Photodynamic therapy

Photodynamic therapy (PDT) is a treatment used mainly for superficial types of skin cancer. PDT is effective in treating actinic keratoses and superficial basal cell carcinomas. It may also be used for treatment of small, thin, low-risk nodular basal cell carcinomas outside of the head and neck area.

Superficial basal cell carcinoma

Intraepidermal carcinoma

Actinic keratoses

PDT is also sometimes used off-label for facial rejuvenation and to treat mild to moderate acne. Several other conditions have also been studied and may respond to PDT such as psoriasis, warts, mycosis fungoides and extramammary Paget's disease.

What is PDT and how does it work?

PDT utilises photosensitising agents, oxygen and light, to create a photochemical reaction that selectively destroys cancer cells. Photosensitising agents are drugs that are administered into the body through topical, oral or intravenous methods. In the body, they concentrate in cancer cells and only become active when light of a certain wavelength is directed onto the area where the cancer is. The photodynamic reaction between the photosensitising agent, light and oxygen kills the cancer cells.

Photosensitising agents 

Methyl aminolevulinic acid cream

• Registered for use in NZ for the treatment of actinic keratoses and superficial basal cell carcinoma
• Used with red light or daylight
• Cutaneous photosensitvity resolves within 24 hours after application

Aminolevulinic acid hydrochloride topical solution

• Registered in the USA for the treatment of actinic keratoses
• Used with blue light

BF-200 ALA gel

• Registered in the USA for the treatment of actinic keratoses
• Nanoemulsion formulation containing 10% aminolaevulinic acid hydrochloride
• Used with red light, BF-RhodoLED  

Porfimer sodium

• Not registered for use in NZ
• Administered intravenously
• Causes generalised cutaneous photosenstivity that can last for months

Benzoporphyrin derivative monacid ring A

• Second-generation photosensitisers undergoing evaluation

Tin ethyl etiopurpurinLutetium texaphyrin

Light sources

Light sources used in PDT include laser or nonlaser light.

Laser light has the advantages of being:

• Monochromatic (exactly one colour/wavelength that corresponds with the peak absorption of the photosensitising agent)
• Coherent (able to focus lightwaves to specific site)
• Intense (high irradiance allowing for shorter treatment times).

Laser light is suitable for small skin lesions whilst nonlaser light is better for the treatment of large skin lesions as the field of illumination is larger. Nonlaser light that emits polychromatic light is also suitable when using different photosensitisers with different absorption maxima.

Natural daylight is used successfully as a light source for the treatment of actinic keratoses.

What is PDT used for?

PDT is currently being used or investigated as a treatment for the following skin conditions:

• Actinic keratoses on the face and scalp
• Basal cell carcinomas
• Intraepidermal squamous carcinoma (squamous cell carcinoma in situ, Bowen disease)
• Squamous cell carcinoma
• Mycosis fungoides (cutaneous T-cell lymphoma)
• Kaposi sarcoma
• Psoriasis
• Viral warts.

How is PDT given?

Stage 1

• Photosensitising drug is applied to the lesion. The skin may be gently scraped (curettage) or needled beforehand to increase the amount of the drug absorbed.
• Waiting for a period of time (usually between 3 and 6 hours) allows the drug to concentrate in the cancer cells.

Stage 2

• Laser light or nonlaser light is shone directly on to the treated area.
• Treatment usually last between 5 and 45 minutes.
• The treated area is covered with a dressing.
• Depending on the type of lesion being treated and the photosensitising chemical used, a 2nd cycle of treatment may be given 7–10 days later.

Stage 3

• A sunburn reaction occurs, which usually heals within 4 to 8 weeks.

What are the possible side effects of PDT?

Side effects from PDT are due to the treated area being sensitive to light. The photosensitivity usually lasts about 24 hours (depending on the specific agent). Side effects may include:

• Burning/stinging sensation
• Swelling and redness
• Crusting
• Itchiness
• Peeling and blisters
• Skin infections.

The treated area should be protected from light exposure using a dressing. A local anaesthetic such as lignocaine (lidocaine) spray may be applied to the treatment area before or during Stage 2 of the procedure to help relieve pain.

The treated skin lesion may blister and ulcerate as the cancer cells die off. This may take several weeks to heal. Scarring is generally minimal (but can be moderate). Loss of pigmentation may occur sometimes and can be permanent.

Although photosensitising drugs concentrate in cancer cells, they can also make healthy cells more sensitive to light. This is not a problem when photosensitising creams are used as they are localised to the treatment site. It is more of a problem when photosensitising drugs are given by mouth or injected intravenously. These patients may find all parts of their body sensitive to light and should take precautions to protect themselves from light for the necessary period of time (may be days or weeks depending on the photosensitising drug used).