Braathen et al

Title: Guidelines on the use of photodynamic therapy for non-melanoma skin cancer: an international consensus.

Author: Braathen LR, Szeimies R-M, Basset-Seguin N, Bissonnette R et al.

Journal Reference: J Am Acad Dermatol 2007;56:125-43 (by clicking on this link you will be leaving this site - Galderma is not responsible for the content)

Objective: to develop practical, up-to-date, international, evidence-based guidelines on the use of topical photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL; Metvix®) for the treatment and prevention of non-melanoma skin cancers (NMSC).

Methods: a comprehensive international literature review using MEDLINE was conducted on topical PDT with ALA and MAL. Practical clinical recommendations made based on the quality of evidence for efficacy, safety/tolerability, cosmetic outcome, and patient satisfaction. Evidence was considered at a meeting of the International Society for Photodermatology in January 2005 and graded on the basis of:

  • Quality (from grade I to IV, where I represents the highest quality of evidence - evidence from at least one properly designed, randomised controlled trial, down to IV - where there are inadequate studies in terms of methodology).
  • Strength (from grade A to E, where A represents the highest strength of evidence - good evidence to support the treatment, down to E - where there is there is good evidence to reject the treatment).

Key Recommendations:

Actinic keratosis (AK) 

  • PDT is highly effective with excellent cosmetic outcomes and should be considered first line therapy - AI rating
  • MAL-PDT - superior cosmetic outcome compared with cryotherapy - AI rating

Bowen's disease (BD)

  • PDT is effective with good cosmesis. It is at least as effective as cryotherapy or 5-FU, with fewer adverse events.
  • PDT should be considered as a first-line therapy - AI rating

Superficial basal cell carcinoma (sBCC)

  • PDT is an effective and reliable treatment option with excellent or good cosmetic outcomes - AI rating
  • PDT offers an advantage in the treatment of large, extensive and multiple lesions - AI rating
  • MAL-PDT has long-term efficacy, with 5-year follow-up data - AI rating

Nodular basal cell carcinoma (nBCC)

  • MAL-PDT is an effective and reliable treatment option and possibly preferable for thin lesions, with good cosmetic outcome - AI rating
  • MAL-PDT has long term efficacy in nBCC, with 5-year data - AI rating

Squamous cell carcinoma (SCC)

There is insufficient evidence to support the use of topical PDT - CIIiii rating

Prevention of NMSC

In immunosuppressed patients PDT may be considered as a means of preventing new AK lesions - BI rating

Evidence is less compelling for prevention of:

  • SCC - CIII rating
  • BCC - C IIiii rating

Further data are required to fully establish the preventive potential of topical PDT.

Conclusion: PDT offers: reliable long-term efficacy together with good tolerability and excellent cosmetic outcomes (with strong evidence for superiority over surgery and cryotherapy for MAL-PDT). Moreover, treatment can be repeated if necessary. The authors conclude that: "PDT can be recommended as a first-line treatment for AK, BD and sBCC. MAL-PDT can also be recommended for  nBCC lesions. Areas where further research is required include the prevention of NMSCs and SCC".