“Rejuvenation with methylaminolevulinatephotodynamic therapy”
Macedo, O.R.; Bussade, M.; Fujimura, M.; Salgado, A.G.; Secco, L.C.; Wippel, C.
Background and objectives:
Photodynamic therapy(PDT) using methyl aminolevulinate (MAL) as a precursor for the photosensitizer protoporphyrin XI (PpXI) has proven to be an effective and well tolerated treatment for actinic keratosis (AKs), non-melanoma skin cancer, basal cell carcinoma, Bowen’s disease as well as off-label uses like photorejuvenation and the treatment of acne vulgaris, sebaceous gland hyperplasia, rosacea, and hirsutism.
Topical photodynamic therapy with methylaminolevulinate (MAL) has proven to be effective and a promising technique in the treatment of actinically damaged and photoaged skin as a new tool in optical skin rejuvenation.
The mecanism of MAL used on PDT is based on intracellular transformation of MAL to Pp XI followed by light exposure, wich induces phototoxicity.
The aim of this study was to assess the efficacy and tolerability of MAL in PDT treatment of AKs and photodamaged skin and introduce a new modality of rejuvenation: nonablative skin resurfacing or photodynamic photorejuvenation using methylaminolevulinate and red light.
Materials and Method:
Ten healthy patients with actinic keratosis and mild to severely facial photodamage were enrolled in the study.
Ten patients (8 females and 2 males), mean age 64 years (range 51 to 78 years old),skin phototypes I- IV with multiple AKs and mild to severe photodamaged skin of face,arms, chest and hands were enrolled. Three patients presented superficial basal cell carcinoma (sBCC) in upper lip and dorsal nose. There was no history of skin diseases. No laser or any other cosmetic treatment was performed in the previous 3 months.
After a superficial curettage for removing scales and crusts, was applied MAL (Metvix Galderma, France) only on Aks and superficial basal cell carcinoma (sBCC) under occlusive and light shielding dressing. After 2 hours the dressing was removed, and a 1mm thick layer of cream was applied on whole face or arms, chest and hands for 1 hour more. After 3 hours the cream was washed with 0.9% saline solution and the face was illuminated with 37J/ cm2 red light (Aktilite CL 128 : Photocure ASA, Oslo, Norway) for 8 minutes on each side of the treated area.All patients tolerated well the pain during the procedure. A single treatment was performed to 8 pacients, 3 pacients who were heavy smokers and with superficial basal cell carcinoma (sBCC) the treatment consisted of 2 sessions 7 days apart.
Digital photography and patient satisfaction surveys were used to assess the degree of healing and global rejuvenation.
PDT exposures were well tolerated. Side effects were primarily light sensitivity, erythema, swelling, scales lasting no more than 7 days.
Post treatment phototoxicity , swelling, erythema, scales are normally found after treatment and gradually faded within 1-3 days.
Pacients were advised to avoid bright light and direct sun exposure for 24-48 hours after the treatment and mandatory use of daily sunblock.
All 10 patients cleared AKs and reported an overall subjective improvement in the quality of their skin without the adverse effects of more invasive technology.
After the first PDT session, all visibile AKs were cleared and after the second one, the basal cell carcinoma were no longer present and a biopsy was performed after showing scar lesion. There was an improvement in the patient’s overall (skin appearance, skin texture, elasticity and in superficial wrinkling). Digital photography and patient satisfaction were assessed after 1 month and 7 patients declared to be very satisfied, 2 moderately and 1 slightly satisfied.
Clinical improvement on photoaging, mottled hyperpigmentation, fine lines, roughness , sallowness was seem on all patients. There was also smoothing and softening of perioral and periorbital rhytides. The cosmetic outcome was always good.
Photodamage, abnormal pigmentation or vascularity, textural problems, rhytides, and laxity due to chronological aging are the primary complaints of the majority of patients. Advances in new technology over the past decade have provided the skin correction specialist with new options for treatment. We demonstrated that MAL PDT when applied to the whole face increases the clearance of AKs with an excellent cosmesis and improvement of the clinical manifestations of chronic photodamage: spots, sallowness, skin texture, and fine lines. All patients rated their overall level of satisfaction as very good. MAL-PDT has been shown to be effective as an alternative treatment for sBCC.
Indications to date are that it is as effective as other therapies while providing significantly better cosmetic outcome. Mechanisms of action of PDT in photochemorejuvenation are lagerly unknown. PDT kills the malignant keratinocytes of AKs via necrotic and apoptotic pathways and the modulation of the immune responses plays a relevant role as well. PpXI can accumulate, although at a lower extent ,also in the keratinocytes and the photodynamic damage could increase the epidermal turnover and reduce the increased thickness of stratum corneum and granular layer. Enhanced metabolism of fybroblast and modulation of the activity of dermal inflammatory infiltrates may represent the biological basis of changes on subepidermic area.
PDT can also prevent the development of new AKs.
The adverse event profile associated with MAL-PDT was consistent with known clinical experience and not unexpected for this treatment modality. Two patients developed an inflammation reaction after treatment, which was reported as aggravated acne. A similar inflammatory response has been reported following ALA-PDT.
As the demand for less invasive, highly effective cosmetic procedures grows, dermatologists must continue to explore and develop new treatment options.
PDT with MAL and red light is a very good alternative in the treatment of patients with AKs that demand an excellent cosmetic outcome and also intend to improve their photodamage skin with high degree of satisfaction. The use of MAL photodynamic full-face broad-application therapy is now able to bridge the world of medical and cosmetic dermatologic surgery. We consider that PDT with MAL is a new tool in optical skin rejuvenation. However more studies are needed to assess the long term duration of these terapeutic effects and in order to better understand the molecular mechanism of rejuvenation.
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