It’s not that it doesn’t work, it is because there are much better options out there. PDT should be employed as a specific treatment as indicated, & not viewed as a ‘what else can we use it for treatment.’  In the context of skin rejuvenation PDT has many limitations including-

• The inability to treat pigmentation & pigmented sunspots
• Minimal to no improvement of wrinkles & fine lines
• Minimal to no dermal remodelling

Better photo rejuvenation treatments include thulium laser resurfacing, BBL & fractional lasers as well as old fashioned Jessner TCA Peels (this works so well!). My main indication for PDT is lesion specific treatment or in the context of reducing solar dysplasia – sun spots in DVA patients.

Less than a week in most cases. For small spots including superficial basal cell cancers such as BCCs & IECs you do not require time off work.

For field treatment of sunspots or solar keratosis, recovery takes between 3-7 days. Recovery takes longer with in-clinic illumination compared to DIY daylight PDT. Be guided by your dermatologist.

Yes. It can be uncomfortable, especially if we treat large amounts of skin & sun damage. For big cases I normally provide pain relief before illumination of PDT. Daylight PDT is less painful. For in-clinic treatments we use a combination of –

• Oral & injectable sedation & painkillers
• Cryotherapy sprays
• Cooling air
• Short breaks

My nurses will ensure that your treatment is comfortable. Remember if you have pain-relief medication you can not drive for at least 6 hours.

This is a new method of delivering PDT. Some dermatologists use this protocol, others will perform traditional in-clinic illumination. Though the literature supports the use of daylight to illuminate the PDT chemicals (known as ALA or aminolaevulinic acid), most dermatologists (including myself), feel that illumination with low level lasers & light emitting diodes are more effective.

Daylight PDT protocol will differ according to your dermatologist. It goes something like this-

1. A photosensitiser agent ( 5-ALA or Metvix) is administered by your dermatologist.
2. After washing your face with an appropriate cleanser, a suitable chemical sunscreen will be applied to the treatment areas. Thick scales are removed prior to application.  Once the skin is prepped, ALA cream is applied on to the treatment areas.
3.  You will then go outside for daylight exposure within 30 minutes of application. Daylight exposure will continue for 2-2.5 hours. Do not expose your skin to direct sunlight, sit in the shade. You can take toilet breaks as required.
4.  After two hours of daylight exposure, remove the residual cream from the treated areas. Wash with Cetaphil cleanser.
5. UV exposure should be avoided for 5 days following treatment. Use sunscreen and moisturisers as needed.
6. It will take 2-5 days before redness in the treated areas subside.

   

Your dermatologist will discuss other options to treat your sun damage, depending on your downtime, budget & goals. Modalities include-

• Cryotherapy or freezing
• Curettage
• Efudix- 5FU
• Daylight PDT
• Aldara- Imiquimod
• Ablative laser resurfacing
• Fractional laser resurfacing
• Chemical peels
• Retinoids – peels, creams & tablets

Laser resurfacing provides the best cosmesis as it markedly reduces sun damage to both DNA & addresses wrinkles & pigmentation.

Efudix is the cheapest way to deal with sun spots. It also works very well, however the recovery takes 3 to 4 weeks.

Quoted clearance rates will differ according to which paper you read. It also depends on how you prep the lesions prior to illumination & adjunctive treatments. As a guide-

Superficial cancers including sBCCs & Bowen’s; cure rate ranging between 80-92%. Depends on the site & treatment cycles.

Solar keratosis, remission rates are usually measured at 12 months & range between 70-80+ %.

Nope. PDT is only suitable for superficial skin cancers. Your dermatologist will guide you accordingly. Most of us follow these guidelines. PDT is suitable for-

• Superficial basal cell cancers
• IEC or superficial squamous cell cancers
• Sunspots including solar keratosis

PDT is not suitable for pigmented lesions or high-risk basal cell – squamous cell cancers.

PDT is a relatively safe procedure; however side effects can occur. These include-

Acute pustular reaction (seen in 5% of cases). This is transient & consists of multiple acne like lesions due to massive inflammation. Looks dramatic & scary but settles down within a few days.

Infection; including cold sore virus. This is why we prescribe antivirals to those with a history of cold sores.

Persistent redness, including a flare up of rosacea. Again common, easily manageable with anti-inflammatories & vascular lasers.

Blistering & hyperacute reactions are known to happen. Spectacular, painful but easily managed by your dermatologist.

Spill over reactions occur because the PDT cream seeps from the original site. Ooops. This results in streaky redness as light activates the chemical on normal skin. It will settle down.

Yes, it does, especially if combined with lasers. The advantage of PDT is that it treats solar dysplasia or DNA damaged skin via a process called photo rejuvenation. Sun damage can be cosmetic, namely brown spots & dots, red splotchy skin, & broken capillaries. Damage can also lead to abnormal or dysplastic cells.

My usual combination for photo rejuvenation is PDT with activation of low level lasers & fractional laser resurfacing. In some cases, I perform lasers prior to application of PDT as it increases absorption rates of the compound. This is termed laser assisted drug delivery. My combinations include-

• PDT & LLLT with blue & red light
• PDT & vascular lasers
• Laser assisted PDT with thulium or low density fractional CO2 laser
• PDT followed by 1927 lasers

DVA patients: No out of pocket expenses if you hold a Gold or White card for skin.

General population: Single lesion from $350, field treatments from $1290.

Though I perform PDT, my advice is that high density thulium lasers including Fraxel give much better results with less discomfort, downtime & in most cases less expense. 

Medicare does not cover PDT treatment. You may get back a nominal sum from some insurance companies.

The Department of Veteran Affairs or DVA covers PDT for the management of sunspots or solar keratosis, basal cell cancers & other superficial skin cancers. Check if you qualify for this procedure; namely Gold Card holders or White Card for skin associated treatments.

Be guided by your dermatologist. Remember, there are many ways to approach skin. Most dermatologists will give you the best options for your skin condition. In some cases, it is PDT, in others simple topicals, tablets, or lasers may be better options.

My most frequently applied indications for PDT is the treatment of superficial cancers, & solar keratosis in DVA patients (as PDT is covered). For general photo rejuvenation, lasers are far more effective, cost effective & less painful than PDT.

Yup, it sure can. Kleresca is actually PDT. It uses a form of aminolaevulinic acid or ALA & is activated by two wavelengths of blue light.  The second wavelength is used as a marketing tool as this is a point of difference compared to normal light sources. PDT can be useful for the management of acne, in particular –

• Patients wanting to spend a lot of money on a trending treatment
• Patients seeking a temporary treatment
• Those who would like to avoid medical treatment

My viewpoint on PDT for acne is that it is a useful modality for select patients. For example, pilots or those who are thinking of joining the aviation industry who are risk averse to the side effects of isotretinoin. Additionally, if isotretinoin is contraindicated, PDT can be a sensible and effective option.