Levulan

Abstract

Photodynamic therapy with short-contact 5-aminolevulinic acid (Levulan[R] Kerastick[R], Dusa Pharmaceuticals, Inc.) and activation by intense pulsed light in an initial treatment and blue light in 3 subsequent treatments has resulted in significant improvement in severity of acne, reduction in the number of lesions, improvement in skin texture, and smoothing of scar edges in an Asian patient with severe (class 4) facial cystic acne and scarring.

Introduction

Photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) photosensitizing agent has been shown to be an effective treatment of mild to moderate acne, (1-3) intractable acne, (4,5) and moderate to severe acne. (6-8) In this new treatment modality, ALA applied to skin lesions is absorbed and converted to protoporphyrin IX (PpIX), a photosensitive compound. When light of the appropriate wavelength activates PpIX, abnormal cells are selectively destroyed. (9)

This is the first report of the use of short-contact ALA PDT with a sequential combination of IPL and blue light in a patient with severe cystic acne of the face.

Case Report

A 25-year old Asian man (Fitzpatrick type 3) presented with severe (class 4) facial cystic acne lesions greater than 5 mm in diameter and resultant scarring (Figure 1A, 2A). The patient had received antibiotic therapy elsewhere but not isotretinoin (Accutane, Roche US Pharmaceuticals).

Treatment was initiated with microdermabrasions and extractions plus Retin-A cream (0.1%) and hydroquinone (6%). Lesions improved only slightly.

The patient then underwent a series of full-face treatments with ALA (Levulan[R] Kerastick[R], Dusa Pharmaceuticals, Inc., Wilmington, MA) photosensitizing agent topically applied without occlusion. Before ALA was applied, the treated area was anesthetized with BLT numbing cream for 30 minutes. ALA also covered the jaw line.

The patient was given 4 treatments at 3-week intervals. Photoactivation of PpIX was accomplished with intense pulsed light (IPL, Vasculite) equipped with a 560-nm filter in the first treatment and with 417-nm blue light (BLU-U, Dusa Pharmaceuticals, Inc.,) in the next 3 treatments. IPL treatment parameters were 41.3 J/[cm.sup.2], two 2.9-msec pulse duration and 17 msec-delay time cycles, and a third 2.9-msec pulse.

[FIGURE 1 OMITTED]

ALA was in contact with skin for 45 minutes before IPL activation and for 1 hour before blue light activation. Durations of exposure to blue light were 8 minutes, 9 minutes, and 11.5 minutes for the 3 treatments. Treated areas were cooled during IPL exposure (Epicool, OptoGenesis) but not during blue light exposure.

Although the initial ALA-PDT-IPL treatment cleared the brown and red spots, bullae containing oil and facial swelling lasted for 5 days. The patient was then given 3 additional once-weekly ALA-PDT treatments with blue light activation. New lesions appeared after this series of treatments, but none were large and cystic. The patient was very happy with the outcome. Figures 1B, 1C, 2B, and 3 show a dramatic reduction in severity and number of lesions, improvement in the texture of the skin, and smoothing of scar edges.

Discussion

In the ALA PDT for acne, researchers have used polychromatic visible light, (1,5) blue light, (2,6,8) red light from a laser, (3,4) and intense pulsed light (7) for PpIX activation. ALA contact times have been 15 minutes, (2) 15 to 30 minutes, (8) 1 hour, (7) 3 hours, (1,3) and 4 hours. (4,5)

To our knowledge, this is the first report that describes ALA PDT with a sequential combination of IPL and blue light in which the treatment significantly improved the severe cystic acne of a patient who had failed conventional treatments. Our results are consistent with those of Gold et al (7) and of Taub (8) who used IPL and blue light, respectively, in multiple treatments of patients with moderate to severe acne. Gold et al 7 obtained 71.8% improvement with 1-hour ALA contact time and 4 treatment sessions while Taub (8) reported 50% to 75% improvement with 2 to 4 treatments and a 15- to 30-minute ALA contact time.

Our patient was of Asian descent. In Japanese patients with recalcitrant acne, Itoh et al prevented recurrence of lesions for 8 months (4) and obtained good to excellent results with a single ALA PDT session followed by glycolic acid chemical peeling and 1% nadifloxacin cream (4) or 0.12% betamethasone valerate cream. (5) Itoh et al used a 635-nm laser (4) and polychromatic visible light. (5)

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ALA PDT with a sequential combination of IPL and blue light is an important treatment option for patients with severe cystic acne. In-office treatment offers improved compliance over at-home antibiotic and skin therapy.

Disclosure: Dr. Melnick has given lectures for and received discounted equipment and products from Dusa Pharmaceuticals, Inc. He holds a very small amount of stock in this company.

References

1. Hongcharu W, Taylor CR, Chang Y, Aghassi D, Suthamjariya K, Anderson RR. Topical ALA-photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol. 2000;115:183-192.

2. Goldman MP, Boyce S. A single-center study of aminolevulinic acid and 417 nm photodynamic therapy in the treatment of moderate to severe acne vulgaris. J Drugs Dermatol. 2003;2:393-396.

3. Pollock B, Turner D, Stringer MR, et al. Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br J Dermatol. 2004;151:616-622.

4. Itoh Y, Ninomiya Y, Tajima S, Ishibashi A. Photodynamic therapy for acne vulgaris with topical 5-aminolevulinic acid. Arch Dermatol. 2000;136:1093-1095.

5. Itoh Y, Ninomiya Y, Tajima S, Ishibashi A. Photodynamic therapy of acne vulgaris with topical delta aminolevulinic acid and incoherent light in Japanese patients. Brit J Dermatol. 2001;144:575-579.

6. Gold MH. The utilization of ALA-PDT and a new photoclearing device for the treatment of severe inflammatory acne vulgaris--results of an initial clinical trial. J Lasers Surg Med. 2003;15(suppl):46.

7. Gold MH, Bradshaw VL, Boring MM, Bridges TM, Biron JA, Carter LN. The use of a novel intense pulsed light and heat source and ALA-PDT in the treatment of moderate to severe inflammatory acne vulgaris. J Drugs Dermatol. 2004;3(suppl 6):S15-S19.

8. Taub AF. Photodynamic therapy for the treatment of acne: a pilot study. J Drugs Dermatol. 2004;3(suppl 6):S10-S14.

9. Kennedy JC, Pottier RH, Pross DC. Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience. J Photochem Photobiol B. 1990;6:143-148.

Address for Correspondence

Stuart Melnick MD

The Laser & Cosmetic Center

652 North Santa Cruz Avenue, Suite B

Los Gatos, CA 95030

Phone: 408-354-7732

e-mail: smeln@yahoo.com

Stuart Melnick MD

The Laser and Cosmetic Center, Los Gatos, CA

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