Daylight Photodynamic Therapy and

Its Relation to Photodamaged Skin

Beni Moreinas Grinblat

Abstract Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Photodynamic therapy (PDT) with artificial Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
red or blue light is an option for treating actinic References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
keratosis and field cancerization. In this chap-
ter, we present a new option of photodynamic
therapy, with natural daylight as the light Introduction
source. The method, called as daylight-PDT,
is a safe, effective, and almost painful treat- Daylight photodynamic therapy (DL-PDT) is an
ment for thin actinic keratosis and an option for option for treatment of thin actinic keratosis. It
patients with multiple lesions. was developed by Wiegell in 2006 (Wiegell et al.
2008) and since that several studies were
Keywords published around the world. The principles of
Daylight photodynamic therapy • Actinic ker- DL-PDT are similar to the conventional PDT,
atosis • Photodynamic therapy • Red light • with activation of photosensitizers resulting in
Blue light • Photodamaged • the formation of reactive oxygen species and cell
Photorejuvenation death. Most of the studies of DL-PDT were
performed using aminolevulinate cream (MAL)
Contents as photosensitizer. MAL is a prodrug that is
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 converted to protoporphyrin (PpIX) inside
Daylight Photodynamic Therapy . . . . . . . . . . . . . . . . . . 316 the cell.
Pre-procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Protoporphyrin is activated by visible light,
Protocol of Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 and in DL-PDT the visible light of the natural
Post-Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
sunlight spectrum makes the activation.
Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 DL-PDT is indicated for treating thin actinic
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 keratosis (grades I and II, according to Olsen
(Olsen et al. 1991)), mainly in patients with mul-
DL-PDT x Photorejuvenation . . . . . . . . . . . . . . . . . . . . . 318
tiple lesions on the scalp and/or face.
Besides treating AKs, DL-PDT seems to
improve other aspects of photodamage, such as
B.M. Grinblat (*) fine wrinkles and pigmentation.
Department of Dermatology, Hospital das Clínicas da
Faculdade de Medicina da Universidade de São Paulo, São
Paulo, Brazil
e-mail: bgrinblat@gmail.com

# Springer International Publishing AG 2018 315

M.C.A. Issa, B. Tamura (eds.), Lasers, Lights and Other Technologies, Clinical Approaches and Procedures in
Cosmetic Dermatology 3, https://doi.org/10.1007/978-3-319-16799-2_22
316
Daylight Photodynamic Therapy
Pre-procedure
There is no specific preparation before treatment
with PDT. Patients should keep using daily
sunscreens.
Protocol of Procedure
Several studies and internationals consensus
(Morton et al. 2015; Gilaberte et al. 2015; Grinblat
et al. 2015a) established the protocol of daylight-
PDT (Fig. 1).
1. The first step is the skin preparation. The objec-
tive is to remove scales and crusts and roughen
the surface of the skin to enhance the MAL
penetration. The curettage of the field is the
most used method, but there are other options
as slightly abrasive pads and micro-
dermabrasion. Microneedling and ablative
lasers might be used but with caution, using
smooth parameters.
2. An organic sunscreen must be applied in the
whole area before or after the skin preparation.
The sunscreen (SPF  30) must be used to
block the ultraviolet radiation and, hence, pre-
vent sunburn during the 2 h of daylight
exposure.
3. In order to block only UV and not visible light
needed to activate PpIX, a chemical sunscreen
must be used. Sunscreens containing physical
Chemical Skin Application
sunscreen preparation of MAL
OR
Skin Chemical Application
preparation sunscreen of MAL
Fig. 1 Protocol of DL-PDT with MAL
B.M. Grinblat
filters such as zinc oxide or titanium dioxide
must not be used, because they reflect some
visible light and thus may reduce the activation
of PpIX by daylight.
4. Fifteen minutes after the skin preparation/sun-
screen application, the photosensitizer should
be applied. Applying a thin layer in the whole
area and a thicker one over the AKs is
recommended. As mentioned before, the
majority of the published studies were
performed with MAL as the photosensitizer
and it is not a recommended occlusion. Usu-
ally, 1–2gr of MAL cream is sufficient to treat
the whole face.
5. Up to 30 min after the MAL application, the
patient has to be exposed to daylight, for
120 min. He must stay outdoors but can stay
under a shadow. In Brazil, the procedure can be
performed in the whole year, even in the winter
(Grinblat et al. 2016). It is recommended to
avoid treatment in very cloudy days and, obvi-
ously, if it is raining.
6. After the illumination (2 h of daylight expo-
sure), the MAL is removed, and the patient has
to avoid the sun exposure for the rest of the day.
Post-Procedure
The erythema after treatment is usually mild and
topical steroids are not recommended in routine.
Patients should keep using daily sunscreens, and
the use of moisturizers is indicated.
2 hours of
Removal of
Daylight
MAL
exposure
2 hours of
Removal of
Daylight
MAL
exposure
Daylight Photodynamic Therapy and Its Relation to Photodamaged Skin
Side Effects
DL-PDT is usually not painful, and the erythema
after treatment is usually mild. Blistering and
crusting are very rare.
Discussion
Several studies were published about DL-PDT in
different countries, and they showed similar
results when DL-PDT was compared to conven-
tional MAL-PDT, when treating thin AKs. The
main advantages of DL-PDT are:
1. The possibility of treating large areas (face and
scalp)
2. There is no equipment involved in the
treatment
3. DL-PDT is almost painless
During conventional photodynamic therapy,
the pain can be intense. Pain occurs when there
is a great amount of PpIX into the cells and in
DL-PDT that does not happen. During the treat-
ment with DL-PDT, there is a continuous activa-
tion of few amounts of porphyrin; there is no
accumulation of PpIX into the cells.
Fig. 2 Before and after one
session of MAL- DLPDT
317
In an Australian study (Rubel et al. 2014),
DL-PDT was compared to conventional PDT
and the clinical results were similar. But, most of
the patients considered DL-PDT much less pain-
ful and most of them preferred DL-PDT.
Australian study showed similar results when
DL-PDT was performed in sunny or cloudy days,
and a Brazilian study (Grinblat et al. 2015b)
showed good results even if DL-PDT was
performed during winter. The Latin-American
consensus (Grinblat et al. 2015a) recommends
2 h of daylight exposure under comfortable
temperatures.
For most of the authors, one single treatment of
DL-PDT is sufficient, but sometimes another ses-
sion is indicated and the authors recommend
3-month interval till the second treatment. In our
experience, patients with intense photodamage
need more than one session.
Daylight-PDT is usually indicated for patients
with multiple thin AK (types I and II). Treating the
whole area, DL-PDT can be considered as a “field
cancerization treatment.”
In 2016, Philipp-Dormston and colleagues
published a study about DL-PDT for “field
cancerization” (Philipp-Dormston et al. 2016).
They defined “field cancerization” as an area
with photodamage and AK. For those authors,
318
Fig. 3 Before and after one
session of MAL- DLPDT
DL-PDT is effective and could prevent the
appearance of new AK lesions in a
photodamaged skin.
We observe reduction of the number of AK
lesions and improvement of the photodamaged
skin (skin texture and pigmentation) in our
patients after treatment with only one MAL-DL-
PDT with 2 h of daylight exposure (Figs. 2 and 3).
DL-PDT x Photorejuvenation
Besides treating multiple AKs, DL-PDT seems to
improve other aspects of photodamage.
Kohl and colleagues published a study about
photodynamic rejuvenation. The authors
observed improvement of hyperpigmentation,
fine wrinkles, and skin tightness after conven-
tional PDT, with IPL, blue light, and red light
(Kohl et al. 2010). Issa and colleagues showed
skin remodeling induced by conventional PDT,
with increase expression of metalloproteinase
9 in the dermis and also of collagen type I (Issa
et al. 2009). In 2010, the same group showed an
increase of collagen and reduction of elastic fibers
after conventional MAL-PDT (Issa et al. 2010).
In 2015, a group of experts published that
besides the clearance and prevention of AK,
B.M. Grinblat
most studies after conventional PDT showed
improvement of skin texture (tactile roughness),
pale skin, wrinkles, mottled pigmentation, facial
erythema, and elastosis (Philipp-Dormston et al.
2016).
There is no data in the literature about photo-
rejuvenation with daylight-PDT, but in our expe-
rience patients treated with DL-PDT showed
improvement of skin texture. As mentioned,
there are several published studies about skin
rejuvenation after conventional PDT, and in our
experience, we can observe improvement of fine
wrinkles with DL-PDT, although lower than the
one observed after conventional PDT. According
to some authors (Philipp-Dormston et al. 2016),
daylight photodynamic therapy could be a com-
plementary and convenient treatment option to
already existing rejuvenation procedures for
patients with actinic field damage.
Conclusion
DL-PDT is safe, effective, almost painless and can
be considered a first-line option in the treatment of
multiple and thin AKs. Besides the excellent cure
rate of AK lesions, an improvement in the texture,
pigmentation, and fine wrinkles can be observed.
Daylight Photodynamic Therapy and Its Relation to Photodamaged Skin
Take Home Messages
• DL-PDT is an option for treatment of thin AK.
• DL-PDT maintains the efficacy of conven-
tional PDT for AK treatment.
• DL-PDT is almost painless. Erythema and
edema are very discreet comparing to
conventional PDT.
• The use of a chemical sunscreen is
recommended before the application of the
photosensitizer.
• DL-PDT seems to improve signs of
photodamage.
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