Nodular BCC Recurrence High After Photodynamic Therapy

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS