A photosensitizer is a chemical compound that can be excited by light of a specific wavelength. This excitation uses visible or near-infrared light. In photodynamic therapy, either a photosensitizer or the metabolic precursor of one is administered to the patient. The tissue to be treated is exposed to light suitable for exciting the photosensitizer. Usually, the photosensitizer is excited from a ground singlet state to an excited singlet state. It then undergoes intersystem crossing to a longer-lived excited triplet state. One of the few chemical species present in tissue with a ground triplet state is molecular oxygen. When the photosensitizer and an oxygen molecule are in proximity, an energy transfer can take place that allows the photosensitizer to relax to its ground singlet state, and create an excited singlet state oxygen molecule. Singlet oxygen is a very aggressive chemical species and will very rapidly react with any nearby biomolecules.
How does Photodynamic Therapy (PDT) work?
In photodynamic therapy a photosensitizer (Levulan®) is applied to the skin. This is absorbed preferentially by certain structures in the skin, such as hair follicles, oil glands, bacteria, or rapidly growing cells. Illumination with a high-intensity light or lasers causes a reaction in the skin, resulting in destruction of the targeted tissue. Skin oiliness is decreased, the appearance of pores is greatly minimized, collagen is stimulated, and pre-cancerous cells are destroyed.
What types of conditions can be treated with PDT?
Photodynamic therapy has been effective in the treatment of sun-damaged skin, acne, warts, and many other diseases. Levulan is in the second stage of clinical trials for other applications and should be officially FDA approved for other uses soon.
Is PDT uncomfortable?
During PDT the skin is washed several times and the activated substance is applied. Either of these may cause stinging. Following treatment there may be some transient itching and a mild sunburn sensation.
Photosensitivity
After PDT, a small amount of activated substance remains in the skin for 24 to 48 hours. Sunlight and even indoor light may affect this and cause redness and itching. Use of sunscreen with zinc oxide and wearing a hat may diminish these undesired effects.
Itching/Burning
Most people experience mild burning or itching for about one hour after the procedure, although this may last a day or two. Mild to moderate redness may be experienced for 24 to 48 hours. Only gentle emollients should be applied to the skin.
Swelling
Areas most likely to swell are around the eyes. This will subside within several hours. Application of ice or cold packs may help.
Peeling
Peeling of treated skin may occur several days after the procedure and can be alleviated by gentle washing and application of a slightly thicker moisturizer.
How much improvement can I expect?
Patients with severe sun damage manifested by actinic keratosis, texture, and tone changes including mottled pigmentation and skin laxity may see excellent results. You may also see improvement of large pores and pitted acne scars.
How many treatments will it take to see the "best results?"
To achieve maximum improvement of sun damage, skin tone and texture, acne, and rosacea, a series of three treatments scheduled 2-3 weeks apart is the most effective.
What are the advantages?
* Reduced scarring and improved cosmetic outcome .
* In contrast with systemic photo sensitizers, persistent sun sensitivity is not a problem past the first 48 hours with this new topical approach.
* Improvement will be noticed in the whole area treated (such as the full face) creating all one color, texture, and tone.
* Levulan - Photo rejuvenation matches the "ideal treatment" for acne and sun damage.
* Well tolerated (essentially painless).
* Easily performed by a specialty clinic environment.
* Non-invasive (no needles or surgery required).
* Excellent cosmetic outcome (particularly in cosmetic sensitive areas of the face).
What are the disadvantages?
* Sunburn confined to the treated areas with redness and peeling for a few days to one week.
* Temporary swelling of the lips and around your eyes if these areas are included in treatment. This usually lasts a few days.
* Darker pigmented patches called liver spots that are actually lentigos will become darker and then peel off leaving normal skin. (This usually occurs over seven to ten days.)
* Repeat treatments may be necessary.
* Those on a "financial budget" may have to plan for this treatment.
What is the Procedure?
* First your skin is prepped with medical-grade Acetone and a Microdermabrasion. (This allows the Levulan to penetrate better and more evenly.)
* A physician or nurse will apply the Levulan solution.
* The Levulan will remain on between 1-3 hours.
* The Levulan is removed with cleanser.
* You will be given special goggles to wear to protect your eyes during the laser treatment.
* During the treatment you may feel stinging, tingling, prickling, or burning of the lesions, but this should go away after the treatment.
* Cooling packs will be applied to your face to decrease swelling.
* After the treatment you will have sunblock applied and you will need to bring a hat to wear home.
* You should stay out of the sun and bright light (even florescent) as much as possible for the next 48 hours.
* The skin may turn red and swollen in the following 3-7 days.
* Some crusting may be noted.
* There may be some discomfort, but no significant pain.
* After 1 week, there might be some residual redness that will subside after a few days and can be covered with makeup such as Jane Iredale Minerals that we retail in our office.
* Photodynamic therapy (PDT) is a special treatment performed using a topical photo sensitizer called Levulan, or aminolevulinic acid (ALA), a special light, and molecular oxygen to selectively destroy abnormal cells. ALA is a natural substance found throughout the body. ALA is activated by light to destroy target tissue cells. The easy access of skin to light-based therapy has led physicians to apply PDT to skin disorders. In dermatology, PDT has been most successful in treating acne vulgaris, actinic (solar) keratosis (AKs).
* Acne ALA-PDT Actinic Keratosis ALA-PDT Photorejuvenation
* Simply stated, ALA-PDT removes sun damaged pre-cancerous skin cells while improving fine lines and blotchy pigment. This treatment also has the unique ability to minimize pores and reduce oil glands effectively treating stubborn acne vulgaris and acne rosacea while improving the appearance of some acne scars. PDT photorejuvenation is also known as Power PhotoFacial or Super PhotoFacial because the results are similar to three to five PhotoFacial treatments.
Benefits of Photodynamic Therapy
* PDT is a very effective treatment for actinic keratosis, which can eventually turn into skin cancer. Treatment of AKs is more challenging when they are diffuse over a large area.
* Photorejuvenation has been effective in the treatment of rosacea. Adding Levulan to the treatment increases the efficacy and reduces the total number of treatments required.
* Most patients notice an improvement in skin texture, reduced pigmentation from sun damage, fewer fine lines and an overall more youthful appearance.
* Treatments using PDT for acne also yield excellent results by shrinking the sebaceous glands and destroying the bacteria that can cause acne.
Who is a good candidate for PDT?
Patients with diffuse actinic keratoses, moderate to severe rosacea, moderate to severe sun damage, textural irregularities, and/or acne are good candidates for PDT with Levulan.
Who is not a good candidate for PDT?
If you are pregnant, have been on isotretinoin within 3 months, or have an active cold sore you should not have this procedure. If you are taking aspirin of blood thinners, you may experience bruising that can take up to two weeks to resolve. If you are tanned or have recently been exposed to the sun in the area you are having treated, you may be more susceptible to potential side effects such as blisters or crusts and/or your treatment may need to be reduced in intensity or postponed until the tan fades. In addition, patients with pacemakers or internal defibrillators should not have this procedure.
How much improvement can I expect?
Patients with severe sun damaged skin manifested by actinic keratosis, texture, and tone changes including mottled pigmentation and skin laxity may see excellent results. You may also see improvement of large pores and pitted acne scars. Active acne can be dramatically reduced.
How many treatments are necessary?
* Achieving maximum improvement is greatly dependent on the treatment plan you and your Physician/Nurse select. Maximum improvement may require two to five treatments. Treatments are spaced two to five weeks apart. Additional treatments may be done at periodic intervals in the future to maintain the rejuvenated appearance of the skin.
Disadvantages and risks of PDT
Every medical procedure involves certain disadvantages and risks and it is important that you understand the disadvantages and risks involved in PDT. Depending on the treatment protocol (how mild or aggressive the treatment is), you may be red and have some swelling and peeling for three to seven days. Darker pigment areas can become darker during this time, but peel off during the peeling process. The majority of patients do not experience complications. It is important that your decision to proceed with PDT is based upon consideration of the alternatives to treatments as well as the risks, benefits, and costs of the proposed plan. Your nurse or clinician will make sure that you fully understand the alternatives, benefits, risks, potential complications, and expected outcomes of this treatment.
Redness and Swelling
Depending on your desired outcome and length of Levulan incubation, the short-term immediate risks include redness that may last from a few days to several days. Swelling is common with more aggressive treatments and usually starts on day one and is over by day three. Once the treatment has been completed you will be sent home with special topical products to moisturize and enhance healing.
Peeling
Peeling and/or superficial crusting is an anticipated side effect of PDT treatment and generally occurs between days three to six post treatment. Most patients are excited about the peeling process because they begin to see the new skin.
Bruising
Bruising is uncommon, although the risk increases if you take aspirin products or are on blood thinners. Bruises are temporary and resolve in one to two weeks.
Discomfort
During a photorejuvenation treatment that utilizes a laser or IPL device, you may experience some discomfort during the procedure likened to the snapping of a rubber band. If the best light treatment choice for you is a visible light source, you may notice your face getting warmer the longer you are exposed to the light source. The sensation of heat has to do with the incubation time of the Levulan. A longer incubation period (how long the Levulan is on prior to light exposure) yields a more aggressive treatment and the resulting warm sensation while in the light source.
Skin wounds, infection, and scarring
Uncommonly, a skin wound such as superficial blisters and scabs can occur, which heal within two to fourteen days. Use of antibiotic ointment on a regular basis usually results in uneventful healing. There is a less than 1% possibility of a skin wound leaving behind a permanent scar. It is also rare for an infection to occur since the skin is usually not broken.
Hypo and Hyper pigmentation
Another risk is a possibility of hypo (too little) or hyper (too much) pigmentation that is very uncommon. This can correct naturally over a few weeks or is usually treatable with prescription creams, chemical peels, or further laser treatments. There is a less than 1% possibility that this could be permanent. There is an increased risk of this with tanned or naturally dark skin. You may need extra treatments than those required of others if your skin is dark in order to be more conservative (gentler with initial and subsequent treatments) with your treatment due to this increased risk. It is also important that you let any tanning lotions fade and do not seek artificial tanning treatments for three to four weeks prior to the procedure.
Multiple and maintenance treatments
Sometimes more than one treatment may be needed to achieve desired results. Occasionally, all actinic keratoses may not fully respond to laser treatment with ALA and additional treatments may be necessary. Subsequent AKs may develop over time and future treatments may be needed. Acne and rosacea are chronic conditions and maintenance treatments may be necessary to remain in remission. Many patients like the rejuvenated appearance and continued improvement they achieve over a series of treatments.
Patient Dissatisfaction
You may be disappointed in the outcome as not everybody achieves every bit of improvement they desire. Although the vast majority of patients are happy with their results, medicine is not an exact science and results are variable. We cannot provide you with any guarantee of your final results.
Post Treatment Care
You should use the skin care regimen that your consultant has provided for you. It is important to avoid sun exposure for the first two days following your treatment and then try to avoid prolonged sun exposure. You may not go in a tanning booth at any time before or during PDT treatments. Doing so will greatly increase your risk of a side effect. If there is any blistering or breakage of the skin after the procedure, you should use an antibiotic ointment at least two times per day to keep the area moist. Please call the office immediately if these are not minimal, localized, or superficial. Please review your home care instruction sheet that details what you should expect on a daily basis.
Financial Responsibility
While photodynamic therapy is a medical treatment, it is also a cosmetic treatment for acne, rosacea, and skin rejuvenation. You will therefore be responsible for payment at the time of service.
Controlling Acne
If you have acne that is not responding to medications, or if you are unable to tolerate oral or topical medications for acne photodynamic therapy with Levulan ALA may be right for you. Combined with a light source, Levulan ALA kills the p.acnes bacteria in your skin, decreases sebum (oil) production and provides long term improvement of acne.
About the Procedure
The procedure is called Photodynamic Therapy (PDT). Whether treating acne or sun damage, the process is very similar. The treatment utilizes a drug, called Levulan ALA, and a light source that can kill the p.acnes bacteria in your skin. Levulan has been used in the skin for decades to treat severe sun damage and skin cancers in adults.
* The product, called Kerastick, is applied topically (directly on the skin) and allowed to incubate painlessly for approximately 1 hour. A light or laser source is then used to "photo-activate" the Levulan ALA and thus directly affect the hair follicle and sebaceous glands.
* Prior to the procedure, your skin will be prepped, ensuring skin is clean and free of all makeup, moisturizers and sunscreens. During the procedure, the Blue- light source is used. It is important to note that there are no ultraviolet rays in this light source.
* The treatment itself takes approximately 10 minutes. You may feel mild stinging or burning when the skin is exposed to the light or laser source. Afterwards there is no, or minimal pain. You should expect mild to moderate redness and scaling that can persist from 0-5 days, like a mild sunburn.
* Patients usually require at least 3 treatments spaced at 3 week intervals to see significant improvement (80% or greater) for months at a time. Depending on the severity of the condition, the number and strength of the required treatments will vary. After achieving long term reduction in acne lesions, infrequent treatments can be done to maintain long term efficacy. Unfortunately, as of now medical insurances do not cover this form of acne treatment.
