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Enfermedad de Bowen , Carcinoma Basocelular , Fotoquimioterapia , Neoplasias Cutáneas , Ácido Aminolevulínico/uso terapéutico , Enfermedad de Bowen/tratamiento farmacológico , Carcinoma Basocelular/tratamiento farmacológico , Carcinoma Basocelular/patología , Humanos , Fármacos Fotosensibilizantes/uso terapéutico , Neoplasias Cutáneas/tratamiento farmacológico , Neoplasias Cutáneas/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Photodiagnostic investigations are essential for the accurate diagnosis of abnormal cutaneous photosensitivity and provide important information for the management of patients with photodermatoses (cutaneous photosensitivity disorders). Although photodiagnosis has been undertaken since the early 1970s, specialist services in the United Kingdom (UK) and Republic of Ireland are limited and there is no formal guidance on diagnostic approach. Indeed, there is a limited literature in this area of methodology and diagnostic practice. OBJECTIVES: The primary objective was to undertake a British Photodermatology Group Workshop to review the role and activities of specialist centres in the UK and Republic of Ireland in order to ascertain whether there were consensus practices. Secondary objectives were to identify key priorities for service, training and research. METHODS: An initial detailed survey review of current activities was undertaken prior to the Workshop and data from this survey were used to inform discussion at the Workshop, which was attended by key photodermatology experts from the UK and Republic of Ireland. RESULTS/CONCLUSIONS: We have undertaken a detailed review of current Photodiagnostic Services in the UK and Republic of Ireland and report on our findings from the 12 centres and we have identified key areas of consensus practice. This is an important step in the process of standardising and optimising procedures and protocols and defining minimum clinical standards for photodiagnostic investigations, which are of such diagnostic importance in Dermatology.
Asunto(s)
Enfermedades de la Piel , Humanos , Irlanda , Encuestas y Cuestionarios , Reino UnidoRESUMEN
BACKGROUND: Topical photodynamic therapy (PDT) is widely used to treat superficial nonmelanoma skin cancer and dysplasia, and is generally well tolerated. However, as with all treatments, adverse effects may occur and awareness may facilitate approaches to prevention and management. OBJECTIVES: To review the available evidence relating to the adverse effects of topical PDT, to help inform recommendations in updated clinical guidelines produced by the British Association of Dermatologists and British Photodermatology Group, and the efficacy of preventative and therapeutic approaches. METHODS: This review summarizes the published evidence related to the adverse effects of topical PDT and attempts to interpret this evidence in the context of patient risk and management. RESULTS: Pain and discomfort during PDT are acute adverse effects, which can be minimized through the use of modified and low-irradiance PDT regimens and do not therefore usually limit successful treatment delivery. Other adverse effects include the risk of contact allergy to photosensitizer prodrugs, although this is rare but should be kept in mind, particularly for patients who have received multiple PDT treatments to larger areas. There are no other significant documented longer-term risks and, to date, no evidence of cumulative toxicity or photocarcinogenic risk. CONCLUSIONS: Topical PDT is usually well tolerated, reinforcing the utility of this important therapeutic option in dermatology practice. The main acute adverse effect of pain can typically be minimized through preventative approaches of modified PDT regimens. Other adverse effects are uncommon and generally do not limit treatment delivery.
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Dolor Agudo/terapia , Manejo del Dolor/métodos , Fotoquimioterapia/efectos adversos , Fármacos Fotosensibilizantes/efectos adversos , Neoplasias Cutáneas/tratamiento farmacológico , Dolor Agudo/etiología , Administración Cutánea , Consenso , Femenino , Humanos , Persona de Mediana Edad , Fotoquimioterapia/métodos , Fármacos Fotosensibilizantes/administración & dosificaciónAsunto(s)
Ácido Aminolevulínico/análogos & derivados , Dolor Asociado a Procedimientos Médicos/diagnóstico , Fotoquimioterapia/efectos adversos , Fármacos Fotosensibilizantes/efectos adversos , Administración Cutánea , Adulto , Anciano , Anciano de 80 o más Años , Ácido Aminolevulínico/administración & dosificación , Ácido Aminolevulínico/efectos adversos , Enfermedad de Bowen/terapia , Carcinoma Basocelular/terapia , Femenino , Fluorescencia , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Asociado a Procedimientos Médicos/etiología , Fotoquimioterapia/métodos , Fármacos Fotosensibilizantes/administración & dosificación , Estudios Retrospectivos , Factores Sexuales , Neoplasias Cutáneas/terapia , Resultado del TratamientoAsunto(s)
Dermatosis del Pie/tratamiento farmacológico , Dermatosis del Pie/radioterapia , Dermatosis de la Mano/tratamiento farmacológico , Dermatosis de la Mano/radioterapia , Psoriasis/tratamiento farmacológico , Psoriasis/radioterapia , Terapia Ultravioleta , 5-Metoxipsoraleno/administración & dosificación , Hospitales de Enseñanza , Humanos , Metoxaleno/administración & dosificación , Terapia PUVA , Fármacos Fotosensibilizantes/uso terapéutico , Estudios RetrospectivosRESUMEN
BACKGROUND: Topical photodynamic therapy (PDT) is an established treatment option for low-risk basal cell carcinoma (BCC). OBJECTIVES: To compare efficacy, cosmesis and tolerability of PDT for BCC with alternative treatments. METHODS: MEDLINE, PubMed, Embase and CENTRAL databases were searched from inception until 1 September 2017. Included studies were randomized controlled trials (RCTs) of PDT for nodular (n) and superficial (s) BCC reporting at least one of the following outcomes: clearance at 3 months and sustained at 1 or 5 years; recurrence at ≥ 1 year; cosmesis; adverse events; tolerability. RESULTS: From 2331 search results, 15 RCTs (2327 patients; 3509 BCCs) were included. PDT efficacy (5-year sustained clearance) was high but inferior to excisional surgery [nBCC pooled risk ratio (RR) 0·76; 95% confidence interval (CI) 0·63-0·91], and without re-treatment of partially responding lesions, was modestly inferior to imiquimod (sBCC: RR 0·81; 95% CI 0·70-0·95) and similar to fluorouracil (sBCC: RR 0·88; 95% CI 0·75-1·04). Five-year sustained clearance was inferior with conventional vs. fractionated PDT (sBCC: RR 0·76; 95% CI 0·68-0·84). PDT cosmesis was superior to surgery (sBCC: RR 1·68, 95% CI 1·32-2·14; nBCC: RR 1·82, 95% CI 1·19-2·80) and cryosurgery (BCC: RR 3·73, 95% CI 1·96-7·07), and without re-treatment of partially responding lesions was similar to imiquimod (sBCC: RR 1·01, 95% CI 0·85-1·19) and fluorouracil (sBCC: RR 1·04, 95% CI 0·88-1·24). Peak pain was higher but of shorter duration with PDT than topical treatments. Serious adverse reactions were rarer with PDT than imiquimod (sBCC: RR 0·05, 95% CI 0·00-0·84) and fluorouracil (sBCC: RR 0·11, 95% CI 0·01-2·04). Combination PDT regimens demonstrated reduced recurrence and improved cosmesis; however, results from these small studies were often nonsignificant. CONCLUSIONS: PDT is an effective treatment for low-risk BCC, with excellent cosmesis and safety. Imiquimod has higher efficacy than single-cycle PDT but more adverse effects. Highest efficacy is with excisional surgery. Fractionated and combination PDT options warrant further study.
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Antineoplásicos/administración & dosificación , Carcinoma Basocelular/terapia , Fotoquimioterapia/métodos , Fármacos Fotosensibilizantes/administración & dosificación , Neoplasias Cutáneas/terapia , Administración Tópica , Antineoplásicos/efectos adversos , Carcinoma Basocelular/patología , Criocirugía/efectos adversos , Criocirugía/métodos , Fraccionamiento de la Dosis de Radiación , Estética , Humanos , Imiquimod/administración & dosificación , Imiquimod/efectos adversos , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/prevención & control , Dolor/diagnóstico , Dolor/etiología , Dimensión del Dolor , Seguridad del Paciente , Fotoquimioterapia/efectos adversos , Fármacos Fotosensibilizantes/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Neoplasias Cutáneas/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Guidelines recommend treating actinic keratoses (AKs) as they are recognized as precursors of invasive squamous cell carcinoma. OBJECTIVE: The objective of this study was to collect real-world clinical data on the use of methyl aminolevulinate daylight photodynamic therapy (MAL DL-PDT) for the treatment of face and scalp AK in Europe. METHODS: A prospective, multicenter, non-interventional study was conducted in six European countries in patients receiving a single treatment of MAL DL-PDT for face and/or scalp AK. Patient-reported outcomes were assessed by patient questionnaires at baseline and at 3 months after treatment, efficacy was assessed at 3 months using a 6-point global improvement scale, and adverse events (AE) were recorded at each visit. RESULTS: Overall, 325 patients were enrolled from 52 investigational centres, 314 of whom attended the 3-month visit. Most patients had multiple lesions (58.4% had >10 lesions) with lesions mainly located on the scalp (60.0%) and/or forehead (54.2%). AKs were predominantly grade I (39.4%) or grade II (33.2%), and 10.5% of patients had grade III lesions. The proportions of patients and physicians that were overall satisfied to very satisfied with the MAL DL-PDT treatment were 80.4% and 90.3%, respectively. The vast majority of patients (90.0%) would consider using MAL DL-PDT again if needed. Physician-assessed efficacy at 3 months was at least much improved in 83.5% of patients, with 45.9% of patients requiring no retreatment. Related AEs were reported in 15% of patients. CONCLUSION: Use of MAL DL-PDT for multiple face and/or scalp AKs resulted in high levels of patient and physician satisfaction in clinical practice in Europe, reflecting the good efficacy and high tolerability of this convenient procedure.
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Ácido Aminolevulínico/análogos & derivados , Actitud del Personal de Salud , Dermatosis Facial/tratamiento farmacológico , Queratosis Actínica/tratamiento farmacológico , Satisfacción del Paciente , Fotoquimioterapia/métodos , Fármacos Fotosensibilizantes/uso terapéutico , Dermatosis del Cuero Cabelludo/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Ácido Aminolevulínico/uso terapéutico , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Fotoquimioterapia/efectos adversos , Médicos/psicología , Estudios Prospectivos , Luz Solar , Encuestas y CuestionariosRESUMEN
Background The Scottish Photobiology Service is the national referral pathway for patients with cutaneous photosensitivity diseases in Scotland. We reviewed the pattern of diagnosis of photosensitivity diseases and investigations performed between 1989 and 2015. Methods and Results Data were collected from the Photodiagnostic Database, annual reports and paper records. The total number of patients assessed each year was stable over the period studied (median 242 [range 231-266]), with most being new patients (median 69 [range 62-73]%). Monochromator phototesting was the most utilised investigation, although the use of provocation testing and photopatch testing has increased. The most common diagnosis was polymorphic light eruption, and there was a trend to increasing diagnosis of photoaggravated atopic eczema. Conclusions The pattern of diagnosis of photosensitivity diseases remains fairly stable in Scotland and we wish to emphasise the importance of this Scottish specialist service for patients with photosensitivity diseases and referrers.
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Programas Nacionales de Salud/estadística & datos numéricos , Fotobiología/estadística & datos numéricos , Trastornos por Fotosensibilidad/diagnóstico , Humanos , Programas Nacionales de Salud/tendencias , Fotobiología/tendencias , Derivación y Consulta/estadística & datos numéricos , Escocia , Enfermedades Cutáneas Genéticas/diagnósticoAsunto(s)
Antioxidantes/administración & dosificación , Jugos de Frutas y Vegetales , Ribes , Protectores Solares/administración & dosificación , Rayos Ultravioleta/efectos adversos , Ácido Ascórbico/administración & dosificación , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastornos por Fotosensibilidad/prevención & control , Fitoterapia/métodos , Polifenoles/administración & dosificación , Envejecimiento de la Piel/efectos de los fármacosRESUMEN
OBJECTIVES: To review the Tayside home phototherapy service, including numbers of patients treated, diagnoses and outcomes, side-effects and safety, cost-effectiveness and absolute costs. To consider why home or outpatient phototherapy is not available to all patients who might benefit and how this could be addressed. STUDY DESIGN: Observational and cost analysis. METHODS: Analysis of the Tayside home phototherapy database 1998 and 2011, home phototherapy patient questionnaires, outcome data, costs and a comparison with outpatient phototherapy. Review of literature and current national guidelines for phototherapy, traditional systemic and biologic therapies for psoriasis. RESULTS: 298 courses of home narrowband UVB (NB-UVB) phototherapy were undertaken by 212 patients between 1998 and 2011, five courses in 1998 increasing to 36 in 2011. The main diagnoses treated were psoriasis (72%), atopic dermatitis (8%), and desensitization of photodermatosis (7%). For psoriasis, 74.5% achieved clearance or minimal residual activity in a median of 30 exposures (range 10-60). The estimated costs to the hospital ranged from £229 to £314 per course (£307 to £422 per effective course for psoriasis), compared with £114 for out-patient therapy (£149 per effective course for psoriasis). The total cost to society (hospital and patient costs) is around £410 per course, compared to an estimated £550 for outpatient therapy for this group of patients. Treatment was well tolerated, erythema rates were similar to outpatient therapy, there were no complaints and the vast majority would choose home over outpatient phototherapy if required in the future. CONCLUSIONS: Hospital supervised home phototherapy appears as safe and effective as outpatient therapy and provides equality of access for patients who cannot attend for outpatient therapy. These patients may otherwise be inadequately treated or given more costly and higher risk systemic therapies, particularly for psoriasis. Commissioners and clinicians involved in dermatology services should provide accessible phototherapy for all patients who might benefit, utilizing home phototherapy where outpatient access is not possible.
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Accesibilidad a los Servicios de Salud/economía , Servicios de Atención de Salud a Domicilio/economía , Fototerapia/economía , Psoriasis/terapia , Atención Ambulatoria/economía , Enfermedad Crónica , Análisis Costo-Beneficio , Bases de Datos Factuales , Investigación sobre Servicios de Salud , Humanos , Psoriasis/economía , Encuestas y Cuestionarios , Reino UnidoRESUMEN
There is good evidence to support the use of topical PDT for superficial nonmelanoma skin cancer and dysplasia; however, there is little information available on the structure, process and outcomes of PDT in clinical practice. We undertook a national survey to determine how PDT was being undertaken in dermatology centres in Scotland. We highlight important information on the practicalities of PDT service delivery and the types of patients and diagnoses treated, and provide preliminary information on the outcomes achieved. These data will be invaluable as a starting point to agree on minimum standards for PDT and criteria to audit against these standards.
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Fotoquimioterapia/normas , Neoplasias Cutáneas/tratamiento farmacológico , Administración Tópica , Auditoría Clínica , Humanos , Guías de Práctica Clínica como Asunto , EscociaRESUMEN
The choice of light source is important for the efficacy of photodynamic therapy (PDT) of non-melanoma skin cancer. We simulated the photodynamic dose (PDD) delivered to a tumour during PDT using theoretical radiation transfer simulations performed via our 3D Monte Carlo radiation transfer (MCRT) model for a range of light sources with light doses up to 75 J cm(-2). The PDD delivered following superficial irradiation from (A) non-laser light sources, (B) monochromatic light, (C) alternate beam diameters and (D) re-positioning of the tumour within the tissue was computed. (A) The final PDD deposited to the tumour at a depth of 2 mm by the Paterson light source was 2.75, 2.50 and 1.04 times greater than the Waldmann 1200, Photocure and Aktilite, respectively. (B) Tumour necrosis occurred at a depth of 2.23 mm and increased to 3.81 mm for wavelengths 405 and 630 nm, respectively. (C) Increasing the beam diameter from 10 to 50 mm had very little effect on depth of necrosis. (D) As expected, necrosis depths were reduced when the tumour was re-positioned deeper into the tissue. These MCRT simulations show clearly the importance of choosing the correct light source to ensure optimal light delivery to achieve tumour necrosis.
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Luz , Método de Montecarlo , Fotoquimioterapia/métodos , Neoplasias Cutáneas/tratamiento farmacológico , Humanos , Modelos Biológicos , Fotoquimioterapia/instrumentación , Factores de TiempoRESUMEN
Whole-body ultraviolet (UV)A1 (340-400 nm) phototherapy was first introduced 30 years ago, but is currently available in the UK in only three dermatology departments. A workshop to discuss UVA1 was held by the British Photodermatology Group in May 2009, the aim of which was to provide an overview of UVA1 phototherapy and its role in practice, and to identify areas in which further studies are required. The conclusions were that UVA1 phototherapy is an effective treatment in several inflammatory skin diseases, including localized scleroderma and atopic eczema (AE); however, deficiencies and limitations exist in the published evidence base. For most diseases, such as AE, other treatments also exist, which are generally more effective than UVA1. However, for some diseases, particularly morphoea, the evidence of efficacy is stronger for UVA1 than for other treatments. Acute adverse effects of UVA1 are minimal. The risk of long-term adverse effects, particularly skin cancer, is unknown. Medium to high doses of UVA1 are needed for efficacy in most situations, but the equipment to deliver such doses is large, expensive and difficult to install. UVA1 is currently underprovided, and the recommendation of the workshop is that more tertiary centres should have access to UVA1 phototherapy in the UK.