G.I. Stables

Prevalence of facial acne in adults

BACKGROUND Acne is usually considered a disorder of adolescence, and a number of studies have examined the prevalence of this condition in the adolescent population. There are, however, relatively few data on the prevalence of acne in the adult population. OBJECTIVE A community-based study was carried out to investigate the current prevalence of facial acne in adults. METHODS Seven hundred forty-nine persons older than 25 years were examined for facial acne by means of the Leeds acne-grading technique. RESULTS A degree of facial acne was recorded in 231 women and 130 men, giving an overall prevalence of 54% (95% confidence interval [CI], 49-58) in women and 40% (95% CI, 35-45) in men (P <.001). The acne observed in volunteers consisted principally of physiological acne, but clinical facial acne (grade > 0.75) was recorded in 3% (95% CI, 1.2-4.8) of men and in 12% (95% CI, 9-15) of women (P <.001). The prevalence of acne did not substantially decrease until after the age of 44 years (P <.001). CONCLUSION This study shows a prevalence of clinical facial acne in women of 12%, which is likely to persist into middle age.

Topical aminolaevulinic acid‐photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action

Background   Acne affects 83–95% of 16‐year‐olds of both sexes, and many seek help from a clinician. Emerging problems with conventional acne treatments, specifically antibiotic resistance of Propionibacterium acnes and fears over the safety and tolerance of oral isotretinoin, create a demand for novel treatment modalities in acne.

Improved response of plaque psoriasis after multiple treatments with topical 5-aminolaevulinic acid photodynamic therapy.

We investigated the clinical response of 10 patients with plaque psoriasis to multiple treatments with photodynamic therapy, using topical application of 5-aminolaevulinic acid followed by exposure to broad-band visible radiation. Treatment was performed up to 3 times per week, with a maximum of 12 treatments, using a light dose of 8 Jcm(-2) delivered at a dose-rate of 15 mW cm(-2). Eight patients showed a clinical response. Out of 19 treated sites, 4 cleared, 10 responded but did not clear and 5 showed no improvement. Of the 4 sites that cleared only 1 did so fully, after 7 treatments, 45 days after the start of therapy. Of the 10 sites that responded partially, the greatest reduction in scale, erythema and induration index occurred after a minimum of 3 and a maximum of 8 treatments. The intensity of 5-aminolaevulinic acid-induced protoporphyrin IX fluorescence, recorded prior to the first treatment, varied between sites on the same patient as well as between patients. There was also a variation in fluorescence intensity recorded from the same site immediately prior to subsequent treatments, although the pretreatment levels generally decreased as the study progressed and then increased as psoriasis relapsed. Biopsies confirmed that fluorescence was localized throughout the epidermis and stratum corneum, but the level was not consistent between sections taken within the same biopsy. We also observed fluorescence at sites distant from the ones that received 5-aminolaevulinic acid, which was not present prior to the start of the treatment programme, but found no evidence of elevated levels of plasma porphyrins. The level of discomfort associated with this therapy increased with increasing values of the calculated photodynamic dose, defined as the product of the initial photosensitizer concentration and the percentage reduction in fluorescence following irradiation. Therefore, although clinical efficacy improved with multiple treatments, unpredictable response and patient discomfort make ALA-PDT unsuitable for the treatment of psoriasis.

Large patches of Bowen's disease treated by topical aminolaevulinic acid photodynamic therapy

Large patches of Bowens disease (intraepidermal carcinoma in situ) can be difficult to treat by conventional methods. Photodynamic therapy (PDT) uses the combination of a photosensitizer, which preferentially accumulates in malignant cells, and photoactivation by visible light to kill the malignant cells, 5‐aminolaevulinic acid (ALA) PDT uses excess exogenous ALA, which produces, via the haem synthesis pathway, a build up of the photosensitizer protoporphyrin IX. We describe the use of topical ALA PDT to treat three patients with three especially large patches of Bowens disease. Following two treatments all three lesions achieved a complete clinical and histological response with a good cosmetic result. ALA PDT is a simple, effective and well tolerated treatment for large patches of Bowens disease.

The variable response of plaque psoriasis after a single treatment with topical 5-aminolaevulinic acid photodynamic therapy

Summary We have investigated the clinical response of 22 patients with plaque psoriasis to photodynamic therapy using topical application of 5‐aminolaevulinic acid followed by a single exposure to broadband visible radiation. Light doses in the range 2–16J/cm2 delivered at dose rates of 10–40mW/ cm2 resulted in a variable clinical response. Seven (35%) patients showed clearing of psoriasis at some treated sites. The intensity of protoporphyrin IX fluorescence was recorded before, during and after treatment. Pre‐illumination fluorescence intensity varied considerably between sites on the same patient and between patients. Protoporphyrin IX fluorescence recovered and persisted after treatment for up to 14 days and became higher than preillumination levels at 25% of sites. The rate of protoporphyrin IX photo‐oxidation during treatment was proportional to both initial fluorescence intensity and incident light dose rate and was almost complete after I6J/cm2. We have defined the photodynamic dose as the product of time‐dependent protoporphyrin IX concentration and light dose and demonstrated that only in those patients who showed clearance of psoriasis was there a relationship between photodynamic dose and clinical response. Discomfort ranged from slinging through to burning, was significant in some patients and tended to be more severe with increasing photodynamic dose but was not predictable. Efficacy may improve by achieving consistent proto porphyrin IX levels or by using multiple treatments.

Photodynamic therapy using aminolaevulinic acid does not lead to clinical improvement in hidradenitis suppurativa

SIR, Hidradenitis suppurativa (HS) is a chronic, inflammatory, scarring disease of the apocrine sweat gland-bearing skin. The primary event in the development of abscesses and sinus tracts is follicular occlusion caused by keratinized, stratified squamous epithelium, with the apocrine glands becoming involved only at a later stage. Treatment approaches are similar to those in acne vulgaris, including topical and systemic antibiotics, hormonal therapy and oral retinoids. Phototherapy with a combination of blue (415 nm) and red (660 nm) light was found significantly to reduce the number of comedones in patients with acne. In addition, photodynamic therapy (PDT) using aminolaevulinic acid (ALA) has been shown to be an effective treatment in acne vulgaris. A study by Hongcharu et al. has provided some evidence to support a reduction of follicular obstruction through changes in keratinocyte shedding and hyperkeratosis as a possible mechanism of action of ALA-PDT in acne, although much higher fluences of light were used in this compared with previous studies. Under the hypothesis that treatment with ALA-PDT could reduce the number of comedonal lesions and subsequently of inflammatory lesions in patients with HS, we performed an open pilot study investigating the effect of ALA-PDT in HS. Local Ethics Committee approval was obtained. Endpoints were defined as significant improvement not requiring any further treatment (agreed by both patient and observer) or three completed treatments, whichever came first. Patients with axillary or groin disease were eligible for enrolment. The severity of the condition was assessed by a scoring system as described by Sartorius et al. as well as with visual analogue scales recording the degree of disease activity and pain as perceived by the patient. The site with the highest HS regional score (groin or axilla) was chosen for treatment. ALA was applied locally (20% in Unguentum; Merck, Darmstadt, Germany) and occluded for 4 h. The treatment area was then anaesthetized by infiltration of local anaesthetic (1% lignocaine), followed by treatment with the therapeutic light source, the Ceramoptec diode laser (633 nm) in three patients and a broadband red light source, CureLight lamp (570–670 nm) in one patient. A total dose of 15 J cm was applied per treatment. A maximum of three treatments at weekly intervals was given, depending on the response. Assessments were performed pretreatment, 1 week following each treatment and 8 weeks after the last treatment. Results are shown in Table 1. Four patients were enrolled, three with axillary disease and one with groin disease. Two patients reached an endpoint: one patient completed three treatments (patient 1), and the other noticed a significant improvement after two treatments, and no more treatments were therefore given (patient 2). At 8-week follow-up, however, the regional HS score had improved only marginally in one patient but had worsened in the other patient compared with baseline values. Of the two patients who did not complete the study, one received only one treatment and then decided against further treatments because of severe burning and stinging (patient 3). The fourth patient had two treatments and then decided against continuing therapy as the condition appeared to worsen (patient 4). Again, regional HS scores at follow-up in both patients did not show any improvement, but marked deterioration in one patient (patient 4).

Investigation of the use of the pulsed dye laser in the treatment of Bowen's disease using 5-aminolaevulinic acid phototherapy.

Background  The use of 5‐aminolaevulinic acid photodynamic therapy (ALA‐PDT) for the treatment of Bowens disease is well established. However, treatment with a continuous light source has the disadvantage of prolonged treatment time during which patients often experience significant discomfort requiring the use of local anaesthetic.

Basal cell carcinoma with a sarcomatous component (carcinosarcoma): A series of 5 cases and a review of the literature

Cutaneous carcinosarcomas are rare biphasic malignant tumors with a malignant epithelial component together with malignant stroma. Five cases treated in the Yorkshire region of England between 2003 and 2006 are presented. The patients were male with an age range from 58 to 84 years. Four lesions occurred on the face and one on the trunk. Each tumor had an epithelial component resembling a typical nodular basal cell carcinoma. The stromal components demonstrated atypical spindle cells and tumor giant cells, undifferentiated stroma, or osteoid formation. All underwent surgical excision and none showed evidence of recurrence (follow-up 3-17 months, one death from unrelated causes). The recent literature concerning the pathogenesis and prognosis of these unusual tumors is reviewed.

Successful treatment of scalp actinic keratoses with photodynamic therapy using ambient light

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Reactivation of ophthalmic herpes zoster following pulsed‐dye laser treatment for inflammatory acne vulgaris

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