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Split approach for the treatment of actinic keratoses with ALA-mediated photodynamic therapy versus treatment with topical imiquimod cream
P3112
P3114
Photodynamic therapy with methyl 5-aminolevulinic acid for the treatment of cutaneous warts Kee Suck Suh, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Jae Woo Baek, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Sang Tae Kim, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Tae Kwon Kim, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Young Seung Jeon, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea
Split approach for the treatment of actinic keratoses with ALA-mediated photodynamic therapy versus treatment with topical imiquimod cream Maria Tsoukas, MD, PhD, University of Chicago, Chicago, IL, United States; David Mann, MD, University of Chicago, Chicago, IL, United States; Ha Do, Chicago Medical School, Chicago, IL, United States; Irene Vergilis Kalner, MD, University of Chicago, Chicago, IL, United States; Roger Kapoor, MD, MBA, University of Chicago, Chicago, IL, United States Background: Actinic keratoses (AKs) and superficial nonmelanoma skin cancers (NMSCs) are very common in elderly and in immunosuppressed populations. Our goal is to compare efficacy of ALA photodynamic therapy (PDT) versus topical application of conventional therapy with imiquimod (Aldara) for the treatment of AKs. Methods: According to institutional review boardeapproved protocol ‘‘split’’ technique is followed. Twenty percent 5-aminolevulinic acid (5-ALA) is applied on skin (proposed N ¼ 30), followed by exposure to 417nm blue light (Blu-U, DUSA) for 16minutes (total light dose of 10J/cm2; ALA incubation: 3hours). Topical application of imiquimod is applied on equivalent body sites, three times weekly for 12 weeks. Clinical evaluation and photography are obtained to monitor skin responses before and after treatment, on days 1, 15, and 30 postexposure. Partial/complete clearance and recurrence of skin lesions are monitored bimonthly during 18 months of followup. Number of the PDT treatments ranges from 2 to 5 sessions, every 2 to 4 weeks apart, depending on the clinial response. Experienced pain, technique preference, and cost effectiveness have been monitored as well.
Topical photodynamic therapy (PDT) is based on the principle of targeted tissue destruction using selective photosensitization via a topical porphyrin precursor, followed by light exposure. It is well established for the treatment of actinic keratoses and superficial nonmelanoma skin cancers. Some studies have reported good efficacy when using PDT to treat cutaneous warts. We carried out a prospective study of methyl 5-aminolevulinic acid (MAL)-PDT in the treatment of cutaneous warts. Hyperkeratotic lesions were gently removed using a curette, and then treated with MAL cream (Metvix, Galderma, UK) under occlusion for 3hours before irradiation with a red light source (Aktilite lamp; PhotoCure ASA, Oslo, Norway). The irradiation intensity is 75 mW/cm2 at a distance of 5cm and total dose is 37J/cm2. The treatment was to be repeated 1 week later if the lesion was not completely removed after the first treatment. Fourteen patients were enrolled into the study (10 males, 4 females). The mean age of patients was 25 years (range, 10-46 years). They had Fitzpatrick skin phototypes III to IV. Nine patients had hand warts and five patients had foot warts. After two treatments with MAL-PDT, the complete removal rate was 79% (11/14 patients). Adverse effects included mild to moderate pain and erythema, which lasted no longer than 48hours and was well tolerated by all patients. None of the patients excluded from the study because of side effects. MAL-PDT, given its noninvasiveness, minimal adverse effects, and good cosmetic results, is a promising alternative treatment for cutaneous warts. Further studies with a larger of patients would be of value. Commercial support: None identified.
Results: Clinical responses (erythema, edema, scaling, and pruritus) are pronounced on posttreatment days 1 to 5 on ALA-PDTetreated sites and resolve in 12 to 15 days with complete skin recovery. Topical imiquimod results in redness, scaling, and crusting of lesional skin but onset of symptoms may be seen 7 to 10 days after the initiation of application and treatment duration is much longer (12 weeks total) compared to PDT. Treatment compliance and reproducibility are better in ALA PDT applied in clinic protocol, versus topical imiquimod. AK recurrence seemed to be equivalent during the 18-month follow-up in healthy elderly patients, with evidence showing remarkable responses to ALA-PDT for the treatment AK and NMSC for patients with immunosuppression, nonresponsive to topical imiquimod. Conclusion: PDT may become first-line ‘‘field’’ treatment in dermatology practice for AK therapy, comprising a modality of choice for chemoprevention in patients under chronic immunosuppression. Commercial support: None identified.
P3113 Failure to acquire a prescribed home phototherapy device: The tip of an iceberg Brad Yentzer, MD, WFU School of Medicine, Winston Salem, NC, United States; Steven Feldman, MD, PhD, WFU School of Medicine, Winston Salem, NC, United States Background: Home phototherapy is a cost effective treatment for patients with extensive psoriasis. However, there are multiple hurdles that must be crossed to obtain these devices. Purpose: We explored the behaviors of psoriasis patients with respect to obtaining a home phototherapy unit after given a prescription. In addition, we examined differences in physicians’ prescribing patterns for home phototherapy versus biologics. Methods: We reviewed survey data from National Biologic Corporation, a manufacturer of phototherapy units, to determine the number of patients who never acquired a home unit after given a prescription from their doctors, and their respective reasons why they did not. Physicians’ prescribing patterns were assessed from data gathered by IMS Health. Physician education of and willingness to prescribe home phototherapy was assessed via a survey distributed at the Ninth Annual Dermatology Chief Residents’ Meeting. Results: Over a 2-year period, 45% of patients that were written a prescription never obtained a phototherapy unit. Of these patients, 72% stated that they did not get a unit secondary to the potential high out of pocket expenses. In 2006, 94,385 new prescriptions for etanercept were written by 4284 dermatologists in the IMS database. These same physicians only wrote 1746 prescriptions for home phototherapy. Only 35% of dermatology residents received formal training on home phototherapy.
P3115 The effects of multiple exposures of visible light radiation on the skin InSeok Seo, PhD, Johnson & Johnson Consumer Companies, Skillman, NJ, United States; Eduardo Ruvolo, MS, Johnson & Johnson Consumer Companies, Skillman, NJ, United States; Frank Liebel, Johnson & Johnson Consumer Companies, Skillman, NJ, United States; Nikiforos Kollias, PhD, Johnson & Johnson Consumer Companies, Skillman, NJ, United States
Conclusions: When it comes to patients receiving more expensive biologics instead of home phototherapy for their psoriasis, high copays and deductibles are just the tip of the iceberg. It is likely that even more patients are never prescribed a home unit because of a lack of training or frustration with lack of insurance coverage.
The apparent non-UV solar radiation which includes visible and infrared light makes up about 90% of solar radiation. It has been shown that visible light (400-800nm) is able to induce changes in the pigmentation. The visible wavelengths penetrate into the skin and induce an unwanted tanning that commercial UVA/UVB sunscreens were not designed to block. The purpose of this study was to determine if skin irradiated with visible light would increase apparent pigment content after a series of doses. One series would receive three low doses (150J/cm2 over 3 days) and the other would receive a large pigment producing dose followed by two low doses (480J/cm2, 150J/cm2 over 2 days). Using diffuse reflectance spectroscopy (DRS) to measure the changes in pigment content, we were able to show significant daily increases in pigmentation after each exposure in the large dose series, and this pigment persisted for weeks. No significant changes were observed in the low-dose series. Based on these results, we conclude that an initial higher conditioning dose of visible light is necessary for significant increases in pigmentation; subsequent lower doses will also produce marked increases in pigment.
Commercial support: 50% is sponsored by National Biological.
Commercial support: Johnson & Johnson.
MARCH 2010
J AM ACAD DERMATOL
AB117
P3114
Photodynamic therapy with methyl 5-aminolevulinic acid for the treatment of cutaneous warts Kee Suck Suh, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Jae Woo Baek, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Sang Tae Kim, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Tae Kwon Kim, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea; Young Seung Jeon, MD, Department of Dermatology, Kosin University College of Medicine, Busan, South Korea
Split approach for the treatment of actinic keratoses with ALA-mediated photodynamic therapy versus treatment with topical imiquimod cream Maria Tsoukas, MD, PhD, University of Chicago, Chicago, IL, United States; David Mann, MD, University of Chicago, Chicago, IL, United States; Ha Do, Chicago Medical School, Chicago, IL, United States; Irene Vergilis Kalner, MD, University of Chicago, Chicago, IL, United States; Roger Kapoor, MD, MBA, University of Chicago, Chicago, IL, United States Background: Actinic keratoses (AKs) and superficial nonmelanoma skin cancers (NMSCs) are very common in elderly and in immunosuppressed populations. Our goal is to compare efficacy of ALA photodynamic therapy (PDT) versus topical application of conventional therapy with imiquimod (Aldara) for the treatment of AKs. Methods: According to institutional review boardeapproved protocol ‘‘split’’ technique is followed. Twenty percent 5-aminolevulinic acid (5-ALA) is applied on skin (proposed N ¼ 30), followed by exposure to 417nm blue light (Blu-U, DUSA) for 16minutes (total light dose of 10J/cm2; ALA incubation: 3hours). Topical application of imiquimod is applied on equivalent body sites, three times weekly for 12 weeks. Clinical evaluation and photography are obtained to monitor skin responses before and after treatment, on days 1, 15, and 30 postexposure. Partial/complete clearance and recurrence of skin lesions are monitored bimonthly during 18 months of followup. Number of the PDT treatments ranges from 2 to 5 sessions, every 2 to 4 weeks apart, depending on the clinial response. Experienced pain, technique preference, and cost effectiveness have been monitored as well.
Topical photodynamic therapy (PDT) is based on the principle of targeted tissue destruction using selective photosensitization via a topical porphyrin precursor, followed by light exposure. It is well established for the treatment of actinic keratoses and superficial nonmelanoma skin cancers. Some studies have reported good efficacy when using PDT to treat cutaneous warts. We carried out a prospective study of methyl 5-aminolevulinic acid (MAL)-PDT in the treatment of cutaneous warts. Hyperkeratotic lesions were gently removed using a curette, and then treated with MAL cream (Metvix, Galderma, UK) under occlusion for 3hours before irradiation with a red light source (Aktilite lamp; PhotoCure ASA, Oslo, Norway). The irradiation intensity is 75 mW/cm2 at a distance of 5cm and total dose is 37J/cm2. The treatment was to be repeated 1 week later if the lesion was not completely removed after the first treatment. Fourteen patients were enrolled into the study (10 males, 4 females). The mean age of patients was 25 years (range, 10-46 years). They had Fitzpatrick skin phototypes III to IV. Nine patients had hand warts and five patients had foot warts. After two treatments with MAL-PDT, the complete removal rate was 79% (11/14 patients). Adverse effects included mild to moderate pain and erythema, which lasted no longer than 48hours and was well tolerated by all patients. None of the patients excluded from the study because of side effects. MAL-PDT, given its noninvasiveness, minimal adverse effects, and good cosmetic results, is a promising alternative treatment for cutaneous warts. Further studies with a larger of patients would be of value. Commercial support: None identified.
Results: Clinical responses (erythema, edema, scaling, and pruritus) are pronounced on posttreatment days 1 to 5 on ALA-PDTetreated sites and resolve in 12 to 15 days with complete skin recovery. Topical imiquimod results in redness, scaling, and crusting of lesional skin but onset of symptoms may be seen 7 to 10 days after the initiation of application and treatment duration is much longer (12 weeks total) compared to PDT. Treatment compliance and reproducibility are better in ALA PDT applied in clinic protocol, versus topical imiquimod. AK recurrence seemed to be equivalent during the 18-month follow-up in healthy elderly patients, with evidence showing remarkable responses to ALA-PDT for the treatment AK and NMSC for patients with immunosuppression, nonresponsive to topical imiquimod. Conclusion: PDT may become first-line ‘‘field’’ treatment in dermatology practice for AK therapy, comprising a modality of choice for chemoprevention in patients under chronic immunosuppression. Commercial support: None identified.
P3113 Failure to acquire a prescribed home phototherapy device: The tip of an iceberg Brad Yentzer, MD, WFU School of Medicine, Winston Salem, NC, United States; Steven Feldman, MD, PhD, WFU School of Medicine, Winston Salem, NC, United States Background: Home phototherapy is a cost effective treatment for patients with extensive psoriasis. However, there are multiple hurdles that must be crossed to obtain these devices. Purpose: We explored the behaviors of psoriasis patients with respect to obtaining a home phototherapy unit after given a prescription. In addition, we examined differences in physicians’ prescribing patterns for home phototherapy versus biologics. Methods: We reviewed survey data from National Biologic Corporation, a manufacturer of phototherapy units, to determine the number of patients who never acquired a home unit after given a prescription from their doctors, and their respective reasons why they did not. Physicians’ prescribing patterns were assessed from data gathered by IMS Health. Physician education of and willingness to prescribe home phototherapy was assessed via a survey distributed at the Ninth Annual Dermatology Chief Residents’ Meeting. Results: Over a 2-year period, 45% of patients that were written a prescription never obtained a phototherapy unit. Of these patients, 72% stated that they did not get a unit secondary to the potential high out of pocket expenses. In 2006, 94,385 new prescriptions for etanercept were written by 4284 dermatologists in the IMS database. These same physicians only wrote 1746 prescriptions for home phototherapy. Only 35% of dermatology residents received formal training on home phototherapy.
P3115 The effects of multiple exposures of visible light radiation on the skin InSeok Seo, PhD, Johnson & Johnson Consumer Companies, Skillman, NJ, United States; Eduardo Ruvolo, MS, Johnson & Johnson Consumer Companies, Skillman, NJ, United States; Frank Liebel, Johnson & Johnson Consumer Companies, Skillman, NJ, United States; Nikiforos Kollias, PhD, Johnson & Johnson Consumer Companies, Skillman, NJ, United States
Conclusions: When it comes to patients receiving more expensive biologics instead of home phototherapy for their psoriasis, high copays and deductibles are just the tip of the iceberg. It is likely that even more patients are never prescribed a home unit because of a lack of training or frustration with lack of insurance coverage.
The apparent non-UV solar radiation which includes visible and infrared light makes up about 90% of solar radiation. It has been shown that visible light (400-800nm) is able to induce changes in the pigmentation. The visible wavelengths penetrate into the skin and induce an unwanted tanning that commercial UVA/UVB sunscreens were not designed to block. The purpose of this study was to determine if skin irradiated with visible light would increase apparent pigment content after a series of doses. One series would receive three low doses (150J/cm2 over 3 days) and the other would receive a large pigment producing dose followed by two low doses (480J/cm2, 150J/cm2 over 2 days). Using diffuse reflectance spectroscopy (DRS) to measure the changes in pigment content, we were able to show significant daily increases in pigmentation after each exposure in the large dose series, and this pigment persisted for weeks. No significant changes were observed in the low-dose series. Based on these results, we conclude that an initial higher conditioning dose of visible light is necessary for significant increases in pigmentation; subsequent lower doses will also produce marked increases in pigment.
Commercial support: 50% is sponsored by National Biological.
Commercial support: Johnson & Johnson.
MARCH 2010
J AM ACAD DERMATOL
AB117