Luís Torezan

Evidence- and consensus-based (S3) Guidelines for the Treatment of Actinic Keratosis - International League of Dermatological Societies in cooperation with the European Dermatology Forum - Short version

Actinic keratosis (AK) is a frequent health condition attributable to chronic exposure to ultraviolet radiation. Several treatment options are available and evidence based guidelines are missing.

A Pilot Split‐Face Study Comparing Conventional Methyl Aminolevulinate‐Photodynamic Therapy (PDT) With Microneedling‐Assisted PDT on Actinically Damaged Skin

Background Topical photodynamic therapy (PDT) is an approved treatment for superficial nonmelanoma skin cancers. To enhance photosensitizer penetration into the epidermis, microneedling (MN) devices or ablative carbon dioxide lasers are combined with PDT. Objectives To compare the efficacy and safety of MN‐assisted PDT with that of conventional PDT in human skin field cancerization. Materials and methods Ten patients with multiple actinic keratoses (AKs) and photodamage were randomized to receive conventional methyl aminolevulinate (MAL) with previous gentle curettage on one side of the face and MAL‐PDT combined with 1.5‐mm‐length MN on the other side after MAL application. After a 90‐minute incubation, patients were illuminated with a red light‐emitting diode and evaluated for improvement of photodamage, clearance of AKs, and side effects before and after 30 and 90 days. Results At day 30, global scores for photodamage, mottled pigmentation, roughness, and sallowness improved on both sides (p < .05), but fine lines improved only on the MN‐PDT side (p = .004). At day 90, facial erythema (p = .04) and coarse wrinkles (p = .002) also improved on the MN‐PDT side, in addition to fine lines for conventional MAL‐PDT (p = .01). Erythema (p = .009), edema (p = .01), crusting (p = .01), and pain (p = .004) were more common and intense on the MN‐PDT side. One patient developed a secondary bacterial infection at day 7 on the MN‐PDT side. Average AK clearance was 88.3%, with no difference between the sides. Conclusion Microneedling‐assisted PDT is a safe and effective method and can produce superior cosmetic results to conventional MAL‐PDT for improving photodamaged skin. Further larger prospective studies are needed to determine whether the addition of MN decreases actinic keratosis.

Aesthetic effects of topical photodynamic therapy.

Topical photodynamic therapy has shown to be effective for the treatment of several aspects of skin ageing. Multiple studies have demonstrated improvement of fine wrinkles, mottled hyperpigmentation, tactile roughness and sallowness. These results are supported by immunohistochemical analysis that revealed both upregulation of collagen production and increased epidermal proliferation. Neocollagenesis as an indirect dermal effect of photodynamic therapy is stimulated through cytokine induction. This article reviews the available literature for photodynamic rejuvenation while discussing cosmetic effects, light sources, adverse effects and the mechanism of action.

Fractional Photothermolysis for the Treatment of Hypertrophic Scars: Clinical Experience of Eight Cases

BACKGROUND Hypertrophic scars are common problems and represent a challenging condition to treat. Fractional photothermolysis has been effective at resurfacing photodamaged skin, acne scars, and atrophic scars, but there are few reports on its use for hypertrophic scars. OBJECTIVE To evaluate the safety and efficacy of 1,550‐nm erbium‐doped fiber laser treatment of hypertrophic scars in eight patients. METHODS Eight patients (skin phototypes II‐IV) with hypertrophic scars received monthly treatments with a 1,550‐nm erbium‐doped fiber laser. Energy settings ranged from 35 to 50 mJ, and eight to 10 passes were applied with treatment levels 6 to 8. An independent physician evaluator assessed the treatment response by comparing pre‐ and posttreatment clinical photographs using a quartile grading scale (grade 1, ≤25%=minimal to no improvement; grade 2, 26‐50%=moderate improvement; grade 3, 51‐75%=marked improvement; grade 4, >75%=near total improvement. RESULTS At four weeks after the last treatment session, a mean grade of 2.4 was achieved based on an independent physicians clinical assessment. Improvement in pigmentation occurred in all hyperpigmented scars. CONCLUSION Hypertrophic scars can be effectively and safely improved with 1,550‐nm erbium‐doped fiber laser treatment. The authors have indicated no significant interest with commercial supporters.

Terapia fotodinâmica em dermatologia: princípios básicos e aplicações

Photodynamic therapy involves the administration of a photosensitizing drug and its subsequent activation by light at wavelengths matching the absorption spectrum of the photosensitizer. Currently, topical photodynamic therapy has received approval for the treatment of cutaneous oncologic conditions such as actinic keratoses, Bowens disease and superficial basal cell carcinoma in many countries in the world. Multicenter randomized controlled studies have demonstrated high efficacy and superior cosmetic outcome over standard therapies. For many non-oncologic dermatological diseases such as acne vulgaris, viral warts and localized scleroderma, case reports and small series have confirmed the potential of photodynamic therapy. After the development of topical photosensitizers 5-aminolevulinic acid (ALA) or its methyl ester (MAL), photodynamic therapy has gained worldwide popularity in dermatology, as these drugs do not induce prolonged phototoxicity as the systemic photosensitizing hematoporphyrin derivatives do. The production of reactive oxygen intermediates such as singlet oxygen depends on the concentration and localization of the photosensitizer in the diseased tissue as well as the applied light dose. Either incoherent lamps or LED arrays are suitable for the cytotoxic effects resulting in tumor destruction or immunomodulatory effects improving inflammatory condition.

Daylight photodynamic therapy for actinic keratoses in São Paulo, Brazil.

To the Editor, There have been several studies about daylight photodynamic therapy (D-PDT) for actinic keratoses (AKs); however, all of them have been performed in Europe. Until now, there have been no studies about D-PDT on other continents. The aim of this study is to present the initial results of a study of the efficacy and safety of D-PDT for AKs in São Paulo, Brazil, and to validate this method in that city.

Pain in photodynamic therapy: mechanism of action and management strategies

Photodynamic therapy involves administration of a photosensitizing drug and its subsequent activation by irradiation with a light source at wavelengths matching the absorption spectrum of the photosensitizer. In many countries around the world, topical photodynamic therapy has been approved for treatment of cutaneous oncologic conditions such as actinic keratosis, Bowens disease, and superficial basal cell carcinoma. Multicenter, randomized, controlled studies have confirmed its efficacy and superior cosmetic outcomes compared to conventional therapies. Nevertheless, this therapeutic method presents some adverse effects, such as erythema, edema, pigmentation, pustules, and pain. There is no doubt that pain is the most severe of the adverse effects, being sometimes responsible for definitive treatment interruption. The pain mechanism has not yet been fully understood, which makes complete pain control a challenge to be conquered. In spite of that, this literature review presents some useful pain management strategies as well as the most important pain-related factors in photodynamic therapy.

Evaluation of the tolerability and safety of a 0.015% ingenol mebutate gel compared to 5% 5-fluorouracil cream for the treatment of facial actinic keratosis: a prospective randomized trial.

Five per cent 5‐fluorouracil (5‐FU) cream is a well‐established treatment for actinic keratosis (AK), and ingenol mebutate gel (IMB) is a novel topical field‐directed therapy.

Daylight photodynamic therapy with MAL cream for large-scale photodamaged skin based on the concept of ‘actinic field damage’: recommendations of an international expert group

Conventional PDT (c‐PDT) is a widely used and approved non‐invasive treatment for actinic keratosis (AK). Recent clinical, histological and immunohistochemical observations have shown that c‐PDT with methyl aminolevulinate (MAL) may also partially reverse the signs of photodamage. However, pain and the need for special light source equipment are limiting factors for its use, especially in the treatment of large areas. More recently, daylight PDT (DL‐PDT) has been shown to be similar to c‐PDT in the treatment of AK, nearly painless and more convenient to perform. To establish consensus on recommendations for the use of MAL DL‐PDT in patients with large‐scale photodamaged skin. The expert group was comprised of eight dermatologists. Consensus was developed based on the personal experience of the experts in c‐PDT and DL‐PDT, and results of an extensive literature review. MAL DL‐PDT for large areas of photodamaged skin was evaluated and recommendations based on broad clinical experience were provided. As supported by evidence‐based data from multicentre studies conducted in Australia and Europe, the authors defined the concept of ‘actinic field damage’ which refers to photodamage associated with actinic epidermal dysplasia, and provide comprehensive guidelines for the optimal use of DL‐PDT in the treatment of actinic field damage. The authors concluded that MAL DL‐PDT has a similar efficacy to c‐PDT at 3‐month (lesion complete response rate of 89% vs. 93% in the Australian study and 70% vs. 74% in the European study (95% C.I. = [−6.8;−0.3] and [−9.5;2.4] respectively) and 6‐month follow‐ups (97% maintenance of complete lesion response) in the treatment of AKs. The authors agree that DL‐PDT is not only efficacious but also nearly pain‐free and easy to perform, and therefore results in high patient acceptance especially for the treatment of areas of actinic field damage.

Development of Multiple Warts After Skin Resurfacing with CO2 Laser

Background. Skin resurfacing with CO2 laser is a common surgical procedure to improve photodamaged skin. Many complications may occur after this procedure, however, common warts is relatively rare. Objective. To report a case of multiple warts after CO2 laser resurfacing and discuss the complete involution of these lesions. Methods. A 78‐year‐old woman with multiple warts after CO2 laser resurfacing is described. Results. The patient developed multiple common warts on the face after resurfacing with CO2 laser. Retinoic acid was introduced and complete involution of the lesions was observed after 5 days with no scars. Conclusion. Although emphasis is placed on the hazards of the laser plume to the medical staff, one should be aware of this complication. We believe that the regression of the lesions was spontaneous rather than induced by the retinoic acid.