Photodynamic Therapy - Patients ask, Dr. Ringpfeil answers
Please feel free to use the blog below to share information about Photodynamic Therapy or to ask Dr. Franziska Ringpfeil a question that might be of interest to others.
Philadelphia and Mainline Center of Dermatology and Cosmetic Surgery
Photodynamic Therapy
Insider Information: Photodynamic Therapy (PDT) For Acne
Photodynamic therapy is an excellent alternative to Accutane (isotretinoin). It achieves similar results and targets acne only where it is.
Photodynamic therapy is covered by insurance for skin cancer / precancer treatments only. It is not covered for acne, scars, sebaceous gland hyperplasias, and skin rejuvenation.
65-70% of our patients fully control their acne after 4-6 PDT treatments ($650 / treatment) when performed every 4 weeks.
I apply Ameluz photosensitizing agent (rather than the Levulan Kerastick, which I find less effective for acne treatment) and let it incubate on the skin under Seran wrap for 1.5 hours and then activated by red light 633 nm for 3-20 minutes. The exact time will be determined by the tolerance or any redness occurring on the skin during activation.
After the treatment, sun light and fluorescent light protection is crucial for 42 hours after the application of the Metvixia. Most people who undergo PDT have some redness mild swelling for 24 hours after each treatment.
5% of patients experience a severe reaction with bright redness, swelling, and reactivation of acne that lasts intensely for one week and may require oral or topical steroid for several days and oral antibiotic for 10-14 days. If this rare reaction occurs, residual redness on the face may take up to 3-4 weeks to fully resolve. In those who have this severe reaction, only one treatment rather than 4-6 is typically necessary to control the acne. While nobody is pleased while in this severe phase, our patients uniformly said they would do it again given that their acne is gone afterwards or needs only minimal topical medication for control. The severe reaction can be avoided if the incubabtion time is reduced. However, for the majority of people that would mean undertreatment and payment for an ineffective treatment.
- Expected Results
- This photosensitizing treatment effectively treats inflammatory acne, rosacea, sebaceous gland hyperplasias as well as precancerous conditions and superficial skin cancers.
- Preparation
- Levulan Kerastick / Metvixia contains a clear solution of aminolevulinic acid that is applied to the skin for 1 to 2 hours (acne), or several hours (cancers / pre cancers), prior to activation with a light source.
- Post treatment instruction
- Sun exposure and fluorescent light exposure must be strictly avoided for 24-48 hours after the treatment as photosensitivity from the Levulan Kerastick / Metvixia persists for this amount of time. A zinc oxide / titanium dioxide containing sunscreen must be applied to any treated area that can not be covered by clothing.
- Time to desired results
- 4-6 treatments every 2-4 weeks for acne. Usually two treatments, 2 weeks apart, for precancerous conditions/skin cancers. 2-6 treatments, two weeks between treatments, for superficial skin cancers.
- Contraindications
- Sensitivity to aminolevulinic acid, photosensitizing medications.
- Lasting results
- Many months with acne/rosacea, up to 10 years with skin cancer.
- Downtime
- Gradually diminishing redness and peeling for several days. Crusting occurs when skin cancers are present. Topical acne/rosacea treatments can be resumed when the redness has faded.
My post acne hyperpigmentation has faded quite a bit (my acne completely went away for maybe 5 months) but is still visible; my acne has returned with considerably less severity so I only have a few small spots at a time now. Do you think this would be a viable option for me/how many treatments do you estimate it would take?
Mild acne typically responds to PDT in 4 treatments. Please schedule a consultation with any dermatologist in our office to learn of you are a candidate or about all options available to you.
Hello! Given that I am severely allergic to the excipients in the Metvixia photosensitizing agent (namely peanut and almond oils), would it be possible to receive photodynamic treatment for acne with the Levulan Kerastick? Also, are there other photosensitizing agents that could be used alternatively?
Metvixia shoud not be used with a known peanut allergy but has not been available in the US for several years. The currently available photosensitizing agents used in photodynamic therapy are Ameluz and Levulan Kerastick. The former is a bit more effective and is our preferred agent. Ameluz contains soybean extracts and might not be used in someone with a soybean allergy. There is no cross reaction to peanut or almond. Levulan Kerastick does not contain any peanut or tree nut oils. If needed, please make arrangements with our office to receive Levulan. We can order it for you.
I am African American and recently received pdt. I was told to expect to be red after the procedure which I was for 2 days. From the 3rd day till now the 7th day my skin turned from red to severely darkened like a deep tan. It is still present and fading extremely slowly. I followed all the post instructions and wors sunscreen and remained indoors for 48hrs. Wanted to know if African Americans should expect darkening and tanned skin following pdt?? Is this a normal reaction? It’s quite alarming and scary. Wondering if this will be permanent.
After PDT, the skin will be bright red for several days and will be pink or hyperpigmented for 14 days or longer. This is a normal reaction. Whether fair or darkly complected the skin will turn back to normal color.
Hi Dr. Ringfeil. I had light therapy for the purpose of clearing my skin, and I tolerated the treatment well, but I was not prepared for how painful it was to endure. It felt like my skin was on literally on fireand ready to melt at any moment — and my nose was the worst. The procedure was described as being uncomfortable, but it was much more than that. It felt scorching hot, and I was kind of freaking out, but tried my best to stay still and endure the heat. It was so much worse, much more painful than I had ever realized. I did well afterwards, with very few side effects and redness. However, it did improve my breakouts. Is there any treatment that can be done for mild acne that is less painful, or can the light be moved further away from my nose and face? I think I need another treatment or something to keep my skin under control. I am not one for being squeamish about pain, quite the opposite, but this therapy was really rough. In general, I am a big fan of your practice, and have been very happy with you handling my dermatology needs. I have also referred several friends to you. Thanks, M
A number of people experience pain during the activation phase of photodynamic therapy. Many attempts have been made in the past to try to overcome or lessen this discomfort such as fanning cold air, distraction, etc. Very recently, we have started using a new technique that truly avoids pain and has the same efficacy. We significantly reduce medicine contact time before starting activation and let the activation happen over a longer time. There are certainly many other options for topical treatment of mild acne. The advantage of photodynamic therapy is its ability to stop acne.
Hello,
I’ am a 22 year old African American female who has had trouble fighting acne since the age of 9. I now have a lot of black scars and enlarged pores from the damage over years. I need to know if you can help me, if you can make this problem go away for good? My life is horrible. I lack self-confidence and because of that i feel bad about myself, i actually hate who i see in the mirror.
I understand your frustration. Improvement in skin color can be achieved after acne breakouts. A dermatologist or experienced aesthetician can formulate a custom treatment plan with a multifaceted approach comprised of meticulous sun protection, mild glycolic acid peels, microdermabrasion treatments and various fading topicals. It will take patience to get there. Enlarged pores are tough to tackle but can be slightly reduced with glycolic acid.
Can you give more insight to the effectiveness on African American Skin? In addition, if financial constraints limit the amount of treatments possible would you recommend one treatment or another treatment for very severe acne in a 16yr old girl who has had all topical treatments, birth control, antibiotics,and regular acne facials at your office?
Photodynamic therapy works on all skin colors. Photodynamic therapy x 4-6 treatments every 4 weeks and isotretinoin treatments x 5-6 months are the only treatments that are associated with cure. The rate is about 75% for isotretinoin and 70% for photodynamic therapy. Both are indicated for severe acne or when acne is recalcitrant. The cost for isotretinoin treatment is a bit higher than that for photodynamic therapy but isotretinoin treatments, its associated office visits and blood work are often covered by insurance benefits.
We are seriously considering a course of PDT for our son’s severe cystic acne. Isotretinoin is simply not an option given that there is a history of major affective disorders on both sides of the family, and we are unwilling to take the risk of triggering depression or first onset bipolar mania. A quick review of the medical literature on PDT suggests that there is very preliminary empirical support for its efficacy in severe acne, but that the ideal regimen has yet to be determined. That said, most articles seem to point to the efficacy of ALA over MAL. ALA certainly seems to be better tested, and has clear superiority over PDT alone. I am curious as to why you have found that you prefer MAL. Is this based on comparative clinical experience from your own practice? Or is there literature I am not seeing? There certainly don’t seem to be any comparative clinical trials out there. This is clearly early days for the evidence base for this treatment for acne.
It is my personal experience and that of many of the leaders in the field of photodynamic therapy that MAL activated by red light works better in acne. I am aware of the larger volume of published data with ALA compared tp MAL. It has simply been available longer. Clinical trials with a new concentration of MAL and red light for acne are currently ongoing at one site in the US and several sites in Europe but availability of this MAL will not be until
2014 or later. It is expected that acne treatment will be the main indication submitted to the FDA after trials are completed. This may even mean that it could gain insurance coverage. We use both formulations in our office, however, very soon we will only be able to offer ALA as the US manufacturer has seized production of MAL for reimbursement reasons.
Can I use photodynamic treatment if I am currently undergoing treatment for malasma (Micro-Derm and Peel)?
Can an individual with malasma use the photodynamic therapy or will the treatment darken the malasma?
While the wave length used in photodynamic therapy (PDT) is not known to trigger, maintain or worsen melasma, PDT induces inflammation in the skin and could temporary darken areas where you still have melasma. If used to treat acne, I would postpone photodynamic therapy until after the melasma is minimized and if used for enlarged pores it could be performed simultaneously. However, the micropeel treatment schedule may become cumbersome when trying to fit all procedures in as you may not have a glycolic acid peel until 4 weeks after PDT and microdermabrasion should wait for 2 weeks after PDT.
Hello, Just a few question i’d like to ask.
Your website states that results for acne will last “Many Months”. I was under the impression that this would be a permenant solution (or, at least a long-term solution). Does the acne come back just as severe as it was, less severly, or not at all?
Does PDT have other positive effects (such as improved skin texture/tone)?
Also, how effective is it compared to the other acne treatments you provide? Thanks in advance for the clarification.
PDT does indeed achieve a permanent solution for acne in 65-70% who undergo
4-6 treatments. In those who do not clear permanently, acne often improves.
There are some who do not respond to PDT. The phrasing “many months” is not how PDT is characterized for the majority of those receiving this treatment and I will change this to better reflect the outcome.
PDT is used in medicine for other purposes, such as destruction of malignant or premalignant cells, reduction of enlarged pores, treatment of acne scars, for skin rejuvenation when sun damage is present as well other less common conditions. It does improve skin texture.
There are only two treatments that are known to provide cure for acne: PDT and isotretinoin treatment. As stated above, their efficacy is not 100% but it is very remarkable. Isotretinon treatment is associated with a 70-75% cure rate after one treatment course of about 5 months.
All other acne treatments aim at control of the acne until acne naturally ceases.
6 years ago I had a course of accutane to treat moderate acne. It cleared the acne up but created some physical issues which stops me from taking it again. Over the last view years the acne has returned to the same level despite topicals such as proactive + a variety of antibiotics (about 2 years worth). I recently sought out PDT therapy from a recommended skin clinic on my fairly light skin. Levulan for 50 min followed by Cure Light for 10 min and IPL. After 4 days of slowly reduced redness (no other issues) there was no peeling and no noticable change in the acne. The acne seems worse to me since there was no topicals being used. The clinic indicates that this is normal and multiple treatments may be required before results are noticable and that acne may increase at first. Could you please comment on this? With nothing positive to see I’m wondering if this is worthwhile or should I have more patience Also is it beneficial to restart the use of Proactive or similar product while adding a topical retinoid, topical antibiotic and take an oral antibiotic in between PDT as described above. I have all this available to me via an original dematologist prior to seeking out clinic with PDT. Is this too much at one time? BTW I live nowhere near Philly otherwise I would be a patient
It can indeed take several sessions before you see the results with PDT.
Exposure time of levulinic acid can be increased yet swelling and redness may increase as well after the procedure. There is no reason not to use other medicines to control your acne while undergoing PDT. A retinoid is almost always appropriate and when needed can be combined with other topicals or even oral antibiotics (for a brief period of time: 1-2 months).
If a retinoid is used the night before PDT, it increases the strength of treatment yet the intense immediate reaction is sometimes too much to tolerate. I would not change 2 variables at the same time.