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.
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.
In the case of a patient planning to have photodynamic therapy and artifil, which do you recommend be done first?
Photodynamic therapy remodels scars and it would be better to go through several treatments of photodynamic therapy before the placement of a permanent filler.
My 14 year old son had pimples on his chin that developed into cystic acne by August. The day before school started I made an appointment at your office with Dr. Nina Abraham. He was put on Doxycycline and topicals-Sodium Sulfacetamide 9%Sulfur4% Wash and Epiduo, which was supposed to last my son 4 months but he managed to use the entire tube up in one month. His theory- the more product, the faster it will work! Unfortunately we didn’t see much improvement in the 5 weeks he was following this skin routine so he just started Accutane the beginning of this week. Since then I heard “through the grapevine” a doctor friend of mine would not put her teenage boys on it nor recommend it for any of their friends. This prompted my search on the internet for the negatives involving boys taking Accutane and found a lot of disturbing and scathing information. Now I am feeling uncomfortable and culpable for my son taking a medication that in the short run will do wonders for my son’s acne as well as self-confidence but in the long run may sacrifice his health! Below is one of the articles I found which is extremely disheartening, to say the least. Originally, Blue Light Therapy seemed like the remedy but drifted…I am curious to hear your thoughts about the potential long-term risks of developing teenagers using this medication.
The treatment with isotretinoin is never a simple decision. We as dermatologist fear that somehow a pregnant woman or girl could get her hands on it. We also respect the wishes of our patients or their parents and discuss side effects of isotretinoin. Naturally, when a medication can cause birth defects if a pregnant woman takes it, other side effects must be considered. It is therefore the best monitored medication in medicine with monthly blood tests, monthly office visits, 6 month f/u visits as well as careful monitoring through the “ipledgeprogram”. Many of our patients decide n not to take isotretinoin or any other oral medication and treatment alternatives are always available.
The most comparable treatment to isotretinoin is photodynamic therapy (not blue light therapy), which has no systemic effects. Blue light therapy can be effective for mild acne or it used to maintain results when acne has been treated.
Unfortunately, there is no treatment yet that turns off acne over night or for that matter in 5 weeks. Even isotretinoin takes 3-4 months to clear acne and it will remain so in 75% of treated individuals after the treatment course is completed after 5 months. 65% of those who undergo photodynamic therapy remain clear after 4-6 treatments, however the immediate side effects of the treatment are sometimes tough to handle for a teenager. (please take a look at the website).
If you feel uncomfortable with isotretinoin because of media coverage or because in several individuals side effects were attributed to isotretinoin -taking years or decades ago, please follow your conscience. Also, in acne or any other treatment, more does not help more. You would not take an extra dose of a blood pressure medicine in order to drop an elevated pressure faster. In acne treatment, an overuse of topical medication leads to irritation of the skin possibly with oincreased acne activity, and taking doxycycline in high doses can severely damage the liver. Please be sure to discourage your son from this dangerous behavior. Please schedule an appointment with Dr Abraham to discuss the alternatives for your son and please encourage him to be patient with his treatment response.
Hi Dr.Ringpfeil,
I am scheduled to have my photodynamic therapy procedure preformed in the middle of October. Here are some questions I have first:
1.) I know I need to stay out of the sun for 48 hours. I am going to Caribbean in December. How many weeks after the procedure do I have to wait before it is safe to be in the sun again. Keep in mind, I am a big sun worshipper (I know, I know,,,,)
2.) Is there a chance my skin can permanently burn from this procedure?
3.) I read on your site that this procedure will help acne for many months. I thought this was a permanent cure (just as Accutane is). Will the results from 4-6 treatments only last months?
4.) In the 5%- after a week does my face look as clear as before the therapy was performed?
5.) Is there anything I can do to “prepare” my sensitive skin for this procedure? Is it ok to continue meds and topicals until the day of?
1. You cannot have sun exposure for 48 hours after the procedure. Afterwards normal sun protection applies. As you know as a dermatologist I cannot support being a sun worshipper. After any procedure, you should have sun protection for 6 weeks in order to avoid pigmentary changes.
2. There is no permanent damage with this procedure
3. I expect the resolution of the acne to be permanent in those who respond (about 65% of all treated until completely clear, most of the time 4-6 treatments).
4. In those 5% who have a dramatic reaction, the face will be clear after about a week to 10 days. There may still be some pink on the face that quickly fades and can easily be covered by make-up.
5. There is no preparation needed. Known sensitivity of the skin does not seem to play a role with this treatment. It is okay to continue all your medications even through the procedure. There are many instances when we encourage the use of a retinoid right before the procedure. However, I prefer that you do not use any retinoid in order to minimize the chance for a dramatic reaction.