T he topical application of 5-amino-levulinic acid (ALA) and exposure to a variety of lasers and light sources and photodynamic therapy (PDT), has become a very popular dermatologic procedure for a variety of clinical concerns affecting our patients. Presently, 20% 5-aminolevulinic acid (Levulan) is the only FDA-approved formulation. ALA-PDT is fast becoming a standard treatment for photorejuvenation with and without actinic keratoses (AKs), acne vulgaris, rosacea, sebaceous gland hyperplasia and hidradenitis suppurativa. Researchers have been evaluating variables, such as drug incubation times, different light sources and more. We now know that short-contact, full-face therapy and a variety of lasers and light sources, including the blue light sources, the intense pulsed light (IPL) sources, and the long-pulsed vascular lasers all effectively activate 20% 5-ALA when treating the entities listed above, as well as many other conditions that we see in practice each day. Now that ALA-PDT has become a therapy that is routinely used to enhance our lasers and light sources, we asked a group of ALA-PDT experts to share with us their thoughts regarding use of this product today. The panel included myself, Amy Forman Taub, M.D. (Chicago, IL); Macrene Alexiades-Armenakas, M.D., Ph.D. (New York, NY); Mitchel P. Goldman, M.D. (La Jolla, CA); Dore Gilbert, M.D. (Newport Beach, CA); and Donald Richey, M.D. (Chico, CA). These physicians use ALA-PDT for a variety of medical and cosmetic dermatologic treatments, and are also members of the American Society for Photodynamic Therapy, a new society dedicated to PDT education and research. (For more information, please visit www.aspdt.org.) Q: What kind of medical and/or cosmetic indications have you treated with ALA-PDT, and what type of results did you see? Dr. Gold: We’ve been using ALA-PDT to enhance a variety of lasers and light sources commonly used in our practice. The common indications are for the treatment of photorejuvenation with or without AKs, moderate to severe inflammatory and cystic acne vulgaris, recalcitrant sebaceous gland hyperplasia, and resistant cases of hidradenitis suppurativa. For our photodamage patients, more than 90% realize outstanding clinical results, and about 75% of patients treated for the sebaceous-related conditions realize improvements greater than 75%. Dr. Taub: We’ve been using ALA-PDT to treat AKs, acne, rosacea, sebaceous gland hyperplasia and hidradenitis suppurativa on the medical side. For the cosmetic side, we’ve been using ALA-PDT mainly for photorejuvenation, oily skin and pore reduction. Our results have been so beneficial with many of the mainstream dermatologic issues that we often turn to PDT as a first- or second-line therapy now. Dr. Alexiades-Armenakas: We use ALA-PDT regularly in my practice for the treatment of photodamage, AKs, acne vulgaris, sebaceous hyperplasia, keratoses pilaris, disseminated superficial actinic porokeratosis (DSAP), lichen sclerosis, superficial basal cell carcinomas, lichenoid drug reactions and scars. I have achieved outstanding results in treating these conditions. (Results have been previously published.1,2) As a result of this research, ALA-PDT has become our first-line therapy of choice for AKs, actinic cheilitis and acne vulgaris. Dr. Goldman: We have been using and experimenting with ALA-PDT since it first became available. We’ve been evaluating its use for a variety of concerns including photodamage, AKs, acne vulgaris, sebaceous gland hyperplasia, keratosis pilaris, and DSAP. ALA-PDT has become one of the most popular procedures we perform in our clinic; patients have benefited from the efforts of our investigations and are seeing outstanding results on a regular basis. Dr. Gilbert: We’ve also been using ALA-PDT for many indications and have been at the forefront of sharing our results with other physicians from around the country. We routinely use it to treat acne vulgaris, AKs, sebaceous gland hyperplasia, and for “aggressive” photofacials. Our results have been outstanding with more than 70% of the patients achieving excellent results. Dr. Richey: We primarily use ALA-PDT for acne, AKs, photorejuvenation with an IPL device. We also use ALA-PDT to treat leukoplakia, sebaceous gland hyperplasia and keratosis pilaris. We use ALA-PDT and the Blu-U device to treat AKs, because it’s been effective and results in 2 to 3 days of downtime for our patients versus the 2 to 3 weeks typically seen with other treatment options. Our results for AKs are also very good with a benefit of patients who are happy with the smoothness and texture of their skin. Our results for acne are good to excellent. The results for PDT show improvements in smoothness and texture. Q: What laser and light sources do you commonly use to activate ALA? Dr. Gold: A variety of lasers and light sources have been shown to effectively activate ALA. We routinely use the ClearLight or Blu-U for blue light sources; the Quantum SR, the SkinStation, the MediLux, and the Sciton BBL for IPL light sources, and the V-Star for vascular lasers. When treating AKs and acne, the IPLs and blue lights work best; for sebaceous gland hyperplasia, the vascular devices work best. Dr. Taub: We use the Aurora device (ELOS — pulsed light technology with radiofrequency), the Blu-U and ClearLight systems, and the XEO (600 nm to 800 nm) IPL. Dr. Alexiades-Armenakas: The main light sources we use in conjunction with ALA in my practice are the long-pulsed pulsed dye laser (V-Beam), the blue light (Blu-U), and intense pulsed light device (Galaxy ELOS). Dr. Goldman: Our choices for drug activation include both the ClearLight and Blu-U systems for blue light activation; the Lumenis One and Quantum SR for IPL drug activation; and the V-Star for pulsed dye laser drug activation. Dr. Gilbert: Our machines of choice for ALA-PDT are the VascuLight IPL, the Lumenis One, Aurora ELOS device, the Blu-U and the V-Star. Dr. Richey: In our clinic, we most commonly use the Blu-U and the Quantum SR IPL. Q: Can you share some practical clinical pearls relative to using ALA-PDT with short-contact and full-face application in your daily practices? Dr. Gold: By adding ALA-PDT to our treatment paradigm, our patients have achieved results faster than what we had been seeing previously. The results are also more pronounced, and for diseases like acne vulgaris, providing long lasting remission times. For photodamage and severe AK patients, although I do not have the study data to support this claim, I sense that ALA-PDT is preventing the occurrence of skin cancers. I am just not seeing my old skin cancer patients back in my office two to three times a year for treatments like I used to. Dr. Taub: The most important thing I’ve learned is how ALA-PDT can really change the face of a dermatology practice. Whether a patient comes in with one AK or many, ALA-PDT is the beginning of a “relationship” with that patient that revolves not only around disease treatment, but also “wellness.” Instead of destroying individual lesions with potentially scarring cryotherapy and just waiting for more AKs to occur, we can step in and take control making our patients “look” better in the process of producing healthy skin. When treating acne, I think a parent of a teenager with acne vulgaris would rather try a 6-week course of ALA-PDT, potentially putting the child in remission for 3 to 12 months, versus having their son or daughter take antibiotics for years or isotretinoin for a few months. Also, the techniques involved in ALA-PDT are not difficult to master. Dr. Alexiades-Armenakas: I use ALA-PDT therapy daily. I spend a great deal of attention to patient counseling prior to and after the actual treatments, including informing patients about the potential adverse effects, predominantly photosensitivity following the procedure. I counsel patients on the absolute need to be out of the sun or bright light for 2 days after the procedure and to wear a broad-brimmed hat if they are going to be outside after treatment. With this proper education, my patients have seen very little downtime following ALA-PDT procedures, making it a very useful cosmetic procedure. Dr. Goldman: We have evaluated various drug incubation times, ranging from 15 to 120 minutes, over the past several years. We’ve found that 1-hour drug incubation times work best for photorejuvenation and acne vulgaris treatments. Prior to applying ALA on a patient, we routinely use the Vibraderm microdermabrasion system before a vigorous acetone wash to enhance the absorption of ALA into the skin. Also, it’s important to keep patients in a darkened room while the ALA is on their skin and not to allow them near the sun. We try to perform as many of the treatments as possible in the late afternoon so patients can drive home immediately after the procedure in the dark to minimize any potential photosensitivity. We instruct our patients to stay indoors for the next 24 hours and we have them apply a thermal water spray, such as Avene Thermal Water, and a cream, such as Niadyne, to minimize erythema and irritation. Finally, we will be working with other clinicians evaluating an iron-chelating agent, which we hope will act as a post-PDT reaction quencher. Dr. Gilbert: We routinely use a 60-minute drug incubation for ALA-PDT. When treating severe AK patients, we’ve found that pre-treating with 5-fluorouracil (Efudex) for 4 to 5 days before the ALA-PDT treatment, enhances the efficacy of the ALA-PDT treatments. In addition, a new treatment paradigm of using the Blu-U therapy for several minutes after IPL or pulsed dye laser treatments seems to be giving even better results. Dr. Richey: In my experience, four sessions are needed to treat acne and two are needed to treat AKs. Also, I use 1-hour drug incubation when treating AKs, and for acne I start with 30 minutes and increase the time with each treatment. When using ALA-PDT for photorejuvenation, it’s helpful to proceed treatment with microdermabrasion. Microdermabrasion is performed for some individuals who we feel need enhanced penetration of the ALA, versus acetone scrub. It’s extremely important for patients to avoid sunlight or wear sunblock during the first 24 hours under UV light. Q: In your experience with ALA-PDT, what kind of patient discomfort or adverse events have you seen? Dr. Gold: In the original treatment protocols, with long drug incubation times, most of our patients suffered from a great deal of pain during the procedure and downtime up to 1 week after the procedure. With the new treatment recommendations of short-contact drug incubation and newer, more advanced lasers and light sources, the pain and downtime have virtually been eliminated. During blue light therapy our patients routinely use a Zimmer cooling device, which has served as an excellent source of pain control. After the therapy, we use moisturizers and cooling waters, along with sunscreens, to minimize any photosensitivity. Dr. Taub: About 95% of our patients have no problem — minimal and tolerable erythema and peeling. The good news is that those who have the most erythema and peeling usually have the best outcomes. About 4% to 5% have about 24 hours of discomfort, characterized as a burning sensation, with pronounced erythema. Our protocol includes NSAIDs, topical emollients and cold packs. With some reassurance, patients are usually okay. And, about 1% of patients have extreme reactions with significant exfoliation and a week of downtime. This group usually includes people who have significant sun damage and who do not comply with the warnings of strict sun avoidance. Dr. Alexiades-Armenakas: For AK and photodamage therapy, patient discomfort has been minimal, and I’ve noticed a significant decrease when I use the V-Beam. When I treat acne patients, discomfort has not been an issue with any of the light sources that I routinely use. If patients experience stinging following the procedure, it is usually due to light exposure and they should be reminded to avoid bright light. Rarely, a patient has required an anti-inflammatory prescription, such as fluocinolone acetonide 0.025% (Synalar) to alleviate erythema or edema. Dr. Goldman: We counsel our patients extensively on sun avoidance following the procedures. I agree that sun exposure is a major reason why patients have discomfort following the procedure. Strict sun avoidance, sunscreens and cooling waters help. Again, with the newer lasers and light sources, patient discomfort during the procedure has been minimal, especially with the use of short-contact therapy. We oftentimes use the Zimmer Air Cooling unit while the patient is getting the Blu-U treatment to further minimize any discomfort. Dr. Gilbert: We have minimal patient discomfort with ALA and IPL treatments, especially with the better cooling devices found on the newer IPL devices. Burning, however, is the major symptom my severely sundamaged patients report during the treatment. This can be minimized by using fans and ice packs. Our patients note that their skin is sometimes dry and itchy for several days following treatment. Moisturizers help with these problems. Dr. Richey: In our experience, redness and swelling are universal after treatment. This correlates with the amount of incubation time, which can be easily decreased during a patient’s next treatment. Usually, this is a sign that the patient has been careless with sun protection in the first 24 to 48 hours. Q: What is your rationale for adding ALA-PDT to your photorejuvenation regimen when you’ve been using lasers and light sources successfully for photorejuvenation for the past several years? Dr. Gold: Adding ALA to this paradigm has given us the opportunity to treat our patients with one or two laser treatments versus the five to six treatments that had been traditionally required. Also, results achieved have been superior with ALA-PDT compared to photorejuvenation alone. For my patients who have had five IPL photorejuvenation treatments in the past, a single IPL-ALA-PDT treatment provides a great approach as a maintenance therapy and acts as a potential preventer of skin cancer. Dr. Taub: Adding ALA gives you three things you can’t get without it. It provides a degree of skin clarity that is a whole magnitude greater than that produced by photorejuvenation alone. The skin is bright, it shines and looks newer. Throw away the old concept that you can’t shrink pores, you can only make them look better. PDT does shrink pores. Finally, the ability to rid the skin of precancerous keratinocytes yields the potential of providing a health/wellness benefit that cosmetic procedures usually don’t confer. Look better, shrink pores and prevent skin cancers. It’s a win, win, win. Dr. Alexiades-Armenakas: By adding ALA-PDT to traditional photorejuvenation treatments, I’ve found that we routinely increase the efficacy of the therapy while reducing the number of treatments needed to achieve the desired results. Also, we are removing precancerous cells and improving the skin texture/tone of the skin more so than with traditional photorejuvenation. Dr. Goldman: ALA-PDT works better than our traditional methods for photorejuvenation. Research that we’ve performed shows that one ALA-PDT-IPL treatment has a similar effect as three IPL treatments, and removes AKs as well. I now very rarely use liquid nitrogen therapy to treat any patient. I recommend ALA-PDT to all my patients requesting photorejuvenation. Dr. Gilbert: We get very good results with conventional photofacial treatments, but with the addition of ALA, we are now able to treat AKs while we improve the texture of the patient’s skin. In addition, sebaceous hyperplasia is dramatically reduced with ALA-PDT. Dr. Richey: I added ALA-PDT to my current photorejuvenation treatments because ALA-PDT is the only treatment or process that produces the textural changes in the pores of skin to create a uniform and attractive smoothing effect. It also accentuates results of the IPL or other laser treatments. Q: What has been your experience in treating acne with ALA-PDT treatments? Dr. Gold: The use of ALA-PDT has had a profound effect on those patients who have suffered from moderate to severe inflammatory acne vulgaris and those with cystic acne. We have used the blue light sources and IPLs successfully in a great number of patients using similar protocols as with photorejuvenation. We’ve found that several treatments, performed every other week, have provided long remission times in many of these patients. In clinical trials, ALA-PDT was used as monotherapy, but we believe combining ALA-PDT with some of our routine topical medications may make them work better. This is a big part of our ongoing research. Dr. Taub: ALA-PDT is the only modality that truly works for severe cystic acne, other than isotretinoin. Although ALA-PDT doesn’t work 100% of the time, it works in a significant number of patients. You can also see a recovery of the integrity of the skin and reduction in scarring that exceeds what you would expect from any essentially non-invasive technique. Also, with isotretinoin becoming more regulated and fears heightening regarding the risks of systemic medications, such as long-term antibiotic use, don’t be surprised if within 5 years ALA-PDT becomes a first-line therapy for acne therapy when topicals don’t work. Dr. Alexiades-Armenakas: ALA-PDT has been a major breakthrough in acne treatment at a critical time when isotretinoin is coming under stricter regulation. I tell patients to expect roughly three treatments. I space those treatments at 3-week to 4-week intervals. Remission rates are seen after a series of ALA-PDT treatments for 1 year or longer. Dr. Goldman: ALA-PDT works very well for those with severe acne vulgaris. We’ve used a variety of lasers and light sources and have found them all effective for treating acne. Our patients are usually instructed that it takes three to four treatments to achieve the desired result and long-term remission rates have been quite impressive. I have also found that the use of a salicylic acid cleanser and toner (CoolClenz) before and after treatment enhances the therapeutic results of PDT. In addition, the use of doxycycline hyclate 20 mg b.i.d. (Periostat) before and after treatment enhances results without causing any additional photosensitivity. Dr. Gilbert: ALA-PDT in the treatment of acne vulgaris is one of the most important clinical uses of this treatment modality. In fact, we use ALA-PDT on all patients who express concern regarding the use of long-term antibiotics or who don’t want to take isotretinoin. Dr. Richey: ALA-PDT absolutely works for acne. I call it the topical isotretinoin because it’s the only proven medical combination that will reduce the size of sebaceous oil glands. Q:What clinical pearls have you learned as you’ve implemented ALA-PDT into your medical and cosmetic practices? Dr. Gold: We’ve learned a great deal since incorporating ALA-PDT into our clinical practice in the late 1990s. Pain control and patient downtime were the most serious drawbacks to patient acceptance of the therapy back then. Short-contact, full-face therapy, and newer and better lasers and light sources, have made this a wonderful advent to our clinical practice. Performing microdermabrasion first definitely improves the penetration of ALA and allows for a 30-minute drug incubation time versus 60 minutes without microdermabrasion. Patients really like that they need two to three photorejuvenation treatments with ALA-PDT versus the five they needed with IPL alone. (I still charge the same total price for three combination treatments as I normally do for five IPL alone treatments.) When treating cystic acne, I will sometimes double and triple pulse on areas where there could be some early scarring when we use either PDL or IPL to activate ALA. We are now offering the most state-of-the-art medical and cosmetic procedures and enhancing the results with ALA-PDT. Downtime has virtually been eliminated and our patients have spread the word of ALA-PDT to new patients who want this type of therapy. Dr. Taub: Start with what you know and build from there. It’s easy to start with PDT for AKs. Insurance companies reimburse it to a large degree and patients usually prefer it to topical therapy, which can leave them unsightly for weeks. Get a Blu-U, which isn’t a huge expense and doesn’t take a lot of your time. Convince yourself that it works and that it’s easy. Next, start treating acne with ALA-PDT and then move on to the other procedures it can be used for. In fact, even if you don’t have a cosmetically oriented practice, you can just do a few short-contact blue light ALA-PDT treatments for mild to moderate photodamage and get similar results to what might have taken five treatments with an $80,000 laser. Dr. Alexiades-Armenakas: ALA-PDT needs to be part of the treatment options offered to all patients who present to your office with AKs or actinic cheilitis. I predict that this will also bode true for those presenting with acne, as well, once this indication achieves FDA clearance. Clearly, patients with photodamage are on a continuum with those who already have definitive AKs, so ALA-PDT is eminently appropriate as a first option for photodamage. Dr. Goldman: This is a procedure that works and works well for many patients. It’s hard to believe that I no longer use liquid nitrogen to treat AKs, or that I no longer use topical retinoids, antibiotics, systemic antibiotics or isotretinoin to treat acne. Photodynamic therapy has changed the way I practice dermatology. I am no longer practicing dermatology as I was taught in the 1980s and 1990s. Dr. Gilbert: Because of the enthusiasm that has been generated for ALA-PDT, incorporating the treatment into my practice has been easy. Our patients have had outstanding clinical results and have helped spread the word in the community. If you are just beginning in this field, treat your staff first and watch as they become advocates for ALA-PDT for your practice. ALA-PDT has been a great addition to our practice. Dr. Richey: My primary pearl to share is my personal enthusiasm and willingness to share this treatment program with your patients. Then, in-house, you must share this enthusiasm with staff that will pass it on to the patients. In-house advertising, such as brochures with before-and-after pictures, helps make this an easy choice for our patients. Increasing Use of ALA-PDT The use of ALA-PDT has tremendously increased over the past several years. More clinical entities and more defined clinical parameters have been developed to make this therapy very useful. These experts have shared with you some of their views regarding use of ALA-PDT in their practices. These physicians regularly lecture at medical meetings on the proper use of ALA-PDT and are available to answer questions you may have. Disclosure Statements Dr. Gold is a consultant, performs research, and owns stock in Dusa Pharmaceuticals, Inc., and Lumenis, Inc. Dr. Gold is a consultant to Sciton and Cynosure. Dr. Goldman is a consultant, has received honoraria, research support and discounted equipment from Lumenis, Dusa and Cynosure. Dr. Taub is a consultant for Dusa. She performs research and receives honoraria for talks. Dr. Alexiades-Armenakas was a former consultant to Dusa. Dr. Gilbert is a Dusa stockholder and occasionally speaks on behalf of the company. Dr. Richey could not be reached by press time to disclose any potential conflicts of interest.
The Ever-Increasing Role of ALA-PDT, Part 2
T he topical application of 5-amino-levulinic acid (ALA) and exposure to a variety of lasers and light sources and photodynamic therapy (PDT), has become a very popular dermatologic procedure for a variety of clinical concerns affecting our patients. Presently, 20% 5-aminolevulinic acid (Levulan) is the only FDA-approved formulation. ALA-PDT is fast becoming a standard treatment for photorejuvenation with and without actinic keratoses (AKs), acne vulgaris, rosacea, sebaceous gland hyperplasia and hidradenitis suppurativa. Researchers have been evaluating variables, such as drug incubation times, different light sources and more. We now know that short-contact, full-face therapy and a variety of lasers and light sources, including the blue light sources, the intense pulsed light (IPL) sources, and the long-pulsed vascular lasers all effectively activate 20% 5-ALA when treating the entities listed above, as well as many other conditions that we see in practice each day. Now that ALA-PDT has become a therapy that is routinely used to enhance our lasers and light sources, we asked a group of ALA-PDT experts to share with us their thoughts regarding use of this product today. The panel included myself, Amy Forman Taub, M.D. (Chicago, IL); Macrene Alexiades-Armenakas, M.D., Ph.D. (New York, NY); Mitchel P. Goldman, M.D. (La Jolla, CA); Dore Gilbert, M.D. (Newport Beach, CA); and Donald Richey, M.D. (Chico, CA). These physicians use ALA-PDT for a variety of medical and cosmetic dermatologic treatments, and are also members of the American Society for Photodynamic Therapy, a new society dedicated to PDT education and research. (For more information, please visit www.aspdt.org.) Q: What kind of medical and/or cosmetic indications have you treated with ALA-PDT, and what type of results did you see? Dr. Gold: We’ve been using ALA-PDT to enhance a variety of lasers and light sources commonly used in our practice. The common indications are for the treatment of photorejuvenation with or without AKs, moderate to severe inflammatory and cystic acne vulgaris, recalcitrant sebaceous gland hyperplasia, and resistant cases of hidradenitis suppurativa. For our photodamage patients, more than 90% realize outstanding clinical results, and about 75% of patients treated for the sebaceous-related conditions realize improvements greater than 75%. Dr. Taub: We’ve been using ALA-PDT to treat AKs, acne, rosacea, sebaceous gland hyperplasia and hidradenitis suppurativa on the medical side. For the cosmetic side, we’ve been using ALA-PDT mainly for photorejuvenation, oily skin and pore reduction. Our results have been so beneficial with many of the mainstream dermatologic issues that we often turn to PDT as a first- or second-line therapy now. Dr. Alexiades-Armenakas: We use ALA-PDT regularly in my practice for the treatment of photodamage, AKs, acne vulgaris, sebaceous hyperplasia, keratoses pilaris, disseminated superficial actinic porokeratosis (DSAP), lichen sclerosis, superficial basal cell carcinomas, lichenoid drug reactions and scars. I have achieved outstanding results in treating these conditions. (Results have been previously published.1,2) As a result of this research, ALA-PDT has become our first-line therapy of choice for AKs, actinic cheilitis and acne vulgaris. Dr. Goldman: We have been using and experimenting with ALA-PDT since it first became available. We’ve been evaluating its use for a variety of concerns including photodamage, AKs, acne vulgaris, sebaceous gland hyperplasia, keratosis pilaris, and DSAP. ALA-PDT has become one of the most popular procedures we perform in our clinic; patients have benefited from the efforts of our investigations and are seeing outstanding results on a regular basis. Dr. Gilbert: We’ve also been using ALA-PDT for many indications and have been at the forefront of sharing our results with other physicians from around the country. We routinely use it to treat acne vulgaris, AKs, sebaceous gland hyperplasia, and for “aggressive” photofacials. Our results have been outstanding with more than 70% of the patients achieving excellent results. Dr. Richey: We primarily use ALA-PDT for acne, AKs, photorejuvenation with an IPL device. We also use ALA-PDT to treat leukoplakia, sebaceous gland hyperplasia and keratosis pilaris. We use ALA-PDT and the Blu-U device to treat AKs, because it’s been effective and results in 2 to 3 days of downtime for our patients versus the 2 to 3 weeks typically seen with other treatment options. Our results for AKs are also very good with a benefit of patients who are happy with the smoothness and texture of their skin. Our results for acne are good to excellent. The results for PDT show improvements in smoothness and texture. Q: What laser and light sources do you commonly use to activate ALA? Dr. Gold: A variety of lasers and light sources have been shown to effectively activate ALA. We routinely use the ClearLight or Blu-U for blue light sources; the Quantum SR, the SkinStation, the MediLux, and the Sciton BBL for IPL light sources, and the V-Star for vascular lasers. When treating AKs and acne, the IPLs and blue lights work best; for sebaceous gland hyperplasia, the vascular devices work best. Dr. Taub: We use the Aurora device (ELOS — pulsed light technology with radiofrequency), the Blu-U and ClearLight systems, and the XEO (600 nm to 800 nm) IPL. Dr. Alexiades-Armenakas: The main light sources we use in conjunction with ALA in my practice are the long-pulsed pulsed dye laser (V-Beam), the blue light (Blu-U), and intense pulsed light device (Galaxy ELOS). Dr. Goldman: Our choices for drug activation include both the ClearLight and Blu-U systems for blue light activation; the Lumenis One and Quantum SR for IPL drug activation; and the V-Star for pulsed dye laser drug activation. Dr. Gilbert: Our machines of choice for ALA-PDT are the VascuLight IPL, the Lumenis One, Aurora ELOS device, the Blu-U and the V-Star. Dr. Richey: In our clinic, we most commonly use the Blu-U and the Quantum SR IPL. Q: Can you share some practical clinical pearls relative to using ALA-PDT with short-contact and full-face application in your daily practices? Dr. Gold: By adding ALA-PDT to our treatment paradigm, our patients have achieved results faster than what we had been seeing previously. The results are also more pronounced, and for diseases like acne vulgaris, providing long lasting remission times. For photodamage and severe AK patients, although I do not have the study data to support this claim, I sense that ALA-PDT is preventing the occurrence of skin cancers. I am just not seeing my old skin cancer patients back in my office two to three times a year for treatments like I used to. Dr. Taub: The most important thing I’ve learned is how ALA-PDT can really change the face of a dermatology practice. Whether a patient comes in with one AK or many, ALA-PDT is the beginning of a “relationship” with that patient that revolves not only around disease treatment, but also “wellness.” Instead of destroying individual lesions with potentially scarring cryotherapy and just waiting for more AKs to occur, we can step in and take control making our patients “look” better in the process of producing healthy skin. When treating acne, I think a parent of a teenager with acne vulgaris would rather try a 6-week course of ALA-PDT, potentially putting the child in remission for 3 to 12 months, versus having their son or daughter take antibiotics for years or isotretinoin for a few months. Also, the techniques involved in ALA-PDT are not difficult to master. Dr. Alexiades-Armenakas: I use ALA-PDT therapy daily. I spend a great deal of attention to patient counseling prior to and after the actual treatments, including informing patients about the potential adverse effects, predominantly photosensitivity following the procedure. I counsel patients on the absolute need to be out of the sun or bright light for 2 days after the procedure and to wear a broad-brimmed hat if they are going to be outside after treatment. With this proper education, my patients have seen very little downtime following ALA-PDT procedures, making it a very useful cosmetic procedure. Dr. Goldman: We have evaluated various drug incubation times, ranging from 15 to 120 minutes, over the past several years. We’ve found that 1-hour drug incubation times work best for photorejuvenation and acne vulgaris treatments. Prior to applying ALA on a patient, we routinely use the Vibraderm microdermabrasion system before a vigorous acetone wash to enhance the absorption of ALA into the skin. Also, it’s important to keep patients in a darkened room while the ALA is on their skin and not to allow them near the sun. We try to perform as many of the treatments as possible in the late afternoon so patients can drive home immediately after the procedure in the dark to minimize any potential photosensitivity. We instruct our patients to stay indoors for the next 24 hours and we have them apply a thermal water spray, such as Avene Thermal Water, and a cream, such as Niadyne, to minimize erythema and irritation. Finally, we will be working with other clinicians evaluating an iron-chelating agent, which we hope will act as a post-PDT reaction quencher. Dr. Gilbert: We routinely use a 60-minute drug incubation for ALA-PDT. When treating severe AK patients, we’ve found that pre-treating with 5-fluorouracil (Efudex) for 4 to 5 days before the ALA-PDT treatment, enhances the efficacy of the ALA-PDT treatments. In addition, a new treatment paradigm of using the Blu-U therapy for several minutes after IPL or pulsed dye laser treatments seems to be giving even better results. Dr. Richey: In my experience, four sessions are needed to treat acne and two are needed to treat AKs. Also, I use 1-hour drug incubation when treating AKs, and for acne I start with 30 minutes and increase the time with each treatment. When using ALA-PDT for photorejuvenation, it’s helpful to proceed treatment with microdermabrasion. Microdermabrasion is performed for some individuals who we feel need enhanced penetration of the ALA, versus acetone scrub. It’s extremely important for patients to avoid sunlight or wear sunblock during the first 24 hours under UV light. Q: In your experience with ALA-PDT, what kind of patient discomfort or adverse events have you seen? Dr. Gold: In the original treatment protocols, with long drug incubation times, most of our patients suffered from a great deal of pain during the procedure and downtime up to 1 week after the procedure. With the new treatment recommendations of short-contact drug incubation and newer, more advanced lasers and light sources, the pain and downtime have virtually been eliminated. During blue light therapy our patients routinely use a Zimmer cooling device, which has served as an excellent source of pain control. After the therapy, we use moisturizers and cooling waters, along with sunscreens, to minimize any photosensitivity. Dr. Taub: About 95% of our patients have no problem — minimal and tolerable erythema and peeling. The good news is that those who have the most erythema and peeling usually have the best outcomes. About 4% to 5% have about 24 hours of discomfort, characterized as a burning sensation, with pronounced erythema. Our protocol includes NSAIDs, topical emollients and cold packs. With some reassurance, patients are usually okay. And, about 1% of patients have extreme reactions with significant exfoliation and a week of downtime. This group usually includes people who have significant sun damage and who do not comply with the warnings of strict sun avoidance. Dr. Alexiades-Armenakas: For AK and photodamage therapy, patient discomfort has been minimal, and I’ve noticed a significant decrease when I use the V-Beam. When I treat acne patients, discomfort has not been an issue with any of the light sources that I routinely use. If patients experience stinging following the procedure, it is usually due to light exposure and they should be reminded to avoid bright light. Rarely, a patient has required an anti-inflammatory prescription, such as fluocinolone acetonide 0.025% (Synalar) to alleviate erythema or edema. Dr. Goldman: We counsel our patients extensively on sun avoidance following the procedures. I agree that sun exposure is a major reason why patients have discomfort following the procedure. Strict sun avoidance, sunscreens and cooling waters help. Again, with the newer lasers and light sources, patient discomfort during the procedure has been minimal, especially with the use of short-contact therapy. We oftentimes use the Zimmer Air Cooling unit while the patient is getting the Blu-U treatment to further minimize any discomfort. Dr. Gilbert: We have minimal patient discomfort with ALA and IPL treatments, especially with the better cooling devices found on the newer IPL devices. Burning, however, is the major symptom my severely sundamaged patients report during the treatment. This can be minimized by using fans and ice packs. Our patients note that their skin is sometimes dry and itchy for several days following treatment. Moisturizers help with these problems. Dr. Richey: In our experience, redness and swelling are universal after treatment. This correlates with the amount of incubation time, which can be easily decreased during a patient’s next treatment. Usually, this is a sign that the patient has been careless with sun protection in the first 24 to 48 hours. Q: What is your rationale for adding ALA-PDT to your photorejuvenation regimen when you’ve been using lasers and light sources successfully for photorejuvenation for the past several years? Dr. Gold: Adding ALA to this paradigm has given us the opportunity to treat our patients with one or two laser treatments versus the five to six treatments that had been traditionally required. Also, results achieved have been superior with ALA-PDT compared to photorejuvenation alone. For my patients who have had five IPL photorejuvenation treatments in the past, a single IPL-ALA-PDT treatment provides a great approach as a maintenance therapy and acts as a potential preventer of skin cancer. Dr. Taub: Adding ALA gives you three things you can’t get without it. It provides a degree of skin clarity that is a whole magnitude greater than that produced by photorejuvenation alone. The skin is bright, it shines and looks newer. Throw away the old concept that you can’t shrink pores, you can only make them look better. PDT does shrink pores. Finally, the ability to rid the skin of precancerous keratinocytes yields the potential of providing a health/wellness benefit that cosmetic procedures usually don’t confer. Look better, shrink pores and prevent skin cancers. It’s a win, win, win. Dr. Alexiades-Armenakas: By adding ALA-PDT to traditional photorejuvenation treatments, I’ve found that we routinely increase the efficacy of the therapy while reducing the number of treatments needed to achieve the desired results. Also, we are removing precancerous cells and improving the skin texture/tone of the skin more so than with traditional photorejuvenation. Dr. Goldman: ALA-PDT works better than our traditional methods for photorejuvenation. Research that we’ve performed shows that one ALA-PDT-IPL treatment has a similar effect as three IPL treatments, and removes AKs as well. I now very rarely use liquid nitrogen therapy to treat any patient. I recommend ALA-PDT to all my patients requesting photorejuvenation. Dr. Gilbert: We get very good results with conventional photofacial treatments, but with the addition of ALA, we are now able to treat AKs while we improve the texture of the patient’s skin. In addition, sebaceous hyperplasia is dramatically reduced with ALA-PDT. Dr. Richey: I added ALA-PDT to my current photorejuvenation treatments because ALA-PDT is the only treatment or process that produces the textural changes in the pores of skin to create a uniform and attractive smoothing effect. It also accentuates results of the IPL or other laser treatments. Q: What has been your experience in treating acne with ALA-PDT treatments? Dr. Gold: The use of ALA-PDT has had a profound effect on those patients who have suffered from moderate to severe inflammatory acne vulgaris and those with cystic acne. We have used the blue light sources and IPLs successfully in a great number of patients using similar protocols as with photorejuvenation. We’ve found that several treatments, performed every other week, have provided long remission times in many of these patients. In clinical trials, ALA-PDT was used as monotherapy, but we believe combining ALA-PDT with some of our routine topical medications may make them work better. This is a big part of our ongoing research. Dr. Taub: ALA-PDT is the only modality that truly works for severe cystic acne, other than isotretinoin. Although ALA-PDT doesn’t work 100% of the time, it works in a significant number of patients. You can also see a recovery of the integrity of the skin and reduction in scarring that exceeds what you would expect from any essentially non-invasive technique. Also, with isotretinoin becoming more regulated and fears heightening regarding the risks of systemic medications, such as long-term antibiotic use, don’t be surprised if within 5 years ALA-PDT becomes a first-line therapy for acne therapy when topicals don’t work. Dr. Alexiades-Armenakas: ALA-PDT has been a major breakthrough in acne treatment at a critical time when isotretinoin is coming under stricter regulation. I tell patients to expect roughly three treatments. I space those treatments at 3-week to 4-week intervals. Remission rates are seen after a series of ALA-PDT treatments for 1 year or longer. Dr. Goldman: ALA-PDT works very well for those with severe acne vulgaris. We’ve used a variety of lasers and light sources and have found them all effective for treating acne. Our patients are usually instructed that it takes three to four treatments to achieve the desired result and long-term remission rates have been quite impressive. I have also found that the use of a salicylic acid cleanser and toner (CoolClenz) before and after treatment enhances the therapeutic results of PDT. In addition, the use of doxycycline hyclate 20 mg b.i.d. (Periostat) before and after treatment enhances results without causing any additional photosensitivity. Dr. Gilbert: ALA-PDT in the treatment of acne vulgaris is one of the most important clinical uses of this treatment modality. In fact, we use ALA-PDT on all patients who express concern regarding the use of long-term antibiotics or who don’t want to take isotretinoin. Dr. Richey: ALA-PDT absolutely works for acne. I call it the topical isotretinoin because it’s the only proven medical combination that will reduce the size of sebaceous oil glands. Q:What clinical pearls have you learned as you’ve implemented ALA-PDT into your medical and cosmetic practices? Dr. Gold: We’ve learned a great deal since incorporating ALA-PDT into our clinical practice in the late 1990s. Pain control and patient downtime were the most serious drawbacks to patient acceptance of the therapy back then. Short-contact, full-face therapy, and newer and better lasers and light sources, have made this a wonderful advent to our clinical practice. Performing microdermabrasion first definitely improves the penetration of ALA and allows for a 30-minute drug incubation time versus 60 minutes without microdermabrasion. Patients really like that they need two to three photorejuvenation treatments with ALA-PDT versus the five they needed with IPL alone. (I still charge the same total price for three combination treatments as I normally do for five IPL alone treatments.) When treating cystic acne, I will sometimes double and triple pulse on areas where there could be some early scarring when we use either PDL or IPL to activate ALA. We are now offering the most state-of-the-art medical and cosmetic procedures and enhancing the results with ALA-PDT. Downtime has virtually been eliminated and our patients have spread the word of ALA-PDT to new patients who want this type of therapy. Dr. Taub: Start with what you know and build from there. It’s easy to start with PDT for AKs. Insurance companies reimburse it to a large degree and patients usually prefer it to topical therapy, which can leave them unsightly for weeks. Get a Blu-U, which isn’t a huge expense and doesn’t take a lot of your time. Convince yourself that it works and that it’s easy. Next, start treating acne with ALA-PDT and then move on to the other procedures it can be used for. In fact, even if you don’t have a cosmetically oriented practice, you can just do a few short-contact blue light ALA-PDT treatments for mild to moderate photodamage and get similar results to what might have taken five treatments with an $80,000 laser. Dr. Alexiades-Armenakas: ALA-PDT needs to be part of the treatment options offered to all patients who present to your office with AKs or actinic cheilitis. I predict that this will also bode true for those presenting with acne, as well, once this indication achieves FDA clearance. Clearly, patients with photodamage are on a continuum with those who already have definitive AKs, so ALA-PDT is eminently appropriate as a first option for photodamage. Dr. Goldman: This is a procedure that works and works well for many patients. It’s hard to believe that I no longer use liquid nitrogen to treat AKs, or that I no longer use topical retinoids, antibiotics, systemic antibiotics or isotretinoin to treat acne. Photodynamic therapy has changed the way I practice dermatology. I am no longer practicing dermatology as I was taught in the 1980s and 1990s. Dr. Gilbert: Because of the enthusiasm that has been generated for ALA-PDT, incorporating the treatment into my practice has been easy. Our patients have had outstanding clinical results and have helped spread the word in the community. If you are just beginning in this field, treat your staff first and watch as they become advocates for ALA-PDT for your practice. ALA-PDT has been a great addition to our practice. Dr. Richey: My primary pearl to share is my personal enthusiasm and willingness to share this treatment program with your patients. Then, in-house, you must share this enthusiasm with staff that will pass it on to the patients. In-house advertising, such as brochures with before-and-after pictures, helps make this an easy choice for our patients. Increasing Use of ALA-PDT The use of ALA-PDT has tremendously increased over the past several years. More clinical entities and more defined clinical parameters have been developed to make this therapy very useful. These experts have shared with you some of their views regarding use of ALA-PDT in their practices. These physicians regularly lecture at medical meetings on the proper use of ALA-PDT and are available to answer questions you may have. Disclosure Statements Dr. Gold is a consultant, performs research, and owns stock in Dusa Pharmaceuticals, Inc., and Lumenis, Inc. Dr. Gold is a consultant to Sciton and Cynosure. Dr. Goldman is a consultant, has received honoraria, research support and discounted equipment from Lumenis, Dusa and Cynosure. Dr. Taub is a consultant for Dusa. She performs research and receives honoraria for talks. Dr. Alexiades-Armenakas was a former consultant to Dusa. Dr. Gilbert is a Dusa stockholder and occasionally speaks on behalf of the company. Dr. Richey could not be reached by press time to disclose any potential conflicts of interest.
T he topical application of 5-amino-levulinic acid (ALA) and exposure to a variety of lasers and light sources and photodynamic therapy (PDT), has become a very popular dermatologic procedure for a variety of clinical concerns affecting our patients. Presently, 20% 5-aminolevulinic acid (Levulan) is the only FDA-approved formulation. ALA-PDT is fast becoming a standard treatment for photorejuvenation with and without actinic keratoses (AKs), acne vulgaris, rosacea, sebaceous gland hyperplasia and hidradenitis suppurativa. Researchers have been evaluating variables, such as drug incubation times, different light sources and more. We now know that short-contact, full-face therapy and a variety of lasers and light sources, including the blue light sources, the intense pulsed light (IPL) sources, and the long-pulsed vascular lasers all effectively activate 20% 5-ALA when treating the entities listed above, as well as many other conditions that we see in practice each day. Now that ALA-PDT has become a therapy that is routinely used to enhance our lasers and light sources, we asked a group of ALA-PDT experts to share with us their thoughts regarding use of this product today. The panel included myself, Amy Forman Taub, M.D. (Chicago, IL); Macrene Alexiades-Armenakas, M.D., Ph.D. (New York, NY); Mitchel P. Goldman, M.D. (La Jolla, CA); Dore Gilbert, M.D. (Newport Beach, CA); and Donald Richey, M.D. (Chico, CA). These physicians use ALA-PDT for a variety of medical and cosmetic dermatologic treatments, and are also members of the American Society for Photodynamic Therapy, a new society dedicated to PDT education and research. (For more information, please visit www.aspdt.org.) Q: What kind of medical and/or cosmetic indications have you treated with ALA-PDT, and what type of results did you see? Dr. Gold: We’ve been using ALA-PDT to enhance a variety of lasers and light sources commonly used in our practice. The common indications are for the treatment of photorejuvenation with or without AKs, moderate to severe inflammatory and cystic acne vulgaris, recalcitrant sebaceous gland hyperplasia, and resistant cases of hidradenitis suppurativa. For our photodamage patients, more than 90% realize outstanding clinical results, and about 75% of patients treated for the sebaceous-related conditions realize improvements greater than 75%. Dr. Taub: We’ve been using ALA-PDT to treat AKs, acne, rosacea, sebaceous gland hyperplasia and hidradenitis suppurativa on the medical side. For the cosmetic side, we’ve been using ALA-PDT mainly for photorejuvenation, oily skin and pore reduction. Our results have been so beneficial with many of the mainstream dermatologic issues that we often turn to PDT as a first- or second-line therapy now. Dr. Alexiades-Armenakas: We use ALA-PDT regularly in my practice for the treatment of photodamage, AKs, acne vulgaris, sebaceous hyperplasia, keratoses pilaris, disseminated superficial actinic porokeratosis (DSAP), lichen sclerosis, superficial basal cell carcinomas, lichenoid drug reactions and scars. I have achieved outstanding results in treating these conditions. (Results have been previously published.1,2) As a result of this research, ALA-PDT has become our first-line therapy of choice for AKs, actinic cheilitis and acne vulgaris. Dr. Goldman: We have been using and experimenting with ALA-PDT since it first became available. We’ve been evaluating its use for a variety of concerns including photodamage, AKs, acne vulgaris, sebaceous gland hyperplasia, keratosis pilaris, and DSAP. ALA-PDT has become one of the most popular procedures we perform in our clinic; patients have benefited from the efforts of our investigations and are seeing outstanding results on a regular basis. Dr. Gilbert: We’ve also been using ALA-PDT for many indications and have been at the forefront of sharing our results with other physicians from around the country. We routinely use it to treat acne vulgaris, AKs, sebaceous gland hyperplasia, and for “aggressive” photofacials. Our results have been outstanding with more than 70% of the patients achieving excellent results. Dr. Richey: We primarily use ALA-PDT for acne, AKs, photorejuvenation with an IPL device. We also use ALA-PDT to treat leukoplakia, sebaceous gland hyperplasia and keratosis pilaris. We use ALA-PDT and the Blu-U device to treat AKs, because it’s been effective and results in 2 to 3 days of downtime for our patients versus the 2 to 3 weeks typically seen with other treatment options. Our results for AKs are also very good with a benefit of patients who are happy with the smoothness and texture of their skin. Our results for acne are good to excellent. The results for PDT show improvements in smoothness and texture. Q: What laser and light sources do you commonly use to activate ALA? Dr. Gold: A variety of lasers and light sources have been shown to effectively activate ALA. We routinely use the ClearLight or Blu-U for blue light sources; the Quantum SR, the SkinStation, the MediLux, and the Sciton BBL for IPL light sources, and the V-Star for vascular lasers. When treating AKs and acne, the IPLs and blue lights work best; for sebaceous gland hyperplasia, the vascular devices work best. Dr. Taub: We use the Aurora device (ELOS — pulsed light technology with radiofrequency), the Blu-U and ClearLight systems, and the XEO (600 nm to 800 nm) IPL. Dr. Alexiades-Armenakas: The main light sources we use in conjunction with ALA in my practice are the long-pulsed pulsed dye laser (V-Beam), the blue light (Blu-U), and intense pulsed light device (Galaxy ELOS). Dr. Goldman: Our choices for drug activation include both the ClearLight and Blu-U systems for blue light activation; the Lumenis One and Quantum SR for IPL drug activation; and the V-Star for pulsed dye laser drug activation. Dr. Gilbert: Our machines of choice for ALA-PDT are the VascuLight IPL, the Lumenis One, Aurora ELOS device, the Blu-U and the V-Star. Dr. Richey: In our clinic, we most commonly use the Blu-U and the Quantum SR IPL. Q: Can you share some practical clinical pearls relative to using ALA-PDT with short-contact and full-face application in your daily practices? Dr. Gold: By adding ALA-PDT to our treatment paradigm, our patients have achieved results faster than what we had been seeing previously. The results are also more pronounced, and for diseases like acne vulgaris, providing long lasting remission times. For photodamage and severe AK patients, although I do not have the study data to support this claim, I sense that ALA-PDT is preventing the occurrence of skin cancers. I am just not seeing my old skin cancer patients back in my office two to three times a year for treatments like I used to. Dr. Taub: The most important thing I’ve learned is how ALA-PDT can really change the face of a dermatology practice. Whether a patient comes in with one AK or many, ALA-PDT is the beginning of a “relationship” with that patient that revolves not only around disease treatment, but also “wellness.” Instead of destroying individual lesions with potentially scarring cryotherapy and just waiting for more AKs to occur, we can step in and take control making our patients “look” better in the process of producing healthy skin. When treating acne, I think a parent of a teenager with acne vulgaris would rather try a 6-week course of ALA-PDT, potentially putting the child in remission for 3 to 12 months, versus having their son or daughter take antibiotics for years or isotretinoin for a few months. Also, the techniques involved in ALA-PDT are not difficult to master. Dr. Alexiades-Armenakas: I use ALA-PDT therapy daily. I spend a great deal of attention to patient counseling prior to and after the actual treatments, including informing patients about the potential adverse effects, predominantly photosensitivity following the procedure. I counsel patients on the absolute need to be out of the sun or bright light for 2 days after the procedure and to wear a broad-brimmed hat if they are going to be outside after treatment. With this proper education, my patients have seen very little downtime following ALA-PDT procedures, making it a very useful cosmetic procedure. Dr. Goldman: We have evaluated various drug incubation times, ranging from 15 to 120 minutes, over the past several years. We’ve found that 1-hour drug incubation times work best for photorejuvenation and acne vulgaris treatments. Prior to applying ALA on a patient, we routinely use the Vibraderm microdermabrasion system before a vigorous acetone wash to enhance the absorption of ALA into the skin. Also, it’s important to keep patients in a darkened room while the ALA is on their skin and not to allow them near the sun. We try to perform as many of the treatments as possible in the late afternoon so patients can drive home immediately after the procedure in the dark to minimize any potential photosensitivity. We instruct our patients to stay indoors for the next 24 hours and we have them apply a thermal water spray, such as Avene Thermal Water, and a cream, such as Niadyne, to minimize erythema and irritation. Finally, we will be working with other clinicians evaluating an iron-chelating agent, which we hope will act as a post-PDT reaction quencher. Dr. Gilbert: We routinely use a 60-minute drug incubation for ALA-PDT. When treating severe AK patients, we’ve found that pre-treating with 5-fluorouracil (Efudex) for 4 to 5 days before the ALA-PDT treatment, enhances the efficacy of the ALA-PDT treatments. In addition, a new treatment paradigm of using the Blu-U therapy for several minutes after IPL or pulsed dye laser treatments seems to be giving even better results. Dr. Richey: In my experience, four sessions are needed to treat acne and two are needed to treat AKs. Also, I use 1-hour drug incubation when treating AKs, and for acne I start with 30 minutes and increase the time with each treatment. When using ALA-PDT for photorejuvenation, it’s helpful to proceed treatment with microdermabrasion. Microdermabrasion is performed for some individuals who we feel need enhanced penetration of the ALA, versus acetone scrub. It’s extremely important for patients to avoid sunlight or wear sunblock during the first 24 hours under UV light. Q: In your experience with ALA-PDT, what kind of patient discomfort or adverse events have you seen? Dr. Gold: In the original treatment protocols, with long drug incubation times, most of our patients suffered from a great deal of pain during the procedure and downtime up to 1 week after the procedure. With the new treatment recommendations of short-contact drug incubation and newer, more advanced lasers and light sources, the pain and downtime have virtually been eliminated. During blue light therapy our patients routinely use a Zimmer cooling device, which has served as an excellent source of pain control. After the therapy, we use moisturizers and cooling waters, along with sunscreens, to minimize any photosensitivity. Dr. Taub: About 95% of our patients have no problem — minimal and tolerable erythema and peeling. The good news is that those who have the most erythema and peeling usually have the best outcomes. About 4% to 5% have about 24 hours of discomfort, characterized as a burning sensation, with pronounced erythema. Our protocol includes NSAIDs, topical emollients and cold packs. With some reassurance, patients are usually okay. And, about 1% of patients have extreme reactions with significant exfoliation and a week of downtime. This group usually includes people who have significant sun damage and who do not comply with the warnings of strict sun avoidance. Dr. Alexiades-Armenakas: For AK and photodamage therapy, patient discomfort has been minimal, and I’ve noticed a significant decrease when I use the V-Beam. When I treat acne patients, discomfort has not been an issue with any of the light sources that I routinely use. If patients experience stinging following the procedure, it is usually due to light exposure and they should be reminded to avoid bright light. Rarely, a patient has required an anti-inflammatory prescription, such as fluocinolone acetonide 0.025% (Synalar) to alleviate erythema or edema. Dr. Goldman: We counsel our patients extensively on sun avoidance following the procedures. I agree that sun exposure is a major reason why patients have discomfort following the procedure. Strict sun avoidance, sunscreens and cooling waters help. Again, with the newer lasers and light sources, patient discomfort during the procedure has been minimal, especially with the use of short-contact therapy. We oftentimes use the Zimmer Air Cooling unit while the patient is getting the Blu-U treatment to further minimize any discomfort. Dr. Gilbert: We have minimal patient discomfort with ALA and IPL treatments, especially with the better cooling devices found on the newer IPL devices. Burning, however, is the major symptom my severely sundamaged patients report during the treatment. This can be minimized by using fans and ice packs. Our patients note that their skin is sometimes dry and itchy for several days following treatment. Moisturizers help with these problems. Dr. Richey: In our experience, redness and swelling are universal after treatment. This correlates with the amount of incubation time, which can be easily decreased during a patient’s next treatment. Usually, this is a sign that the patient has been careless with sun protection in the first 24 to 48 hours. Q: What is your rationale for adding ALA-PDT to your photorejuvenation regimen when you’ve been using lasers and light sources successfully for photorejuvenation for the past several years? Dr. Gold: Adding ALA to this paradigm has given us the opportunity to treat our patients with one or two laser treatments versus the five to six treatments that had been traditionally required. Also, results achieved have been superior with ALA-PDT compared to photorejuvenation alone. For my patients who have had five IPL photorejuvenation treatments in the past, a single IPL-ALA-PDT treatment provides a great approach as a maintenance therapy and acts as a potential preventer of skin cancer. Dr. Taub: Adding ALA gives you three things you can’t get without it. It provides a degree of skin clarity that is a whole magnitude greater than that produced by photorejuvenation alone. The skin is bright, it shines and looks newer. Throw away the old concept that you can’t shrink pores, you can only make them look better. PDT does shrink pores. Finally, the ability to rid the skin of precancerous keratinocytes yields the potential of providing a health/wellness benefit that cosmetic procedures usually don’t confer. Look better, shrink pores and prevent skin cancers. It’s a win, win, win. Dr. Alexiades-Armenakas: By adding ALA-PDT to traditional photorejuvenation treatments, I’ve found that we routinely increase the efficacy of the therapy while reducing the number of treatments needed to achieve the desired results. Also, we are removing precancerous cells and improving the skin texture/tone of the skin more so than with traditional photorejuvenation. Dr. Goldman: ALA-PDT works better than our traditional methods for photorejuvenation. Research that we’ve performed shows that one ALA-PDT-IPL treatment has a similar effect as three IPL treatments, and removes AKs as well. I now very rarely use liquid nitrogen therapy to treat any patient. I recommend ALA-PDT to all my patients requesting photorejuvenation. Dr. Gilbert: We get very good results with conventional photofacial treatments, but with the addition of ALA, we are now able to treat AKs while we improve the texture of the patient’s skin. In addition, sebaceous hyperplasia is dramatically reduced with ALA-PDT. Dr. Richey: I added ALA-PDT to my current photorejuvenation treatments because ALA-PDT is the only treatment or process that produces the textural changes in the pores of skin to create a uniform and attractive smoothing effect. It also accentuates results of the IPL or other laser treatments. Q: What has been your experience in treating acne with ALA-PDT treatments? Dr. Gold: The use of ALA-PDT has had a profound effect on those patients who have suffered from moderate to severe inflammatory acne vulgaris and those with cystic acne. We have used the blue light sources and IPLs successfully in a great number of patients using similar protocols as with photorejuvenation. We’ve found that several treatments, performed every other week, have provided long remission times in many of these patients. In clinical trials, ALA-PDT was used as monotherapy, but we believe combining ALA-PDT with some of our routine topical medications may make them work better. This is a big part of our ongoing research. Dr. Taub: ALA-PDT is the only modality that truly works for severe cystic acne, other than isotretinoin. Although ALA-PDT doesn’t work 100% of the time, it works in a significant number of patients. You can also see a recovery of the integrity of the skin and reduction in scarring that exceeds what you would expect from any essentially non-invasive technique. Also, with isotretinoin becoming more regulated and fears heightening regarding the risks of systemic medications, such as long-term antibiotic use, don’t be surprised if within 5 years ALA-PDT becomes a first-line therapy for acne therapy when topicals don’t work. Dr. Alexiades-Armenakas: ALA-PDT has been a major breakthrough in acne treatment at a critical time when isotretinoin is coming under stricter regulation. I tell patients to expect roughly three treatments. I space those treatments at 3-week to 4-week intervals. Remission rates are seen after a series of ALA-PDT treatments for 1 year or longer. Dr. Goldman: ALA-PDT works very well for those with severe acne vulgaris. We’ve used a variety of lasers and light sources and have found them all effective for treating acne. Our patients are usually instructed that it takes three to four treatments to achieve the desired result and long-term remission rates have been quite impressive. I have also found that the use of a salicylic acid cleanser and toner (CoolClenz) before and after treatment enhances the therapeutic results of PDT. In addition, the use of doxycycline hyclate 20 mg b.i.d. (Periostat) before and after treatment enhances results without causing any additional photosensitivity. Dr. Gilbert: ALA-PDT in the treatment of acne vulgaris is one of the most important clinical uses of this treatment modality. In fact, we use ALA-PDT on all patients who express concern regarding the use of long-term antibiotics or who don’t want to take isotretinoin. Dr. Richey: ALA-PDT absolutely works for acne. I call it the topical isotretinoin because it’s the only proven medical combination that will reduce the size of sebaceous oil glands. Q:What clinical pearls have you learned as you’ve implemented ALA-PDT into your medical and cosmetic practices? Dr. Gold: We’ve learned a great deal since incorporating ALA-PDT into our clinical practice in the late 1990s. Pain control and patient downtime were the most serious drawbacks to patient acceptance of the therapy back then. Short-contact, full-face therapy, and newer and better lasers and light sources, have made this a wonderful advent to our clinical practice. Performing microdermabrasion first definitely improves the penetration of ALA and allows for a 30-minute drug incubation time versus 60 minutes without microdermabrasion. Patients really like that they need two to three photorejuvenation treatments with ALA-PDT versus the five they needed with IPL alone. (I still charge the same total price for three combination treatments as I normally do for five IPL alone treatments.) When treating cystic acne, I will sometimes double and triple pulse on areas where there could be some early scarring when we use either PDL or IPL to activate ALA. We are now offering the most state-of-the-art medical and cosmetic procedures and enhancing the results with ALA-PDT. Downtime has virtually been eliminated and our patients have spread the word of ALA-PDT to new patients who want this type of therapy. Dr. Taub: Start with what you know and build from there. It’s easy to start with PDT for AKs. Insurance companies reimburse it to a large degree and patients usually prefer it to topical therapy, which can leave them unsightly for weeks. Get a Blu-U, which isn’t a huge expense and doesn’t take a lot of your time. Convince yourself that it works and that it’s easy. Next, start treating acne with ALA-PDT and then move on to the other procedures it can be used for. In fact, even if you don’t have a cosmetically oriented practice, you can just do a few short-contact blue light ALA-PDT treatments for mild to moderate photodamage and get similar results to what might have taken five treatments with an $80,000 laser. Dr. Alexiades-Armenakas: ALA-PDT needs to be part of the treatment options offered to all patients who present to your office with AKs or actinic cheilitis. I predict that this will also bode true for those presenting with acne, as well, once this indication achieves FDA clearance. Clearly, patients with photodamage are on a continuum with those who already have definitive AKs, so ALA-PDT is eminently appropriate as a first option for photodamage. Dr. Goldman: This is a procedure that works and works well for many patients. It’s hard to believe that I no longer use liquid nitrogen to treat AKs, or that I no longer use topical retinoids, antibiotics, systemic antibiotics or isotretinoin to treat acne. Photodynamic therapy has changed the way I practice dermatology. I am no longer practicing dermatology as I was taught in the 1980s and 1990s. Dr. Gilbert: Because of the enthusiasm that has been generated for ALA-PDT, incorporating the treatment into my practice has been easy. Our patients have had outstanding clinical results and have helped spread the word in the community. If you are just beginning in this field, treat your staff first and watch as they become advocates for ALA-PDT for your practice. ALA-PDT has been a great addition to our practice. Dr. Richey: My primary pearl to share is my personal enthusiasm and willingness to share this treatment program with your patients. Then, in-house, you must share this enthusiasm with staff that will pass it on to the patients. In-house advertising, such as brochures with before-and-after pictures, helps make this an easy choice for our patients. Increasing Use of ALA-PDT The use of ALA-PDT has tremendously increased over the past several years. More clinical entities and more defined clinical parameters have been developed to make this therapy very useful. These experts have shared with you some of their views regarding use of ALA-PDT in their practices. These physicians regularly lecture at medical meetings on the proper use of ALA-PDT and are available to answer questions you may have. Disclosure Statements Dr. Gold is a consultant, performs research, and owns stock in Dusa Pharmaceuticals, Inc., and Lumenis, Inc. Dr. Gold is a consultant to Sciton and Cynosure. Dr. Goldman is a consultant, has received honoraria, research support and discounted equipment from Lumenis, Dusa and Cynosure. Dr. Taub is a consultant for Dusa. She performs research and receives honoraria for talks. Dr. Alexiades-Armenakas was a former consultant to Dusa. Dr. Gilbert is a Dusa stockholder and occasionally speaks on behalf of the company. Dr. Richey could not be reached by press time to disclose any potential conflicts of interest.
