Shedding light on the itch of cholestasis Ibbotson, S.
British journal of dermatology (1951),
December 2019, 2019-Dec, 2019-12-00, 20191201, Letnik:
181, Številka:
6
Journal Article
Recenzirano
Linked Article: Hussain et al. Br J Dermatol 2019; 181:1138‐1145.
Summary
Background
Topical photodynamic therapy (PDT) is widely used to treat superficial nonmelanoma skin cancer and dysplasia, and is generally well tolerated. However, as with all treatments, ...adverse effects may occur and awareness may facilitate approaches to prevention and management.
Objectives
To review the available evidence relating to the adverse effects of topical PDT, to help inform recommendations in updated clinical guidelines produced by the British Association of Dermatologists and British Photodermatology Group, and the efficacy of preventative and therapeutic approaches.
Methods
This review summarizes the published evidence related to the adverse effects of topical PDT and attempts to interpret this evidence in the context of patient risk and management.
Results
Pain and discomfort during PDT are acute adverse effects, which can be minimized through the use of modified and low‐irradiance PDT regimens and do not therefore usually limit successful treatment delivery. Other adverse effects include the risk of contact allergy to photosensitizer prodrugs, although this is rare but should be kept in mind, particularly for patients who have received multiple PDT treatments to larger areas. There are no other significant documented longer‐term risks and, to date, no evidence of cumulative toxicity or photocarcinogenic risk.
Conclusions
Topical PDT is usually well tolerated, reinforcing the utility of this important therapeutic option in dermatology practice. The main acute adverse effect of pain can typically be minimized through preventative approaches of modified PDT regimens. Other adverse effects are uncommon and generally do not limit treatment delivery.
What's already known about this topic?
Photodynamic therapy (PDT) is widely used in dermatology.
Pain is the most well documented adverse effect.
Methods of effective pain relief are limited.
What does this study add?
This review scrutinizes the literature relating to adverse effects of PDT and management approaches.
PDT‐induced pain can usually be effectively prevented and managed through adjustments to PDT regimens, such as using lower irradiance light delivery.
Phototoxic reactions are to be expected.
Other adverse effects are typically uncommon and not limiting.
Linked Editorial: Wulf. Br J Dermatol 2019; 180:695–696.
Plain language summary available online
Summary
Background
Topical photodynamic therapy (PDT) is an established treatment option for low‐risk basal cell carcinoma (BCC).
Objectives
To compare efficacy, cosmesis and tolerability of PDT for ...BCC with alternative treatments.
Methods
MEDLINE, PubMed, Embase and CENTRAL databases were searched from inception until 1 September 2017. Included studies were randomized controlled trials (RCTs) of PDT for nodular (n) and superficial (s) BCC reporting at least one of the following outcomes: clearance at 3 months and sustained at 1 or 5 years; recurrence at ≥ 1 year; cosmesis; adverse events; tolerability.
Results
From 2331 search results, 15 RCTs (2327 patients; 3509 BCCs) were included. PDT efficacy (5‐year sustained clearance) was high but inferior to excisional surgery nBCC pooled risk ratio (RR) 0·76; 95% confidence interval (CI) 0·63–0·91, and without re‐treatment of partially responding lesions, was modestly inferior to imiquimod (sBCC: RR 0·81; 95% CI 0·70–0·95) and similar to fluorouracil (sBCC: RR 0·88; 95% CI 0·75–1·04). Five‐year sustained clearance was inferior with conventional vs. fractionated PDT (sBCC: RR 0·76; 95% CI 0·68–0·84). PDT cosmesis was superior to surgery (sBCC: RR 1·68, 95% CI 1·32–2·14; nBCC: RR 1·82, 95% CI 1·19–2·80) and cryosurgery (BCC: RR 3·73, 95% CI 1·96–7·07), and without re‐treatment of partially responding lesions was similar to imiquimod (sBCC: RR 1·01, 95% CI 0·85–1·19) and fluorouracil (sBCC: RR 1·04, 95% CI 0·88–1·24). Peak pain was higher but of shorter duration with PDT than topical treatments. Serious adverse reactions were rarer with PDT than imiquimod (sBCC: RR 0·05, 95% CI 0·00–0·84) and fluorouracil (sBCC: RR 0·11, 95% CI 0·01–2·04). Combination PDT regimens demonstrated reduced recurrence and improved cosmesis; however, results from these small studies were often nonsignificant.
Conclusions
PDT is an effective treatment for low‐risk BCC, with excellent cosmesis and safety. Imiquimod has higher efficacy than single‐cycle PDT but more adverse effects. Highest efficacy is with excisional surgery. Fractionated and combination PDT options warrant further study.
What's already known about this topic
Topical photodynamic therapy (PDT) is one of a range of established treatment options for low‐risk basal cell carcinoma (BCC).
BCC clearance is reported to be higher with imiquimod than with single‐cycle PDT.
What does this study add?
This is the largest systematic review and meta‐analysis to date of PDT for BCC and incorporates National Institute for Health and Care Excellence‐approved GRADE assessment of evidence quality, including 15 RCTs (2327 patients with 3509 BCCs).
Serious adverse reactions are less common with PDT than with imiquimod.
Peak pain is higher with PDT than topical therapies but is of shorter duration.
Fractionated PDT offers superior clearance to conventional PDT.
Combination PDT treatments show promise but require further study.
Linked Editorial: Lim. Br J Dermatol 2018; 179:1240–1241.
Plain language summary available online
Summary
Background
Despite decades of use, the actual amounts of topical corticosteroids (TCS) and emollients used in moderate‐to‐severe atopic dermatitis (AD) under real‐world conditions are ...unknown. Thus, it remains unclear whether inadequate use is widespread.
Objectives
To quantify the use of TCS and emollients in moderate‐to‐severe AD.
Methods
Double‐blinded drug prescribing was recorded prospectively at the point of drug dispensing within a catchment area of approximately 450 000 people over a 31‐year period in a population‐based cohort marked by failure of disease control in primary care (n = 844). For each patient, prescribing was recorded over a 12‐month period in order to minimize fluctuations.
Results
This approach resulted in a near‐complete dataset, which was essentially free of reporting bias and recording bias. Atopic comorbidities matched expected frequencies. Median use of TCS was statistically significantly higher in juvenile patients (age < 16 years) compared with adult patients (49·2 vs. 38·1 g per month), in male vs. female patients (46·8 vs. 29·7 g per month) and in patients receiving concurrent asthma treatment (40·4 vs. 26·7 g per month). TCS use was strongly associated with antidepressant treatment. Emollient use was unexpectedly low with a median of 9·6 g per day (range 1·4–30·1). Results were replicated in an independent validation cohort.
Conclusions
Deficient use of emollients may be a factor contributing to AD severity. Our analysis showed that the use of TCS does not exceed current guidelines. Accurate quantification of topical treatments provides a widely accessible strategy to measure the real‐world impact of novel AD treatments.
What's already known about this topic?
Both emollient and topical corticosteroid (TCS) use have been a mainstay of atopic dermatitis (AD) treatment for over 60 years.
The actual quantities used by patients under real‐world conditions are unknown.
What does this study add?
The real‐world use of emollients is fourfold lower than the amount recommended in current guidelines.
Underuse of emollients may be a significant factor in disease exacerbation.
The use of TCS is significantly higher in male patients and is higher in patients with AD who also have asthma.
The use of TCS is strongly associated with concurrent antidepressant treatment.
Linked Comment: Strowd and Feldman. Br J Dermatol 2020; 182:836–837.
Plain language summary available online
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