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PHOTODYNAMIC THERAPY - A ‘SIMPLE’ TWO STEP
PROCESS
First step:
Levulan Kerastick (20% aminolevulinic acid - ALA) is a
clear solution which is applied to freshly cleaned skin.
ALA occurs naturally in the body, and is involved in heme
synthesis. The skin absorbs the ALA and converts it to a
natural photosensitizer called Protoporphryn IX (Pp IX).
After a period of 30-60 minutes, the area is illuminated
with an appropriate light source. This 30-60 minute
application time is termed the Levulan incubation period.
Short incubations of Levulan are a departure of the
traditional method of leaving the Levulan on for 14-18 hours
(overnight) prior to activation with light. Short incubation
times retain efficacy but diminish discomfort and side
effects. There is normally NO discomfort to the patient with
short incubation times and 8-10 minutes of BLU-U light
therapy or IPL activation.
(Note: Levulan is indicated for the treatment of actinic
keratosis with an incubation time of 14-18 hours and
activation under the BLU-U for 16 minutes and 40 seconds.
Unfortunately, this length of incubation time results in
painful treatments with prolonged redness of the skin.
Recently, research has shown that one can achieve superb
clinical results with incubation times of 30-60 minutes and
exposure times of 8-12 minutes under the BLU-U.)
Second step:
The area of skin which was treated with the Levulan is
now illuminated to start the Photodynamic process of singlet
oxygen production. Levulan may be activated with any of the
following light sources; Blu-U Light System, ClearLight
System, Intense Pulse Light Systems or Pulse Dye Lasers. See
protocols section for appropriate use with the different
technologies. Light activation results in the release of
singlet oxygen from Pp IX and destruction of the target cell
membrane.
Patients should avoid exposure of the areas treated with
the Levulan Kerastick to sunlight or bright indoor light for
24 hours following blue light treatment. Exposure may result
in stinging and/or burning sensation and may cause erythema
or edema of the lesions. Patients should protect treated
lesions from the sun by wearing a wide-brimmed hat or
similar head covering of light-opaque material. Sunscreens
will not protect against photosensitivity reactions caused
by visible light. However, opaque sun-blocking agents such
as zinc oxide will provide some protection in the first 24
hours. Levulan should be washed off the skin using soap and
water following the light activation.
Dr. Martin Braun has had the most experience in Canada to
date using Levulan with the BLU-U employing his short
incubation time protocol which is as follows:
| ACNE: |
| 1. |
15 minutes twice weekly or 30 minutes once weekly
under the BLU-U alone. There are no side effects with
this treatment, and efficacy is about 50% reduction
in lesions for papular-pustular acne.
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| 2. |
A far better treatment is to use Levulan with the
BLU-U: First, wash the face with soap and water and
then degrease the skin with an acetone scrub or
perform microdermabrasion. Then apply one Kerastick of
Levulan over the entire face and allow it to incubate
for 30 minutes. Then place the patient under the BLU-U
for 8-10 minutes with the facial skin 10 cm from the
light source. There will be no pain with this
treatment. However, the patient must stay away from
sunlight for 24 hours following this treatment.
Remember to wash off the Levulan with soap and water
and perhaps a second acetone wash AFTER the BLU-U
exposure. Treatments can be repeated every 2-4 weeks.
The patient will experience redness and perhaps some
peeling for 3-7 days. Hydrocortisone 1% cream QID will
help post-treatment. Hydrocortisone ointment is better
if acne is not involved. |
| 3. |
Subsequent treatment sessions may need longer
incubation times depending on the patient's response
and tolerance to redness and peeling. Try adding 15
minutes incubation time per treatment session
depending on patient tolerance. Some individuals do
not become very red following Levulan treatment, and
could probably tolerate longer incubation times of
60-120 minutes. |
| 4. |
The preceding incubation times are for the face. Other
areas of the body, such as the neck, chest, upper limbs,
and back require longer incubation times as they are
not as sebaceous as the face. Usually, most patients
will tolerate incubation times of 2-3 hours on these
areas. Plus, it is easy to cover up any redness for a
few days when the face is not involved in the
treatment. |
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WHAT IS PHOTODYNAMIC THERAPY?
HOW MUCH IMPROVEMENT CAN I EXPECT?
HOW MANY TREATMENTS WILL IT TAKE TO SEE THE “BEST RESULTS”?
WHAT ARE THE DISADVANTAGES?
WHAT ARE THE ADVANTAGES?
TREATMENT STEPS
WHY MICRODERMABRASION?
WHAT IS PHOTODYNAMIC THERAPY?
Photodynamic Therapy (PDT) is a special treatment performed with a topical
photosensitizing agent called Levulan (5-aminolevulinic acid or ALA) activated
with the correct wavelength of light. This is also known as “ALA/PDT treatment”.
These treatments remove sun damaged pre-cancerous zones and spots called actinic
keratosis. Sun damage, fine lines, and blotchy pigmentation are also improved
because of the positive effect of Levulan and the light treatment. ALA/PDT
treatment also has the unique ability to minimize pores and reduce oil glands,
effectively treating stubborn acne vulgaris, acne rosacea, and improve the
appearance of some acne scars.
HOW MUCH IMPROVEMENT CAN I EXPECT?
Patients with severe sun damaged skin manifested by actinic keratosis, texture, and tone changes including mottled pigmentation and skin laxity may see excellent results. You may also see improvement of large pores and pitted acne scars. Active acne can improve dramatically.
HOW MANY TREATMENTS WILL IT TAKE TO SEE THE “BEST RESULTS”?
To achieve maximum improvement of pre-cancerous (actinic keratosis) sun damage, skin tone and texture, a series of three treatments 2-4 weeks apart is the most effective. Some patients with only actinic keratosis are happy with just one treatment. More treatments can be done at periodic intervals in the future to maintain the rejuvenated appearance of the skin.
WHAT ARE THE DISADVANTAGES?
Following PDT, the treated areas can appear red with some peeling for 2-7 days. Some patients have an exuberant response to PDT, and experience marked redness of their skin. Temporary swelling of the lips and around your eyes can occur for a few days. Darker pigmented patches called liver spots can become temporarily darker and then peel off leaving normal skin. (This usually occurs over seven to ten days.) Repeat treatments may be necessary as PDT medicine is not an exact science.
WHAT ARE THE ADVANTAGES?
| 1. |
Easier for patients than repeated topical liquid nitrogen, Efudex (5FU), or Aldara because the side effects are minimal, rapid healing, and only 1-3 treatments required. |
| 2. |
The ALA/PDT treatment at our clinic is painless verses liquid nitrogen, 5-FU, and Aldara. |
| 3. |
Reduced scarring and improved cosmetic outcome compared with cautery, surgery and Efudex. Liquid nitrogen can leave white spots on your skin. |
| 4. |
Levulan improves the whole facial area treated creating
all one color, texture, and tone rather than just spot treating with liquid nitrogen, cautery and
surgery. In summary, PDT matches the “Ideal treatment” for photodamaged
skin:
- well tolerated (essentially painless)
- easily performed by a specialty clinic environment
- non-invasive (no needles or surgery required)
- excellent cosmetic outcome (particularly in cosmetic sensitive areas of the face)
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TREATMENT STEPS
| 1. |
Patients who have a history of recurring cold sores (Herpes simplex type I) should start oral Valtrex 500 mg tablets, two tablets twice daily for three days - starting this prescription the morning of your PDT treatment. The prescription for this product will be ordered for you. |
| 2. |
Make sure your skin is clean and free of all makeup, moisturizers, and sunscreens. Bring a hat, sunglasses, and scarf when appropriate to the clinic. |
| 3. |
Photography will be done by the staff before the Levulan is applied. |
| 4. |
You must sign a consent form. |
| 5. |
An acetone scrub is performed. This will enhance the absorption of the Levulan and to give much more even uptake. |
| 6. |
Levulan is applied topically to the whole area - whole zone to be treated (such as the whole face, back of the hands, extensor part of the forearms). This is done by Dr. Braun or his staff. |
| 7. |
The Levulan is left on for 30-60 minutes before any light treatment. |
| 8. |
The Levulan is activated with a unique spectrum of light beginning with low energy levels. This is painless but requires about 8 minutes to complete. |
| 9. |
Post-treatment instructions will be given to you to care for your improved skin. |
WHY MICRODERMABRASION?
A typical short contact photodynamic therapy treatment begins with a
light microdermabrasion. This technique is used to remove any dead skin cells on the surface
of the face, which allows for better penetration of the aminolevulinic acid. The
microdermabrasion is followed by a topical application of aminolevulinic acid, which is
left in place for approximately 30 to 60 minutes. The medication is then removed using
an alcohol swab, soap and water. Finally, the patient is treated with a laser or light source.
Photodynamic Therapy is an essentially painless procedure for the patient. While initial results may be seen as early as the first session, some patients require a series of three to five sessions to see significant results. However, it really depends on the patient and the severity of the skin condition being treated.
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