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Int. J. Mol. Sci. 2016, 17, 309 8 of 10 of heat. However, in this study there was only a 3 ̋C increase in skin temperature after illumination with the halogen light. The ideal alternative to daylight illumination for daylight PDT could be a combination of the different light sources. There may also be some patient types for whom some of the lamps are more appropriate than others. Thus, in our clinic we have an arrangement in which the slide projector is on a top shelf and is able to illuminate the patient with the help of a mirror. The advantage of lamps compared with daylight is the constant fluence rate directly on the lesion whereas daylight yields different fluence rates depending on the position of the patient. On the other hand the uniformity of irradiation from the lamps is an important issue. The light sources used in this study did not vary more than a Standard Deviation (SD) of 7%. Daylight PDT is especially useful for treatment of field cancerization. Therefore, ambient or diffuse light must be able to illuminate the entire treatment area. The studied light sources have the drawback that most of the light is direct and therefore the position of the patient relative to the light source will have a large impact on PpIX photobleaching. Also, topical alternative therapies are available and it will normally not be a major problem or a great risk to postpone daylight PDT for actinic keratosis until spring or summer. However, in our experience daylight PDT is a very tolerable treatment with good compliance. It is easy for elderly patients to have one time daylight PDT compared with self-administration of topical formulations for a longer time period. We could postpone the patients until spring or summer but we are getting more and more patients with AKs so it is useful to be able to perform daylight PDT all year round. These findings open perspectives for optimized PDT treatment, and future studies are needed to clarify whether indoor daylight PDT using the light sources described in this paper is as effective a treatment as conventional PDT in patients with actinic keratoses. Our measurements in the greenhouse show that 25%–30% of the fluence is filtered by the greenhouse glass. There is an even suppression of the light intensity across the wavelengths in the PpIX spectrum. However, as expected there is suppression of the UVB-radiation by the glass. Measurements showed that it was possible to receive 9.4 Standard Erythema Dose (SED)/per hour out in the open on the day of clear blue sky compared with 0.8 SED inside the greenhouse. An average citizen in Denmark can receive 3–4 SED before developing erythema. Accordingly, sun protection for patients using the greenhouse becomes less important. The greenhouse can be used for daylight PDT during the summer because the light intensity is high. In periods of lower light intensity, e.g. October-March in Denmark there is a risk of not reaching the treatment threshold. 3. ExperimentalSection 3.1. Light Sources The spectra of the lamps were recorded at different distances using a spectroradiometer (Jaz, Ocean Optics, Florida, FL, USA). Illuminance was measured with a lux meter, model E2 (Hagner, Solna, Sweden). We used the following five light sources: (1) a slide projector (Kindermann GmbH, Eibelstadt, Germany) model Silent 2500, which is mounted with a 250-W halogen light bulb. Light from the light bulb shines through the empty slide holder, condenser lenses and the projection lens. A concave mirror behind the lamp also helps to direct the light. The slide projector has a heat filter, which makes the spectrum above 630 nm different from that of the overhead projector; (2) an overhead projector (Medium GmbH, Düsseldorf, Germany), model OHP 536. It is mounted with a 400-W halogen light bulb. An overhead projector is similar to the slide projector. Normally, after the light leaves the projection lens, an angled plane mirror reflects and reverses the image so it appears right-side up on a vertical projection screen (mirror dismantled). The light from the lamp is directed towards the projection lens by a plastic lens of the Fresnel type placed beneath the glass plate on top of which the transparency is placed; (3) a white LED lamp (Nor-tec, Kolding, Denmark) model 74,643 with a 50-W LED emitter; (4) an LED panel with diffuse light consisting of four panels of 30 cm ˆ 120 cm (CadaPDF Image | Alternatives to Outdoor Daylight for Photodynamic Therapy
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