In conventional photodynamic therapy (PDT) for the

treatment of actinic keratoses (AK), 5-aminolevulinic

acid (ALA) or methyl aminolevulinate(MAL)is applied
tothe skin after gentle curettage and stays there for a
defined period of time (often 3 hours) to ensure
accumulation of protoporphyrin IX (PpIX).
 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.
 The emission spectrumof the lamps must
coverwavelengths 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 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. Illumination must then be
performedcontinuously for 2 hours.
 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.
 Inflammation causes erythema, discomfort, and
irritation of the skin for days after treatment, and
often results in downtime away from work.
 To further reduce erythema the PDT treatment may
be combined with topical glucocorticosteroid without
losing efficacy.
 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.
(Temperatures below10°C)
 An alternative is daylight illumination in a
greenhouse.
 Daylight fluence rate will fluctuate a good deal over
the day depending on the sun’s angle and cloud cover.

 If skin PpIX fluorescence measurements are performed

at the end of treatment outdoors or in a greenhouse,
it is possible to establish the minimum daylight fluence
rate necessary to ensure total PpIX activation.
 Patients with AK are generally advised to use sun
protection and limit their sun exposure.
 Two hours outdoors will, in many locations, result in a
sunburn and daylight PDT is thus preceded by
sunscreen application by the clinician.
 If the treatment takes place in a greenhouse, the glass
will absorb most of the UVR wavelengths that can
provoke erythema, and sunscreen pretreatment may
thus be omitted.
 After daylight exposure, excess MAL/ALA is removed
and the patients must avoid outdoor light for the rest
of the day.

 If the patients go outside, covering the skin with

clothes, wearing a hat, and applying a physical
sunscreen to protect exposed skin.
 The light intensity outside or in a greenhouse at the
end of treatment will nearly always be sufficient and
generally there will be no need for measuring the
fluence rate.

 The drawbacks of daylight PDT mentioned above call

for alternatives to daylight while maintaining the 2
hour exposure time.
JAMA Dermatology, O’Gorman et al present a clinical
study in which operating room LED light is used for
indoor“ daylight PDT,” illustrating that this type of
lamp constitutes an alternative to daylight.
 For PDT to be effective with an artificial light source
certain criteria have to be met.

 Figure shows that more and more PpIX accumulates in the

skin over time during conventional PDT until illumination
starts, typically after 3 hours.
 To achieve this, the light fluence rate must be
sufficient to activate all PpIX within the 2 hours of
illumination.

 However, if the fluence rate has to be controlled it can

be done very inexpensively by using a Luxmeter.
 Lux is a surrogate measure that can be performed very
affordably and without special skills
 Daylight PDT is very popular among patients with AK
 most patients decline treatment with conventional PDT after
having experienced this changed treatment modalitywith few
adverse effects.
 Another consequence of daylight PDT is that
 the patientswish to havemuchlarger areas of skin treated each time
they visit the clinic.
 It is very easy for dermatologists to gain experience with This new
daylight PDT modality.
 Advantageous for the clinic and at the same time preferred by
patients.
THANK YOU . . .