Carin Sandberg

A randomized, multicentre study of directed daylight exposure times of 11/2 vs. 21/2 h in daylight-mediated photodynamic therapy with methyl aminolaevulinate in patients with multiple thin actinic keratoses of the face and scalp

Background  Actinic keratoses (AKs) are common dysplastic skin lesions that may differentiate into invasive squamous cell carcinomas. Although a superior cosmetic outcome of photodynamic therapy (PDT) is advantageous compared with equally effective treatments such as cryotherapy and curettage, the inconvenience of clinic attendance and discomfort during therapy are significant drawbacks. Daylight‐mediated PDT could potentially reduce these and may serve as an alternative to conventional PDT.

Important factors for pain during photodynamic therapy for actinic keratosis

Photodynamic therapy (PDT) is an efficient treatment for actinic keratosis. A common problem, however, is pain. The aim of this study was to investigate pain during PDT for actinic keratosis. The possibility of using capsaicin cream for pain relief was also assessed. Pain was investigated during aminolaevulinic acid PDT in 91 patients. Size, redness, scaling and induration of the lesions were recorded. Maximum pain during treatment was registered, using a visual analogue scale (0-10). The pain-reducing efficacy of capsaicin was tested in a pilot study in six patients (10 lesions). These patients were pre-treated with capsaicin cream for one week before commencing PDT. Pain was found to be normally distributed around a mean value of visual analogue scale 4.6. Larger lesions gave more pain (p=0.001). The redness of the actinic lesions was found to be related to PDT-induced pain (p=0.01), the reduction of actinic area (p=0.007), and the cure rate (p=0.01). The redder the actinic area, the better the treatment outcome and the more pain experienced. Patients with the largest reduction in the actinic area experienced more pain (p=0.053). The most important factors for presence of pain seem to be the size and the redness of the lesion. No significant pain relief was experienced after pre-treatment with capsaicin.

Daylight-mediated photodynamic therapy of moderate to thick actinic keratoses of the face and scalp: a randomized multicentre study.

Summary Background  Photodynamic therapy (PDT) is an attractive therapy for nonmelanoma skin cancers and actinic keratoses (AKs). Daylight‐mediated PDT is a simple and tolerable treatment procedure for PDT. Methyl aminolaevulinate (MAL)‐PDT is approved for the treatment of thin or nonhyperkeratotic AKs on the face and scalp. However, thick AK lesions are often treated as well when present in the field‐cancerized treatment area.

Nerve blocks enable adequate pain relief during topical photodynamic therapy of field cancerization on the forehead and scalp.

Background  Topical photodynamic therapy (PDT) is an effective method when treating extensive areas of sun‐damaged skin with multiple actinic keratoses (AKs) (field cancerization) on areas such as the forehead and scalp, and offers excellent cosmetic outcome. The major side‐effect of PDT is the pain experienced during treatment.

Bioavailability of aminolaevulinic acid and methylaminolaevulinate in basal cell carcinomas: a perfusion study using microdialysis in vivo

Background  Photodynamic therapy is becoming a popular treatment for superficial nonmelanoma precancerous and cancerous lesions, showing excellent cosmetic results. Nevertheless, the reported cure rates vary and the transdermal penetration of drugs has been discussed as a limiting factor, particularly for treatment of nodular basal cell carcinoma (BCC).

Fluorescence contrast and threshold limit: implications for photodynamic diagnosis of basal cell carcinoma

This study was designed to evaluate what application time of delta-5-aminolaevulinic acid (ALA) results in highest contrast between tumour and normal skin, in the interval 1-4 h, when using photodynamic diagnosis (PDD) of basal cell carcinomas (BCC) located on the face. Moreover, a value of the demarcation limit has been derived based on the fluorescence variation in normal skin adjacent to the tumour. Forty patients were included in the study, randomly allocated to four different groups with varying ALA application time in the range 1-4 h. The contrast, defined as the ratio between the fluorescence intensity in ALA-treated tumour tissue and normal skin, was calculated for each patient, and the mean values in each group were evaluated as a function of ALA application time. In addition, the fluorescence intensity variation in ALA-treated normal skin adjacent to the tumour was assessed. The results from this study show a peak of the mean contrast values after 3 h ALA application, but due to large interpatient variation, the mean contrast did not differ significantly in the interval 2-4 h. After 2 h ALA application, the fluorescence intensity variation in the normal ALA-treated skin was found to be at a maximum, which suggests that 2 h ALA application is not preferable when using PDD. Based on data of the fluorescence variation in ALA-treated normal skin after 3 and 4 h ALA application, a tolerance interval was calculated implying that values above 1.4 times the mean normal fluorescence indicate an abnormal condition. This tolerance limit agrees well with results obtained in a former study.

Mobile teledermoscopy—there's an app for that!

Background: The introduction of the smartphone with high-quality, built-in digital cameras and easy-to-install software may make it more convenient to perform teledermatology. In this study we looked at the feasibility of using a smartphone (iPhone 4®) with an installed application especially developed for teledermatology (iDoc24®) and a dermoscope (FotoFinder Handyscope®) that is customized to attach to the smartphone to be able to carry out mobile teledermoscopy. Objectives: To study the diagnostic accuracy of this mobile teledermoscopy solution, to determine the interobserver concordance between teledermoscopists (TDs) and a dermatologist meeting the patient face-to-face (FTF), and to assess the adequacy of the TDs’ management decisions and to evaluate the image quality obtained. Patients/Methods: During a 16-week period, patients with one or more suspicious skin lesions deemed to need a biopsy or excision were included. The smartphone app was used to send a clinical image, a dermoscopy image and relevant clinical information to a secure Internet platform (Tele-Dermis®). Two TDs assessed the incoming cases, providing a specific primary diagnosis and a management decision. They also graded the image quality. The histopathological diagnosis was used as the gold standard. Results: Sixty-nine lesions were included. The FTF dermatologist’s diagnostic accuracy was 66.7%, which was statistically higher than TD 1 (50.7%, P=0.04) but similar to TD 2 (60.9%, P=0.52). The interobserver concordances between the FTF dermatologist and the two TDs and between the respective TDs showed moderate to substantial agreement. The TDs provided adequate management decisions for 68 (98.6%) and 69 (100%) lesions, respectively. The image quality was rated as excellent or sufficient in 94% and 84% of the cases by the respective TDs. Conclusion: This novel mobile teledermoscopy solution may be useful as a triage tool for patients referred to dermatologists for suspicious skin lesions.

Smartphone Teledermoscopy Referrals: A Novel Process for Improved Triage of Skin Cancer Patients

In this open, controlled, multicentre and prospective observational study, smartphone teledermoscopy referrals were sent from 20 primary healthcare centres to 2 dermatology departments for triage of skin lesions of concern using a smartphone application and a compatible digital dermoscope. The outcome for 816 patients referred via smartphone teledermoscopy was compared with 746 patients referred via the traditional paper-based system. When surgical treatment was required, the waiting time was significantly shorter using teledermoscopy for patients with melanoma, melanoma in situ, squamous cell carcinoma, squamous cell carcinoma in situ and basal cell carcinoma. Triage decisions were also more reliable with teledermoscopy and over 40% of the teledermoscopy patients could potentially have avoided face-to-face visits. Only 4 teledermoscopy referrals (0.4%) had to be excluded due to poor image quality. Smartphone teledermoscopy referrals allow for faster and more efficient management of patients with skin cancer as compared to traditional paper referrals.

Transcutaneous electrical nerve stimulation for pain relief during photodynamic therapy of actinic keratoses.

Topical photodynamic therapy (PDT) is an effective treatment for actinic keratoses (AKs) on the face and scalp (1, 2). The major side-effect of PDT is pain during treatment (3). Patients receiving PDT for AKs on the face and scalp often experience severe pain during treatment. The difficulty of finding a pain-relieving strategy has been highlighted in earlier studies (4, 5). Untreated AK lesions may increase the risk of developing squamous cell carcinoma (SCC) (6). Since PDT can be used to treat field cancerization, has good cure rates and gives excellent cosmetic results (7), it is necessary to find new strategies to reduce the pain experienced to an acceptable level. Transcutaneous electrical nerve stimulation (TENS) is used as pain relief in acute and chronic pain (8). The mechanism behind TENS is based on the gate control theory (9, 10). A TENS unit consists of an external stimulator and electrodes applied directly to the skin. TENS has been investigated to treat different kinds of pain, e.g. procedural pain, with varying results (11, 12). The aim of this pilot study was to investigate whether TENS can reduce the amount of pain experienced by patients undergoing PDT of AKs located on the face and scalp.PATIENTS AND METHODS

Fluorescence diagnostics of basal cell carcinomas comparing methyl-aminolaevulinate and aminolaevulinic acid and correlation with visual clinical tumour size.

Fluorescence diagnostics based on aminolaevulinic acid (ALA) fluorescence has been suggested as an in vivo pre-surgical tool for tumour demarcation. We performed fluorescence diagnostics of 35 basal cell carcinomas (BCCs) undergoing photodynamic therapy (PDT) using methyl-aminolaevulinate (MAL). In addition, a semi-automated thresholding algorithm was implemented to detect the potential tumour region. The mean tumour fluorescence contrast was found to be 1.65 ± 0.06 during the first MAL-PDT session, and increased to 1.84 ± 0.07 at the second treatment (p < 0.01). This could imply that disruption of the skin barrier and inflammatory responses after the first session of PDT led to higher accumulation of proto-porphyrin IX during the second session of PDT. The tumour areas detected based on fluorescence in small BCCs (< 1 cm(2)) were in general (n = 18/23) larger than the visual clinical tumour size. In addition, the fluorescence contrast using MAL (1.65 ± 0.06) was found to be significantly higher (p<10(-4)) than the contrast (data from previous study) after application of ALA (1.20 ± 0.06). Thus, MAL generally provides higher tumour contrast than ALA in BCCs, and should be preferred for use in fluorescence diagnostics. Correlation between fluorescence, lack of treatment response and/or pain was not observed.