Patients undergoing in-office treatment with PDT will have their skin cleansed with acetone and then undergo ALA application to the targeted treatment area. Incubation times will vary based on anatomical region and severity of actinic damage.8 Both the patient and light technician are required to wear a protective eye covering to ensure ocular safety during the 10 to 15 minutes of irradiation with the blue light. Patients commonly report heat but minimal pain during irradiation.
Immediately following PDT patients may develop erythema and mild edema that may persist for 2 to 10 days.8 Patient postprocedure counseling includes remaining indoors and at least 6 feet from any window for 36 hours following the treatment to avoid exposure to ambient light and minimize the risk of continued activation of PpIX.8,9
The available research consistently indicates that early treatment of both visible AK lesions and nonvisible sun-damaged skin can eliminate the potential for malignant transformation and decrease the burden of cutaneous SCC.3 Treatment efficacy is dependent on patient adherence to therapy; therefore, it is important to educate patients on procedure expectations, any known adverse events, side effects, and postprocedure care to alleviate patient frustration and anxiety. Also, it is widely accepted that there is no way to clinically determine which AK lesions will transform into invasive SCC and recur after treatment.2 As a result, it is crucial to emphasize the importance of patient follow-up after any recommended treatment therapy. Patient follow-up should include monitoring of treatment efficacy, tolerability, and patient adherence. The majority of studies recommend patient monitoring every 6 to 12 months, but the frequency of individual patient monitoring depends on associated malignancy and the development of new AK lesions.2,4 Patients with AKs are at increased risk for other cutaneous malignancies and should receive education on the importance of skin self-monitoring for any concerning changes such as lesions that bleed, enlarge quickly, or do not heal. In addition, management of all AKs and field cancerization should include primary prevention with patient counseling on reducing UV radiation exposure with regular use of broad-spectrum sunscreen, wearing sun-protective clothing including a wide-brimmed hat, avoiding artificial UV tanning sources, and avoiding sun exposure during peak UV hours.7
Treating field cancerization is a shift in the traditional paradigm of treating individual lesions. Utilizing the AK-FAS can improve identification and severity grading of AKs and skin prone to sun damage. AK grading tools that rely on lesion counts — such as the Olsen and Roewert-Huber scales — have not been reproducible when grading severity.5 Utilizing a tool for assessing the field affected by AKs, such as the AK-FAS, may lead to a more standardized approach and increase the effectiveness of AK disease management.5,9 Identifying and treating field cancerization can reduce the development of new lesions and AK recurrence.5,9 As such, individual patient factors must be evaluated in the clinical decision-making process to develop patient-centric management plans. When choosing a therapy, treatment should account for the type and severity of lesions, patient tolerance to treatment-induced skin reactions, adherence to recommended therapy, duration of treatment, and cost-related factors for the individual patient.3
Amy J. Bronson, EdD, PA-C, is assistant professor and program director for the Master of Physician Assistant Studies at Colorado Mesa University, Grand Junction; Nikki Williams, MSPAS, PA-C, is assistant professor and director of didactic education for the Master of Physician Assistant Studies at Colorado Mesa University, Grand Junction; and Dr Steven R. Murray is professor of teaching at the College of Letters & Science of the University of California, Berkeley.
- Ayer G. Photo damage and actinic keratosis: a case study approach. Derm Nurs. 2017;16(1):22-25.
- Bolognia, JL, Schaffer, JV, Duncan KO, Ko, CJ. Dermatology Essentials. New York, New York: Elsevier Saunders; 2014.
- Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch of Derm. 1988;124(6);869-871.
- Goldberg, G. Treatment considerations in actinic keratosis. Europ Acad Dermatol Venereol. 2017;31(2):12-16.
- Dreno B, Cerio R, Dirschka T, et al. A novel actinic keratosis assessment scale for grading actinic keratosis disease severity. Acta Dermatol Venereol. 2017;97:1108-1113.
- Martin MM. In-office painless aminolevulinic acid photodynamic therapy. J Clin Aesthet Dermatol: 2016;9(2):19-26.
- Fleming P, Zhou S, Bobotsis R, et al. Comparison of the treatment guidelines for actinic keratosis: a critical appraisal and review. J Cutan Med Surg. 2017;21(5):408-417.
- Ozog DM, Rkein AM, Fabi SG, et al. Photodynamic therapy: a clinical consensus guide. Dermatol Surg. 2016;42:804-827.
- Wan MT, Lin JY. Current evidence and applications of photodynamic therapy in dermatology. Clinic Cosm Invest Derm. 2014;7:145-163.