ARTICLE
Auteur(s) : Sung-il In, Jae Yeol Lee, You Chan Kim
Department of Dermatology, Ajou University School
of Medicine, 5 Wonchon-Dong, Yeongtong-Gu, Suwon 443-721,
South Korea
accepté le 5 Mai 2010
Sebaceous gland disorders, such as nevus sebaceous (NS),
sebaceous hyperplasia, and Fordyce's spots, can be a cosmetic
concern and necessitate therapeutic interventions. However, the
treatment modalities, including surgical excision, cryotherapy,
chemical application, ablative laser vaporization, have shown
limited values in terms of pain, prolonged healing time, scarring
and intralesional recurrences [1]. Topical PDT is now successfully
used in the treatment of some sebaceous gland disorders [2].
However, only one case treated with aminolevulinic acid (ALA)-PDT
to NS has been reported [3]. In this study, we report the effects
of ALA and methyl aminolevulinate (MAL) PDT in the treatment of NS
on the face.
Material and methods
We treated 12 NS patients (5 men and 7 women; aged 5-39 years;
Fitzpatrick's skin type IV-V) with PDT. Topical 20% ALA
(Medacala®, Hamberg, Germany) or methyl aminolevulinate
(Metivix®, Galderma, France) was applied to the lesions,
followed by occlusion with polyurethane film (Tegaderm®,
3M, St. Paul, USA). Incubation time was 3 hours in MAL PDT,
and 4 hours in ALA PDT, respectively. After 3 or
4 hours, the lesions were irradiated with 630 ± 50 nm
light emitting diodes (LED) devices without anesthesia. We
performed CO2 laser ablasion prior to the PDT treatment to enhance
penetration of the photosensitizer, and ALA or MAL application was
confined to the lesion. The light intensity was set to
100 mW/cm2. The light dose was
80-160 J/cm2. Topical PDT regimen was delivered
repeatedly at 1 to 4 weeks intervals to each patient.
Clinical improvement was assessed by semiquantitative visual
analysis at 1 month after treatment by the lesional responses.
No response was defined as less than 25%, mild improvement as
25-50%, moderate improvement as 51-75% and marked improvement as a
more than 75% decrease of lesional volume. Side effects were
evaluated on follow-up visits.
Results
All the patients showed clinical improvement of the lesions (table 1). Three of 12 patients
(25%) showed mild improvement. Seven (58%) and two (17%) of
12 patients showed moderate and marked improvement
respectively (figures 1, 2). In the
case of good responders, the lesion gradually regressed with
flattening and decreased in size with each treatment session. All
the patients tolerated the treatments well without any significant
adverse effects. There were only mild discomforts like erythema and
burning sensations. During the follow-up period (3-24 months,
average of 7.6 months), two patients showed partial recurrence
after one and three months after completion of treatment,
respectively.
Table 1 Summary of PDT for 12 patients
with NS
|
Patient No.
|
Sex/ Age (years)
|
Area/ Size (cm)
|
Photo-sensitizer
|
Treatment sessions
|
Fluence (J/cm2)
|
Intensity (mW/cm2)
|
Results
|
F/U (months)
|
Side effects
|
|
1
|
F/9
|
Rt.cheek 3 × 1.5
|
ALA
|
2
|
100-120
|
100
|
++
|
3 (recurred)
|
Erythema
|
|
2
|
F/21
|
Lt.cheek 3 × 3
|
MAL
|
2
|
100-120
|
100
|
++
|
3
|
Erythema
|
|
3
|
M/39
|
Lt.temple 1.5 × 0.5
|
ALA
|
2
|
80-100
|
100
|
+
|
3 (recurred)
|
None
|
|
4
|
F/5
|
Forehead 2 × 1.5
|
ALA
|
3
|
100
|
100
|
++
|
6
|
Erythema
|
|
5
|
F/11
|
Forehead 1 × 1
|
ALA
|
3
|
80-90
|
100
|
++
|
24
|
Erythema
|
|
6
|
M/7
|
Lt.cheek 4 × 3
|
ALA
|
4
|
20-60
|
100
|
+
|
14
|
Burning
|
|
7
|
F/17
|
Lt.cheek 0.5 × 2
|
MAL
|
4
|
100-110
|
100
|
++
|
3
|
None
|
|
8
|
M/10
|
Forehead 1 × 4
|
ALA
|
5
|
100
|
100
|
+
|
3
|
Erythema
|
|
9
|
M/12
|
Rt.temple 0.5 × 0.5
|
ALA
|
6
|
80-100
|
100
|
+++
|
12
|
Erythema
|
|
10
|
F/16
|
Rt.cheek 1 × 0.5
|
ALA
|
9
|
100-160
|
100
|
++
|
3
|
Erythema
|
|
11
|
F/19
|
Lt.temple 0.5 × 2
|
ALA
|
9
|
80-110
|
100
|
++
|
12
|
Erythema
|
|
12
|
M/32
|
Lt.mandible 2 × 1.5
|
ALA
|
5
|
80-110
|
100
|
+++
|
5
|
Erythema
|
Discussion
Surgical excision has been mainly used for NS lesions. However in
some patients, surgical removal is not a viable alternative, owing
to the extent of the lesion and the areas affected. We performed
PDT on patients with NS on the face because NS often represents a
cosmetic concern for affected patients, especially when it presents
on the face. Furthermore, the depth of a lesion on the face may be
thinner than that on the scalp, which led us to expect a more
favorable efficacy of PDT on NS over the face. Concern regarding
the occurrence of malignant neoplasms raises the question of the
efficacy of non-surgical treatment, including PDT [4]. However,
secondary neoplasms may be detected with close follow-up of the
cutaneous lesions.
Divaris et al. [5] presented the selective accumulation of
ALA in sebaceous glands rather than adjacent areas after
intraperitoneal injection into albino mice. On the basis of these
results, there have been some reports about topical ALA-PDT for the
treatment of acne vulgaris, sebaceous hyperplasia, and NS, with
noticeable benefits [3, 6, 7]. In the application of NS, Dierickx
et al. [3] reported the first successful treatment of NS with
ALA-PDT. In our study, all 12 cases of NS showed mild to
marked improvement after PDT. Thus, current reports, including our
results, indicate that topical PDT can be an alternative treatment
for sebaceous hyperplasia and NS, while it is less effective for
Fordyce's spots [2, 8].
CO2 lasers have been applied as one of the useful
treatment modalities for NS lesions. However, there were limited
values in lesional size reduction, and some side effects like scar
formation using only CO2 laser abrasion. In our present
study, CO2 laser (Sharplan 30C CO2 laser,
Sharplan lasers Inc., Israel), with 0.05 second irradiation time of
1W in the superpulse mode, was only used for epidermal abrasion
prior to the PDT for effective ALA absorption and uniform
irradiation to the flat surface. Because CO2 laser
abrasion was performed until the papillary dermis was exposed, it
did not work on the dermal lesion of NS. Therefore, the improvement
of the NS lesion was mainly caused by PDT, not be the
CO2 laser.
ALA is usually applied to the lesion to include more than
5 mm of surrounding area, to treat subclinical lesions of
malignant skin tumors or infections, with PDT. However, we applied
ALA only on the lesions, to reduce side effects. As a result, our
study showed no severe side effects and relatively good efficacy,
applying ALA only on the lesion may be an effective and safe
method.
In conclusion, topical PDT may be considered as an effective
alternative treatment modality of NS. Despite its relative
simplicity, optimal disease-specific parameters including
irradiance, wavelength and total dose characteristics have yet to
be established. To reach a consensus about standardized therapy,
larger studies with longer follow-up times are needed.
Acknowledgements
Financial source: none. Conflict of interest: none.
References
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