatologyAmerican Medical Association

Published: Dec 1, 2014

References