Special Article
Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: An international consensus

https://doi.org/10.1016/j.jaad.2006.06.006Get rights and content

Topical photodynamic therapy (PDT) is used to treat nonmelanoma skin cancers, such as actinic keratoses, Bowen's disease, and basal cell carcinoma (superficial and nodular). This article presents up-to-date, practical, evidence-based recommendations on the use of topical PDT using 5-aminolevulinic acid or methyl aminolevulinate for the treatment (and prevention) of nonmelanoma skin cancers. A systematic literature review was conducted (using MEDLINE), and recommendations were made on the basis of the quality of evidence for efficacy, safety/tolerability, cosmetic outcome, and patient satisfaction/preference. Topical PDT is highly effective in the treatment of actinic keratoses, Bowen's disease, superficial and thin nodular basal cell carcinomas, with cosmesis typically superior to that achieved with existing standard therapies. PDT may also be a means of preventing certain nonmelanoma skin cancers in immunosuppressed patients.

Section snippets

Method

These recommendations were developed during a meeting of the International Society for Photodynamic Therapy in Dermatology in January 2005. A systematic literature review was conducted (using MEDLINE), and recommendations were made based on the quality of evidence for efficacy, safety/tolerability, cosmetic outcome, and patient satisfaction/preference. Cosmetic outcome and patient preference are important considerations when treating superficial NMSCs, which generally respond well to treatment

Epidemiology of NMSCs

NMSCs are the most common malignancies in the Caucasian population, accounting for more than one third of all adult cancers in the United States, with approximately 900,000 to 1,200,000 new cases per year,3 up to 18- to 20-fold more than malignant melanoma.4 The incidence of NMSC has been steadily increasing worldwide at a rate of 3% to 8% per year since 1964,5 with greater increases nearer the equator.6 In Australia, the incidences of squamous cell carcinoma (SCC) and basal cell carcinoma

Actinic keratosis

  • PDT is a highly effective treatment for AK, offering the advantage of excellent cosmetic outcome, and should therefore be considered as a first-line therapy. AI

  • MAL-PDT has a superior cosmetic outcome compared with cryotherapy. AI

Bowen's disease

  • Topical PDT is effective in BD, achieving good cosmesis, and is at least as effective as cryotherapy or 5-FU, but with fewer adverse events. Topical PDT should be considered as a first-line therapy for BD. AI

Squamous cell carcinoma

  • There is insufficient evidence to support the routine use of

References (91)

  • P.G. Calzavara-Pinton

    Repetitive photodynamic therapy with topical delta-aminolaevulinic acid as an appropriate approach to the routine treatment of superficial non-melanoma skin tumours

    J Photochem Photobiol B

    (1995)
  • H.A. Kurwa et al.

    A randomized paired comparison of photodynamic therapy and topical 5-fluorouracil in the treatment of actinic keratoses

    J Am Acad Dermatol

    (1999)
  • C.M. Jones et al.

    Photodynamic therapy in the treatment of Bowen's disease

    J Am Acad Dermatol

    (1992)
  • J.C. Kennedy et al.

    Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience

    J Photochem Photobiol B

    (1990)
  • C.S. Ong et al.

    Skin cancer in Australian heart transplant recipients

    J Am Acad Dermatol

    (1999)
  • C.C. Otley et al.

    Skin cancer as a contraindication to organ transplantation

    Am J Transplant

    (2005)
  • P. Jensen et al.

    Skin cancer in kidney and heart transplant recipients and different long-term immunosuppressive therapy regimens

    J Am Acad Dermatol

    (1999)
  • R.M. Szeimies et al.

    Non-oncologic indications for ALA-PDT

    J Dermatolog Treat

    (2002)
  • P. Babilas et al.

    Photodynamic therapy in dermatology—an update

    Photodermatol Photoimmunol Photomed

    (2005)
  • T.L. Diepgen et al.

    The epidemiology of skin cancer

    Br J Dermatol

    (2002)
  • A. Green

    Changing patterns in incidence of non-melanoma skin cancer

    Epithelial Cell Biol

    (1992)
  • G.G. Giles et al.

    Incidence of non-melanocytic skin cancer treated in Australia

    Br Med J (Clin Res Ed)

    (1988)
  • Staples MP, editor. National cancer control initiative 2003. The 2002 National non-melanoma skin cancer survey. A...
  • J.N. Bouwes Bavinck et al.

    The risk of skin cancer in renal transplant recipients in Queensland, Australia. A follow-up study

    Transplantation

    (1996)
  • Szeimies RM. Epidemiology of actinic keratosis, squamous cell carcinoma and basal cell carcinoma. Presented at the...
  • K. Gardlo et al.

    Metvix (PhotoCure)

    Curr Opin Investig Drugs

    (2002)
  • C. Fritsch et al.

    Preferential relative porphyrin enrichment in solar keratoses upon topical application of delta-aminolevulinic acid methylester

    Photochem Photobiol

    (1998)
  • F. Gad et al.

    Photodynamic therapy with 5-aminolevulinic acid induces apoptosis and caspase activation in malignant T cells

    J Cutan Med Surg

    (2001)
  • B.B. Noodt et al.

    Apoptosis and necrosis induced with light and 5-aminolaevulinic acid-derived protoporphyrin IX

    Br J Cancer

    (1996)
  • J.M. Dodson et al.

    Malignant potential of actinic keratoses and the controversy over treatment. A patient-oriented perspective

    Arch Dermatol

    (1991)
  • R.M. Szeimies et al.

    Photodynamic therapy using topical methyl 5-aminolevulinate compared with cryotherapy for actinic keratosis: a prospective, randomized study

    J Am Acad Dermatol

    (2002)
  • M. Freeman et al.

    A comparison of photodynamic therapy using topical methyl aminolevulinate (Metvix®) with single cycle cryotherapy in patients with actinic keratosis: a prospective, randomized study

    J Dermatolog Treat

    (2003)
  • G. Dragieva et al.

    Topical photodynamic therapy in the treatment of actinic keratoses and Bowen's disease in transplant recipients

    Transplantation

    (2004)
  • M. Tarstedt et al.

    A randomized multicenter study to compare two treatment regimens of topical methyl aminolevulinate (Metvix)-PDT in actinic keratosis of the face and scalp

    Acta Derm Venereol

    (2005)
  • D.J. Piacquadio et al.

    Photodynamic therapy with aminolevulinic acid topical solution and visible blue light in the treatment of multiple actinic keratoses of the face and scalp: investigator-blinded, phase 3, multicenter trials

    Arch Dermatol

    (2004)
  • E.W.B. Jeffes

    Levulan®: the first approved topical photosensitizer for the treatment of actinic keratosis

    J Dermatolog Treat

    (2002)
  • M.R. Alexiades-Armenakas et al.

    Laser-mediated photodynamic therapy of actinic keratoses

    Arch Dermatol

    (2003)
  • S. Smith et al.

    Short incubation PDT versus 5-FU in treating actinic keratoses

    J Drugs Dermatol

    (2003)
  • M. Goldman et al.

    ALA/PDT in the treatment of actinic keratosis: spot versus confluent therapy

    J Cosmet Laser Ther

    (2003)
  • D. Touma et al.

    A trial of short incubation, broad-area photodynamic therapy for facial actinic keratoses and diffuse photodamage

    Arch Dermatol

    (2004)
  • S.R. Wiegell et al.

    Pain associated with photodynamic therapy using 5-aminolevulinic acid or 5-aminolevulinic acid methylester on tape-stripped normal skin

    Arch Dermatol

    (2003)
  • A.-M. Wennberg

    Pain, pain relief and other practical issues in photodynamic therapy

    Australas J Dermatol

    (2005)
  • N.H. Cox et al.

    Guidelines for management of Bowen's disease. British Association of Dermatologists

    Br J Dermatol

    (1999)
  • G.F. Kao

    Carcinoma arising in Bowen's disease

    Arch Dermatol

    (1986)
  • S.B. Ball et al.

    Treatment of cutaneous Bowen's disease with particular emphasis on the problem of lower leg lesions

    Australas J Dermatol

    (1998)
  • Cited by (0)

    The recommendations set forth in this article have been prepared for dermatologists on behalf of the International Society for Photodynamic Therapy in Dermatology and reflect the best data available at the time this report was prepared. Caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations of this report. It may be necessary or even desirable to depart from the recommendations in the interests of specific patients or special circumstances. Just as adherence to these recommendations may not constitute a defense against a claim of negligence, so deviation from them should not necessarily be deemed negligent.

    Funding sources: The work of the IPDT was supported by an educational grant from Galderma International, Paris, France.

    Disclosure: Dr Braathen has received speakers' honoraria from Galderma International. He is currently a consultant for PhotoCure. The department of Dermatology, chaired by Dr Braathen, has received financial support from Galderma International and PhotoCure for performing clinical trials. Dr Szeimies received financial support for performing clinical trials, has served as a consultant for, and has received speakers' honoraria from Galderma International. He has received financial support from Biocam GmbH, Energist, Medac, 3M, PhotoCure, Waldmann Medizintechnik, and Wavelight AG for performing clinical trials. Dr Basset-Seguin does consultant work for Galderma and has a consultancy agreement with 3M. Dr Bissonnette has served as a consultant and received research grants to conduct clinical trials from PhotoCure. He has received research grants to conduct basic and clinical trials from DUSA Pharmaceuticals, QLT Inc, and Quest Pharmatech. Dr Foley has been paid for PDT trials sponsored by PhotoCure ASA, Galderma, and QLT; and non-NMSC trials by Peplin and 3M. He has received honoraria and travel bureaux from PhotoCure and Galderma for presentations at national and international congresses and symposia and has received honoraria for attending meetings as a member of Galderma Australia's Medical Advisory Board. He has acted as a consultant to Galderma Australia, 3M Australia, and Peplin. Dr Pariser has served as an investigator and consultant with Galderma International and an investigator with PhotoCure and DUSA Pharmaceuticals. Dr Wennberg has taken part in clinical trials with Galderma International, Photocure, 3M, and Fujisawa. She has received fees for giving lectures from Galderma International, PhotoCure, 3M, Fujisawa, and Schering Plough. Dr Morton has received financial support for performing clinical trials and speakers' honoraria from Galderma. He has received travel scholarships from 3M, PhotoCure, and Phototherapeutics Ltd and has received support for performing clinical trials from PhotoCure and Schering AG.

    View full text