Treatment of Mild to Moderate Inflammatory Acne: DISCUSSION
Beginning with Kennedy’s pioneering studies, topical ALA has been studied in skin because it is a nontoxic, naturally occurring substance that targets cells involved in porphyrin synthesis. This new photosensitizing drug has the ability to penetrate the stratum corneum in a variety of skin tumors, basal cell carcinomas, solar keratoses, and squamous cell carcinoma as well as sebaceous glands. Topically applied ALA to photo-aged and photo- damaged skin leads to the accumulation of the photosensitizer, which is activated by exposure to light, and decrease sun-induced, uneven skin pigme- ntion changes and disorders of the pilosebaceous unit.
Hongcharu et al. reported on the use of 5- ALA-PDT for the treatment of acne vulgaris of the back in 22 patients utilizing broadband light and three-hour drug incubation. Significant clinical and statistical improvement of the acne scores were noted after four weekly treatments in all patients compared to control areas; these results persisted for up to 20 weeks. Adverse effects included acneiform folliculitis, postinflammatory hyperpigmentation, superficial peeling and crusting. Itoh et al. reported on an intractable case of acne vulgaris on the face that was treated with 5-ALA PDT after four-hours of drug incubation and a 635nm pulsed excimer-dye laser. The treated area remained clear during the eight-month follow-up period. Erythema and edema were observed after therapy followed by crusting until the areas healed at 10 days. Goldman has reported on short contact (15-minute drug incubation) 5-ALA PDT and an intense pulsed light device or blue light for the treatment of acne vulgaris 58 JH Lee, et al and sebaceous hyperplasia. Treatment was noted to be pain-free and without adverse effects. Relative clearing of the acne vulgaris was observed after two to four weekly treatments. Gold evaluated 10 patients with moderate to severe acne vulgaris utilizing short-contact (30-minute to 1-hour drug incubation) 5-ALA PDT and the blue light system. Four weekly sessions resulted in a response of approximately 60% that persisted till a three-month post-therapy treatment follow-up. Sessions were well-tolerated with no adverse effects. Therefore, in our study, we chose to use 1-hour ALA incubation.
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The results of our study suggest that ALA-PDT with IPL for drug activation is a promising option for acne treatment. Additional studies to optimize ALA-PDT treatment strategies are warranted. For example, preoperative degreasing with 70% alcohol prior to the application of ALA may enhance penetration and result in better outcomes. In addition, frequent treatments at shorter intervals may also improve results. We did nothing in this study to optimize or alleviate the side effects of ALA-PDT. It is unlikely that we by chance used the best conditions of PDT for acne. The dose- response characteristics of ALA-PDT treatment for acne are unknown. Therefore, these and other ideas may be worth pursuing because it is now clear that acne vulgaris responds to ALA-PDT.
As patient requests for less invasive treatment increase and highly effective treatments for common cosmetic skin conditions expand, dermatologists continue to explore and develop new treatment modalities. However, the series of sequential treatments and the high cost of ALA are a burden for some patients. As improved photosensitizers and less expensive light sources are developed, PDT will undoubtedly become a more commonly used alternative for the treatment of a variety of facial epidermal and pilosebaceous disorders.
