The ability of laser treatment to affect wound healing and subsequently minimize scar formation has been investigated in recent years. However, no systematic review links these clinical trials. The ...aim of this study was to systematically review and evaluate clinical evidence for early laser intervention to reduce scar formation in studies where laser treatment was introduced less than 3 months after wounding. We searched PubMed using relevant keywords in June 2017. Titles, s and articles were sorted according to inclusion and exclusion criteria. Methodological quality was evaluated according to Cochrane Collaborations risk‐of‐bias assessment guideline by two independent authors. Twenty‐five articles met the inclusion criteria. In total, 22 of 25 studies were controlled studies, and 17 of 25 studies compared laser treatment vs. untreated control scars. The following laser devices have been investigated: pulsed dye laser (PDL), potassium‐titanyl‐phosphate (KTP) laser, fractional erbium:glass 1540 nm/1550 nm, fractional/full ablation erbium‐doped yttrium aluminium garnet (Er:YAG) laser or fractional CO2 laser. Eighteen studies applied laser treatments 2–4 times with 2‐ to 8‐week intervals, while seven studies applied only one laser treatment. Follow‐up time ranged from 1 to 12 months with 18 studies using a follow‐up time ≤3 months. In general, laser‐treated wounds and scars showed benefit from laser intervention, though not always reaching significance. Significant scar improvement was found in three of four studies using laser treatment in inflammation phase, in six of 16 studies with laser initiated in the proliferation phase and in two of five studies in the remodelling phase. High risk of bias was found in randomization and allocation concealment, and low risk of bias with regard to blinding of outcome assessment and lost to follow‐up. In conclusion, laser intervention when introduced in inflammation, proliferation or remodelling phase has the potential to reduce cutaneous scar formation. Further, high‐quality studies are needed before standard protocols can be implemented in clinical practice.
Basal cell carcinoma (BCC) is the most common type of cancer and an increasing incidence stimulates the interest in new treatments such as electrochemotherapy (ECT) with bleomycin. This systematic ...review focuses on literature from the MEDLINE, Embase, Web of Science, and Cochrane databases. Bleomycin‐ECT studies (n = 32) were sorted by the level of evidence adjusted for their BCC data only. The studies included a single randomised controlled trial (RCT), 15 uncontrolled clinical trials, three registry studies, six prospective case series and seven retrospective case series. A Cochrane risk‐of‐bias assessment of the RCT identified some minor concerns but no predicted risk of bias. The studies were also grouped by bleomycin administration routes: intravenous (n = 14), intralesional (n = 9) and mixed reporting/usage (n = 9). A meta‐analysis was not conducted due to the lack of RCTs and the heterogeneity of the included studies. The results of the RCT generally reflected the findings of the other included studies and showed a 92% complete response in 65 bleomycin‐ECT–treated BCCs after 2 months, improving to 100% after re‐treatment, with a low risk of recurrence. Based on the RCT results and overall data, future studies on BCC treatment with bleomycin‐ECT should include large RCTs that compare bleomycin‐ECT with standard of care, cost analyses, and clinical feasibility.
Summary
Background
Topical photodynamic therapy (PDT) is an approved treatment for actinic keratosis (AK). To enhance the efficacy of PDT for AKs, physical and chemical pretreatments have been ...suggested.
Objectives
To compare the efficacy and safety of the combination of topical calcipotriol (CAL) before methyl aminolaevulinate (MAL)‐PDT for AKs of the scalp vs. conventional MAL‐PDT in a randomized controlled clinical trial.
Methods
Twenty patients with multiple AKs on the scalp were randomized to receive conventional MAL‐PDT with previous curettage on one side of the scalp and CAL‐assisted MAL‐PDT once a day for 15 days before illumination on the other side. After 3 months, patients were evaluated for clearance of AKs, side‐effects and histopathology before and after the procedure. Protoporphyrin IX (PpIX) fluorescence was measured before and after illumination on both sides.
Results
All 20 patients completed the study. Overall AK clearance rates were 92·1% and 82·0% for CAL‐PDT and conventional PDT, respectively (P < 0·001). Grade 1 AKs showed similar response rates for both sides (P = 0·055). However, grade II AKs showed more improvement on the CAL‐PDT side (90%) than on the MAL‐PDT side (63%) (P < 0·001). Before illumination, PpIX fluorescence intensity was higher on the CAL‐assisted side (P = 0·048). The treatment was more painful on the CAL‐PDT side, although well tolerated. The mean visual analogue scale score was 5·4 ± 1·4 on the CAL‐PDT side and 4·0 ± 0·69 on the conventional MAL‐PDT side (P = 0·001). Side‐effects such as erythema (P = 0·019), oedema (P = 0·002) and crusts (P < 0·001) were more pronounced on the CAL‐assisted side. Histopathological analyses were obtained from five patients and both sides showed improved keratinocyte atypia following PDT, with slightly more improvement on the CAL‐assisted side.
Conclusions
CAL‐assisted PDT proved to be safe and more effective than conventional MAL‐PDT for the treatment of AKs on the scalp. CAL pretreatment increased PpIX accumulation within the skin and may have enhanced the efficacy in this first human trial.
What's already known about this topic?
Topical vitamin D pretreatment enhances methyl aminolaevulinate (MAL)‐induced protoporphyrin IX (PpIX) in hairless mice.
Topical vitamin D prior to aminolaevulinic acid photodynamic therapy (PDT) enhances treatment efficacy of nonmelanoma skin cancers in mouse skin models.
What does this study add?
In human skin, calcipotriol (CAL)‐assisted MAL‐PDT proved to be superior to MAL‐PDT alone and was well tolerated.
Topical preconditioning of actinic keratoses with CAL‐assisted MAL induced PpIX formation to a greater extent compared with the side that was not pretreated.
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Summary
Background
Physical pretreatments can potentiate the efficacy of daylight photodynamic therapy (dPDT), but clinical comparative studies remain limited.
Objectives
Performed in large skin ...areas with actinic keratoses (AKs) and photodamage, this blinded, randomized clinical trial compared the efficacy and safety of dPDT after tailored skin pretreatment using ablative fractional laser (AFL) or microdermabrasion (MD).
Methods
Two ≥ 50‐cm2 side‐by‐side skin areas were randomized to receive a single treatment with AFL‐dPDT or MD‐dPDT. Pretreatment parameters were tailored according to AK grade and skin constitution to ensure standardized immediate end points. Subsequently, methyl aminolaevulinate was applied, followed by 2‐h daylight exposure. The primary outcome comprised blinded assessment of AK clearance at the 3‐month follow‐up.
Results
In 18 patients with 832 AKs, AFL‐dPDT provided significantly higher AK clearance (81% vs. 60%, P < 0·001), led to fewer new AKs (P < 0·001) and showed superior improvement in dyspigmentation (P = 0·003) and skin texture (P = 0·001) vs. MD‐dPDT. Peaking at days 3–6, AFL‐PDT induced more intensified local skin responses (P = 0·004), including instances of Staphylococcus aureus infection (n = 3). Patients nonetheless preferred AFL‐dPDT (P = 0·077), due to lower pretreatment‐related pain (P = 0·002) and superior cosmesis (P = 0·035) and efficacy compared with MD‐dPDT.
Conclusions
AFL‐dPDT is an effective treatment for patients with AK with extensive field cancerization, although AFL pretreatment is associated with intensified local skin reactions.
What's already known about this topic?
Different physical skin pretreatments have been shown to potentiate the efficacy of daylight photodynamic therapy (dPDT), but comparison studies are lacking.
What does this study add?
Using tailored pretreatment parameters to obtain standardized immediate end points prior to dPDT, ablative fractional laser provided superior lesional clearance and enhanced rejuvenating effects, but increased local skin reactions compared with pretreatment with microdermabrasion.
Ablative fractional laser‐assisted dPDT represents a viable, intensified treatment strategy for patients with multiple actinic keratoses and large areas of photodamaged skin.
Linked Editorial: Wolf. Br J Dermatol 2019; 180:697–698.
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Summary
Background
In recent years, various lasers have increasingly been applied during wound healing to minimize scar formation. However, no consensus regarding treatment procedures exists.
...Objectives
To assess scar formation clinically after three nonablative fractional laser (NAFL) exposures, targeting the inflammation, proliferation and remodelling wound healing phases in patients vs. untreated controls.
Methods
A randomized controlled trial was performed using a split‐wound design to assess excisional wound halves treated with 1540‐nm NAFL vs. no laser treatment. Three NAFL exposures were provided: immediately before surgery, at suture removal and 6 weeks after surgery. NAFL exposures were applied using two handpieces, sequentially distributing energy deeply and more superficially in the skin (40–50 mJ per microbeam). Evaluated at 3 months of follow‐up, the primary outcome was blinded, on‐site evaluation using the Patient Observer Scar Assessment Scale (POSAS total; range from 6, normal skin to 60, worst imaginable scar). Secondary outcomes comprised blinded evaluation on the Vancouver Scar Scale (VSS) and standardized assessment comparing scar sides, carried out by blinded on‐site, photo and patient assessments. This trial was registered with ClinicalTrials.gov (NCT03253484).
Results
Thirty of 32 patients completed the trial. At the 3‐month follow‐up, the NAFL‐treated scar halves showed improvement compared with the untreated control halves on POSAS total: NAFL treated, median 11, interquartile range (IQR) 9–12 vs. control, median 12, IQR 10–16; P = 0·001. The POSAS subitems showed that the NAFL‐treated halves were significantly less red and more pliable, and presented with smoother relief than the untreated controls. VSS total correspondingly revealed enhanced appearance in the NAFL‐treated halves: median 2, IQR 1–2·5 vs. control, median 2, IQR 1·75–3, P = 0·007. The standardized assessment comparing appearance of scar halves demonstrated a low degree of correspondence between on‐site, photo and patient assessments. NAFL‐treated scars were rated as superior to untreated scars by 21 of 29 patients.
Conclusions
NAFL‐treated scars showed subtle improvement compared with untreated control scars.
What's already known about this topic?
There are indications that early laser treatment may reduce scar formation during wound healing.
No consensus exists regarding the optimal treatment procedure for early laser treatment to reduce scar formation.
What does this study add?
This is the first trial investigating the clinical effect of three nonablative fractional laser (NAFL) treatments, initiated as early as immediately before surgery and repeated throughout the wound healing phases.
NAFL‐treated scars showed subtle superiority over untreated control scars.
NAFL may be promising as an integrated part of surgical procedures and postsurgical care to reduce scar formation.
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Summary
Light‐based hair removal (LHR) is one of the fastest growing, nonsurgical aesthetic cosmetic procedures in the United States and Europe. A variety of light sources including lasers, e.g. ...alexandrite laser (755 nm), pulsed diode lasers (800, 810 nm), Nd:YAG laser (1064 nm) and broad‐spectrum intense pulsed light (IPL, 590–1200 nm), are available and used widely for such procedures in dermatological/clinical settings under proper supervision. Patient selection and appropriate fluence settings are managed by professionals to maximize efficacy while minimizing adverse events. In the past 5 years, LHR devices have been sold directly to consumers for treatment in the home. In this review, we outline the principles underlying laser and IPL technologies and undertake an evidence‐based assessment of the short‐ and long‐term efficacy of the different devices available to the practising dermatologist and discuss the efficacy and human safety implications of home‐use devices.
Summary
Background
Photodynamic therapy (PDT) is approved for selected nodular basal cell carcinomas (nBCC) but efficacy is reduced for large and thick tumours. Ablative fractional lasers (AFXL) ...facilitate uptake of methyl aminolaevulinate (MAL) and may thus improve PDT outcome.
Objectives
To evaluate efficacy and safety of AFXL‐mediated PDT (AFXL‐PDT) compared with conventional PDT of high‐risk nBCC.
Methods
Patients with histologically verified facial nBCC (n = 32) defined as high‐risk tumours were included; diameter > 15 mm, tumours located in high‐risk zones, or on severely sun‐damaged skin. Tumours were debulked and patients randomized to either AFXL‐PDT (n = 16) or PDT (n = 16). Fractional CO2 laser treatment was applied at 5% density and 1000 μm (80 mJ) ablation depth. MAL was applied under occlusion for 3 h and illuminated with a 633‐nm light‐emitting diode source, 37 J cm−2. Clinical assessments were performed at 3, 6, 9 and 12 months and biopsies were taken at 12 months.
Results
Clinical cure rates at 3 months were 100% (16 of 16 AFXL‐PDT) and 88% (14 of 16 PDT, P = 0·484). Recurrences tended to occur later and in lower numbers after AFXL‐PDT at 6, 9 and 12 months (6%, 19%, 19%) than PDT (25%, 38%, 44%) (P = 0·114). Histology at 12 months documented equal tumour clearance after AFXL‐PDT (63%, 10 of 16) and PDT (56%, 9 of 16). Cosmetic outcomes were highly satisfactory after both treatments (P > 0·090).
Conclusions
Long‐term efficacy was similar after PDT and AFXL‐PDT with a trend for a favourable short‐term cure rate after AFXL‐PDT. AFXL‐PDT needs further refinement for nBCC and at present is not recommended over PDT.
What's already known about this topic?
Photodynamic therapy (PDT) is approved in Europe for selected cases of basal cell carcinoma (BCC), but efficacy rates are reduced for nodular tumours.
Ablative fractional lasers (AFXL) disrupt the skin barrier and facilitate the uptake of topical photosensitizers into deep skin compartments.
What does this study add?
The efficacy of AFXL‐mediated PDT compared with conventional PDT is evaluated for the first time in a randomized clinical trial for high‐risk nodular BCC.
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