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wan and Lin Multiple treatments can also increase efficacy. PDT rep- resents an attractive option for superficial SCC given its improved cosmetic profile and similar recurrence rate when compared with cryotherapy or 5-fluorouracil. However, due to the metastatic potential and reduced efficacy rates, PDT cannot be recommended for invasive SCC. Basal cell carcinoma Current treatment for BCC includes Mohs micrographic surgery, excisional surgery, curettage and electrodessication, radiation, cryotherapy, PDT, laser therapy, topical treatments (imiquimod and 5-fluorouracil), and vismodegib (Erivedge®, Roche Pharmaceuticals, Basel, Switzerland). Generally, PDT is recommended as a treatment option for superficial and thin nodular BCC (thickness ,2 mm). However, some investiga- tors accept 2–3 mm thick BCC for PDT when combined with pretreatment of lesion curettage. Preparation of the lesion prior to treatment is common, and more important for nodular BCC. Superficial debridement in a manner insufficient to cause pain is a common practice; some clinicians perform this weeks or hours in advance. One study showed a complete response, with histologic confirmation in 22 of 24 lesions (92%) treated with PDT and prior debridement.69,70 ALA-PDT treatment of BCC A 10-year longitudinal study that reviewed clinical and histopathologic examination of 60 lesions found that the complete response rate for primary lesions after superficial curettage was 78%, with 63% after one session and 90% after two sessions. This study used ALA-PDT with halogen light (light intensity 150–230 mW/cm2). The cosmetic outcome was rated as good or excellent in over 91% of the evalu- ated cases.71 Another study (n=94) compared the complete response rate (mean follow-up 25 months) for superficial BCC in patients who received ALA-PDT (31/31, 100%) ver- sus surgery (28/29, 96.55%). Patients with nodular BCC had better response rates with surgery (16/17, 94.12%; P=0.88) than those treated with ALA-PDT (15/17, 88.24%).72 Blue light PDT alone for BCC is controversial because lesions with a vertical growth greater than 2 mm have not been studied extensively. Clinicians should use ALA-PDT with caution for treatment of BCC, especially nodular BCC, because ALA-PDT did not seem to be an effective option for treatment of nodular BCC in one randomized controlled trial (n=173) with 3-year follow-up; recurrence rates for surgical excision (2.3%) were substantially less compared with PDT (30.3%).73 However, combined therapy of ALA- PDT and 5% imiquimod has been suggested to achieve a Dovepress 15% improvement in complete remission of nodular BCC compared with ALA-PDT alone.74 MAL-PDT in treatment of BCC One noninferiority trial reported no significant difference between MAL-PDT and cryotherapy in the treatment of superficial BCC.75 Another trial showed that MAL-PDT was not inferior to surgery for treatment of nodular BCC at 3-month and 24-month follow-up.76 One French group confirmed that, at 3 months, the treatment difference (cryotherapy versus MAL-PDT) was -2.2% (P=0.49). At 5 years, the overall lesion recurrence rate was 22% with MAL-PDT and 20% with cryotherapy.77 Szeimies et al determined that, at 3 months, the mean lesion count reduction was 92.2% for MAL-PDT versus 99.2% for surgery but this difference did not achieve statistical significance. Signifi- cantly, at 12 months, however, 9.3% of lesions (11 of 118) recurred in the MAL-PDT group versus none in the surgery group (0 of 117).77 Although MAL-PDT is noninferior to cryotherapy and surgery, the cosmetic advantage associated with MAL-PDT is of great interest for low-risk superficial BCC, because lesions are often multiple, typically affecting skin sites predisposed to dystrophic scarring (such as the trunk).78–80 In randomized trials comparing different treatment modalities for BCC, a recent study demonstrated increased efficacy of imiquimod over MAL-PDT (83.4% versus 72.8%) at 12-month follow-up. This again argues for the advantage of using combination therapies with PDT, namely adding on imiquimod after treatment.81 A consensus group in Canada and Europe analyzed nine studies and report that use of MAL-PDT can be considered as a safe and effective treatment for BCC in patients with Gorlin syndrome, the efficacy being proportionate to the thickness of the lesion.82 PDT has been observed to have chemopreventive effects in patients with Gorlin syndrome.83,84 Cutaneous T cell lymphoma PDT has been widely used in the treatment of mycosis fun- goides, an indolent subtype of cutaneous T cell lymphoma. A few studies and various case reports have reported complete or partial responses in the treatment of mycosis fungoides. Most of these report efficacy of MAL-PDT and ALA-PDT in the treatment of plaque-type (stage I) myco- sis fungoides, but decreased efficacy against tumor-type (stage II) mycosis fungoides, and there has been a single report of erosive mycosis fungoides on the face treated successfully with ALA-PDT using red light.70,85–89 As is Clinical, Cosmetic and Investigational Dermatology 2014:7 150 submit your manuscript | www.dovepress.com DovepressPDF Image | applications of photodynamic therapy dermatology
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