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EDITORIAL
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PpIX Fluorescence, AU
In conventional photodynamic therapy (PDT) for the treatment of actinic keratoses (AK), 5-aminolevulinic acid (ALA) or
methyl aminolevulinate (MAL) is applied to the skin after gentle
curettage and stays there for a defined period of time (often
3 hours) to ensure accumulation of protoporphyrin IX
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(PpIX).1 During this time the
treated area must be covered against light by a bandage. After
the PpIX accumulation, certified lamps are used for a short illumination of the photosensitized skin to activate PpIX.2,3 In
this process PpIX loses its activity and fluorescence property.
The emission spectrum of the lamps must cover wavelengths
that are absorbed by PpIX to a high degree, and absorbed by
other skin components to a low degree. This is done to ensure skin penetration, especially when treating thicker lesions. The absorption peaks of PpIX are found around 412, 509,
544, 582, and 635 nm, mainly in the blue, green, and red parts
of the spectrum.4 Conventional PDT is often associated with
pain and inflammation, and PDT with daylight as the activating light source, daylight PDT, was invented to overcome
some of these problems.5
The expression daylight PDT implies that the conventional light source has simply been replaced by daylight. This,
however, is not the most important change in the methodology. The fundamental change is that PpIX is activated continuously by daylight exposure from about 30 minutes after MAL
application, when PpIX starts forming in the skin (Figure).5 Illumination must then be performed continuously for 2 hours.6
The treated area does not have to be protected from light at any
time. With this procedure there is no build-up of PpIX because
it is inactivated as quickly as it is formed (Figure). During the
first half hour the patients may be outdoors, indoors, or driving home, but should then be outdoors during the following 2
hours of daylight illumination, eg, in their own garden. The advantage of this PDT procedure is that it is practically painless,
as opposed to conventional PDT, while it also reduces posttreatment inflammation to some degree.7 Inflammation causes erythema, discomfort, and irritation of the skin for days after treatment, and often results in downtime away from work.8 To
further reduce erythema the PDT treatment may be combined
with topical glucocorticosteroid without losing efficacy.9
In general, daylight PDT can be performed all year around
in countries south of latitude 45 north, which includes Southern Europe, South America, Australia, and most of the United
States. North of these geographical locations there are certain limitations due to low temperatures and low light intensity, mainly from October to April.10 Temperatures below 10C
will be too cold for elderly people with AK to endure, especially if it is also windy. This is particularly relevant if the AKs
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Time, h
The upper curve illustrates protoporphyrin IX (PpIX) in skin covered from light
and the lower curve illustrates a small PpIX formation half an hour after methyl
aminolevulinate (MAL) application and no accumulation at all during the
following 2 hours of daylight photodynamic therapy (PDT). AU indicates
arbitrary units; pdt, photodynamic therapy; PpIX, protoporphyrin IX.
E1
Opinion Editorial
jamadermatology.com