A 68-year-old white male presented with a history of a slowly enlarging erythematous plaque on his left posterior upper arm over the past 7 years. On physical examination, the patient had a 4-cm erythematous, finely scaling, well-demarcated plaque on his left posterior, mid upper arm (Figure 1). Biopsy of the lesion confirmed a diagnosis of Bowen's disease (Figure 2). Given the extensive size of the lesion and location, we opted to treat the patient with photodynamic therapy with topical aminolevulinic acid.
Day one, the patient presented for application of the aminolevulinic acid hydrochloride 20% (ALA) solution at 2:35 pm. The entirety of the contents from a Levulan[R] Kerastick[R] (ALA), 350 mg, was topically applied to the plaque of Bowen's disease on the patient's left posterior upper arm. The plaque was then occluded with a completely opaque dressing (Figure 3). He was instructed to keep this area dry and out of the sun until follow-up the next day at 8 am.
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Day two, the patient returned for follow-up and photodynamic therapy (PDT) using a 630-nm dye laser. A prescribed light dose of 150 Joules/[cm.sup.2] was calculated. The PDT calibrated output power was 2.98 Watts. The treatment area was 12.57[cm.sup.2]. Dose rate being equal to output power/treatment area was 0.237W/[cm.sup.2]. The treatment time, light dose/dose rate, was determined to be 632 seconds (10.5 minutes).
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The ALA was left in place for a total of 18 hours, 25 minutes before treatment. The area was locally anesthetized using 9cc of 2% lidocaine with epinephrine. A 630-nm dye laser was then used to activate the protoporphyrin IX. The perpendicular treatment distance was 7.0 cm with a treatment area of 12.57[cm.sup.2] and field diameter of 4.0 cm (Figure 4). The patient remained motionless during the course of the procedure with out any discomfort. The patient noted significant aching in the treatment zone over the next 18 hours which was relieved with oral narcotics. This quickly resolved and was subsequently asymptomatic for the remainder of the healing process.
At 2 weeks follow-up, the treated plaque was erythematous and still appeared to be significantly inflamed (Figure 5). One week later, at 3 weeks, the erythema and inflammation had substantially subsided (Figure 6). At 1 month, there was very trace erythema in the treatment zone with focal alopecia of the entire area (Figure 7). At two and a half months follow-up, there was no clinical evidence of tumor, only persistent alopecia (Figure 8). The patient remains disease free at over 2 years follow-up (Figure 9). There is still complete alopecia involving the entire 4-mm treatment area. The alopecia supports the fact that topical ALA photodynamic therapy with 630-nm dye laser effectively treats down to the level of the follicular epithelial atypia seen in Bowen's disease.
ERIC C. PARLETTE MD LCDR MC USNR
DERMATOLOGY DEPARTMENT, NAVAL MEDICAL CENTER, SAN DIEGO, CA
ADDRESS FOR CORRESPONDENCE:
Eric C. Parlette MD LCDR MC USNR
Naval Medical Center, San Diego
34520 Bob Wilson Drive, Suite 300
San Diego, CA 92134-2300
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