INTRODUCTION
In the United States, photodynamic therapy (PDT) is an approved treatment for actinic keratoses in which a photo-sensitizer is applied to the skin and then activated by a light source producing reactive oxygen species which results in local tissue destruction. During PDT, the photosensitizing agent of 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) which is also approved in some countries for the treatment of superficial basal cell carcinomas and has enhanced absorption due to increased lipophilicity is applied to the skin. The chemical sensitizer is preferentially absorbed by pre-malignant cells and converted to protoporphyrin IX which creates reactive oxygen species resulting in necrosis and death of the pre-malignant cells when illuminated with select wavelengths of light in the protoporphyrin absorption spectrum, namely red (630 nm) or blue (417 nm) light. More recently, modifications of standard protocol, including temperature-modulated PDT and laser assisted delivery of ALA or MAL have been reported for improved clinical outcomes in photodynamic therapy. We report our experience with two protocols for PDT. The first utilizes a nonablative fractional 1927nm diode laser (Perméa handpiece, Clear + Brilliant® System, Solta Medical) prior to application of ALA and illumination with blue light following incubation at a warm room temperature. This aims to enhance penetration of topical ALA and has the added benefit of improved treatment of photodamage including lentigines in patients with extensive eld disease. Additionally, in patients with significant sebaceous hyperplasia, performance of PDT with red light illumination followed by treatment with a 595 nm pulsed dye laser (Vbeam, Syneron Candela Corporation) allows for effective targeting of sebaceous glands.1
Technique
For Patients with Actinic Keratoses and Actinic Damage The patient’s face is cleansed and topical EMLA cream (lidocaine 2.5% and prilocaine 2.5%) is applied for twenty minutes. Patients are then treated with a nonablative fractional 1,927 nm diode laser (Perméa handpiece, Clear + Brilliant® System, Solta Medical) consisting of one vertical pass and one horizontal pass each with 50% overlap for an effective four total passes at the predefined medium setting. ALA 20% topical solution is then applied topically in three passes of different directions to the patient’s face and allowed to incubate in a dimly lit room at a temperature of 78-80 degrees Fahrenheit for one hour.2 Following incubation, the ALA is activated with blue light (417 nm, Omnilux Medical) for 4 minutes and 10 seconds providing a dose of 10 J/cm2. The ALA is then rinsed off the patient’s face. The patient is instructed to wear a hat, sunscreen, and avoid direct visible or ultraviolet light for 48-72 hours with strict sun avoidance following this period. For Patients With Significant Sebaceous Hyperplasia The patient’s face is degreased with acetone. ALA 20% topical solution is then applied topically in three passes of different directions to the patient’s face and then allowed to incubate in a dimly lit room at a temperature of 78-80 degrees Fahrenheit for two hours. Following incubation, the ALA is activated with red light (633 nm, Omnilux Medical) for 5 minutes and 51 seconds providing a dose of 37 J/cm2. The patient’s individual sebaceous hyperplasia lesions are then treated with a 595 nm pulsed dye laser with a 10 mm spot size, uence of 7.5 J/cm2, and a pulse duration of 10 milliseconds. The ALA is then rinsed off the patient’s face. The patient is instructed to wear a hat, sunscreen, and avoid direct visible or ultraviolet light for 48-72 hours with strict sun avoidance following this period.
